What validated instruments, that measure implementation outcomes, are suitable for use in the Paediatric Intensive Care Unit (PICU) setting? A systematic review of systematic reviews.

BACKGROUND/AIMS: The measurement of implementation outcomes can establish the success of implementing evidence into practice. However, implementation outcomes are seldom measured in acute healthcare settings, such as Paediatric Intensive Care Units (PICU), and if they are used, are likely to be non-validated, site or intervention-specific measures. To address this literature gap, this systematic review of systematic reviews aims to identify validated instruments to measure implementation outcomes of new EBP interventions in a PICU setting. METHODS: A systematic review of systematic reviews was conducted in two phases. Phase One: Five electronic databases were searched between 06/10/22 and 14/10/22. Systematic reviews were selected using pre-determined eligibility criteria. Methodological quality was assessed using the Critical Appraisal Skills Programme tool and a data extraction table was used to allow further synthesis. Phase Two: Secondary eligibility criteria were used to extract and review instruments from the systematic reviews selected in Phase One. Instruments were analysed and mapped to the Consolidated Framework of Implementation Research (CFIR). RESULTS: Phase One: Searches resulted in 3195 unique papers. Five systematic reviews were eligible for inclusion. All examined the psychometric properties of each instrument, utilising different methods to do so; three considered their pragmatic or usability properties; and one identified instruments that were transferrable to different settings. Each systematic review identified that most included instruments had limited evidence of their validity or reliability and had poor psychometric properties. Phase two: 93 instruments were screened, and nine were eligible for analysis. After analysis and CFIR mapping, two instruments were identified as potentially adaptable to the PICU setting. CONCLUSIONS: The methodological quality of implementation outcome measurement instruments is inadequate, warranting further validation research. Two instruments were identified that cover multiple CFIR domains and have scope to be adapted for use when implementing evidence-based practice into the PICU. Further work is needed to adapt and further validate an instrument for use in practice. TRIAL REGISTRATION: For transparency of procedures and methods, the protocol for this systematic review was registered with PROSPERO (registration number CRD42022361638L).

The 2022-2023 Pediatric Respiratory Illness Surge: Survey of Acute and Critical Care Resource Use.

OBJECTIVE: A surge of pediatric respiratory illnesses beset the United States in late 2022 and early 2023. This study evaluated within-surge hospital acute and critical care resource availability and utilization. The study aimed to determine pediatric hospital acute and critical care resource use during a respiratory illness surge. METHODS: Between January and February 2023, an online survey was sent to the sections of hospital medicine and critical care of the American Academy of Pediatrics, community discussion forums of the Children's Hospital Association, and PedSCCM-a pediatric critical care website. Data were summarized with median values and interquartile range. RESULTS: Across 35 hospitals with pediatric intensive care units (PICU), increase in critical care resource use was significant. In the month preceding the survey, 26 (74%) hospitals diverted patients away from their emergency department (ED) to other hospitals, with 46% diverting 1-5 patients, 23% diverting 6-10 patients, and 31% diverting more than 10 patients. One in 5 hospitals reported moving patients on mechanical ventilation from the PICU to other settings, including the ED (n = 2), intermediate care unit (n = 2), cardiac ICU (n = 1), ward converted to an ICU (n = 1), and a ward (n = 1). Utilization of human critical care resources was high, with PICU faculty, nurses, and respiratory therapists working at 100% capacity. CONCLUSIONS: The respiratory illness surge triggered significant hospital resource use and diversion of patients away from hospitals. Pediatric public health emergency-preparedness should innovate around resource capacity.

Early Sepsis Response System Does Not Correlate with Pediatric Early Warning Score in Sepsis Recognition.

Sepsis is a leading cause of pediatric morbidity and mortality worldwide with early recognition and management improving patient outcomes. Early recognition warning systems, utilizing the electronic medical record (EMR), are recommended for children's hospitals. Validated pediatric early warning score (PEWS) recognize hospitalized children at risk for worsening and need for higher level of care. The goal of this study was to develop a novel pediatric sepsis early response warning system and compare this tool with the existing generic PEWS system in recognizing sepsis. A novel early sepsis warning system was integrated into the EMR of a tertiary pediatric children's hospital. In patients meeting criteria a best practice alert (BPA) triggers and children with a sepsis BPA trigger were evaluated from December, 2018 through May, 2020. BPA data was analyzed and identified children meeting sepsis criteria. Subjects identified as having sepsis were then correlated with PEWS scores at the time of the BPA. The BPA triggered in 736 pediatric subjects, with 181 in the emergency department, 275 in the pediatric inpatient floor and 280 in the pediatric intensive care unit. Pediatric sepsis criteria identified 524 of 736 (71%) as having sepsis. PEWS scores identified only 66 (13%) of the 524 subjects who had sepsis. Implementation of a sepsis trigger tool into EMR is feasible. Best practice alerts identify subjects with early sepsis and can be implemented to electronic medical record.

Health Disparities in the Management and Outcomes of Critically Ill Children and Neonates: A Scoping Review.

To date, health disparities in critically ill children have largely been studied within, not across, specific intensive care unit (ICU) settings, thus impeding collaboration which may help advance the care of critically ill children. The aim of this scoping review is to summarize the literature intentionally designed to examine health disparities, across 3 primary ICU settings (neonatal ICU, pediatric ICU, and cardiac ICU) in the United States. We included over 50 studies which describe health disparities across race and/or ethnicity, area-level indices, insurance status, socioeconomic position, language, and distance.

Brief report: incidence and outcomes of pediatric tracheal intubation-associated cardiac arrests in the ICU-RESUS clinical trial.

BACKGROUND: Tracheal intubation (TI)-associated cardiac arrest (TI-CA) occurs in 1.7% of pediatric ICU TIs. Our objective was to evaluate resuscitation characteristics and outcomes between cardiac arrest patients with and without TI-CA. METHODS: Secondary analysis of cardiac arrest patients in both ICU-RESUS trial and ancillary CPR-NOVA study. The primary exposure was TI-CA, defined as cardiac arrest occurred during TI procedure or within 20 min after endotracheal tube placement. The primary outcome was survival to hospital discharge with favorable neurological outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged). RESULTS: Among 315 children with cardiac arrests, 48 (15.2%) met criteria for TI-CA. Pre-existing medical conditions were similar between groups. Pre-arrest non-invasive mechanical ventilation was more common among TI-CA patients (18/48, 37.5%) compared to non-TI-CA patients (35/267, 13.1%). In 48% (23/48), the TI-CA occurred within 20 min after intubation (i.e., not during intubation). Duration of CPR was longer in TI-CA patients (median 11.0 min, interquartile range [IQR]: 2.5, 35.5) than non-TI-CA patients (median 5.0 min, IQR 2.0, 21.0), p = 0.03. Return of spontaneous circulation occurred in 32/48 (66.7%) TI-CA versus 186/267 (69.7%) non-TI-CA, p = 0.73. Survival to hospital discharge with favorable neurological outcome occurred in 29/48 (60.4%) TI-CA versus 146/267 (54.7%) non-TI-CA, p = 0.53. CONCLUSIONS: Fifteen percent of these pediatric ICU cardiac arrests were associated with TI. Half of TI-CA occurred after endotracheal tube placement. While duration of CPR was longer in TI-CA patients, there were no differences in unadjusted outcomes following TI-CA versus non-TI-CA. TRIAL REGISTRATION: The ICU-RESUS (ClinicalTrials.gov Identifier: NCT02837497).

Evaluation of the use of telemedicine in pediatric intensive care units: a cluster-randomized trial.

INTRODUCTION: Telemedicine has shown promising results, allowing specialists to provide rapid and effective care in remote locations. However, to our knowledge, current evidence is not robust enough to prove the effectiveness of this tool. This cluster-randomized trial (CRT) aimed to evaluate the impact of telemedicine on clinical care indicators in pediatric intensive care units (PICUs). METHODS: An open-label CRT was conducted in 16 PICUs within the Brazilian public health system. The trial took place from August 2022 to December 2023 and compared an intervention group, which received telemedicine support, with a control group, which received usual PICU care. The primary outcome was the PICU length of stay. The main secondary outcomes were mortality rate and ventilator-free days. RESULTS: A total of 1393 participants were included, 657 in the control group and 736 in the intervention group. The mean PICU length of stay was 10.42 (SD, 10.71) days for the control group and 11.52 (SD, 10.80) days for the intervention group. The overall mean of ventilator-free days was 6.82 (SD, 7.71) days. Regarding mortality, 7.54% of participants died in total. No significant difference was found in the outcomes between the groups. CONCLUSION: Despite the potential benefits of telemedicine, its effective implementation in the Brazilian public health system faces considerable challenges, highlighting the continued importance of investigating and improving the role of telemedicine in pediatric critical care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT05260710 and ReBEC - RBR-7×j4wyp.

Prevalence of use of physical restraints in pediatric intensive care units and correlated variables: A Spanish multicenter study.

OBJECTIVE: To calculate the prevalence of physical restraint (PR) use in Spanish PICUs and (2) to analyze the correlation between the prevalence of PR use and the sociodemographic, clinical variables of the patients and the PICU structural and organizational variables. METHODS: We conducted a multicenter prevalence study from January 2022 to January 2023 in Spanish PICUs. The method of data collection was by direct observation, review of the patient's medical history, and asking the professionals involved in the patient's care. Three weekly 24-hour prevalence observations (morning, afternoon, and night) were conducted for 6 months. RESULTS: A total of 336 patients were included in the study, obtaining an overall crude prevalence of PR use of 16 % (95 %CI: 15 %-17.7 %). Pediatric patients with respiratory pathology received the highest number of hours of PR, with significant differences observed when comparing respiratory cases with post-surgical cases. Statistical significance was also observed when comparing the mean scores of hours of PR according to admission diagnosis (p = 0.01), with respiratory patients being the ones who were restrained the longest (24 h [20-24]) and infectious patients the least (15 h [14-20]). Patients who receive PR upon admission remain in this situation for more hours (24 h [15-24] and in the PICUs that specifically recorded PR application, fewer hours of PR occurred (20 h [4-24]). CONCLUSIONS: The use of PR is still present in the PICUs analyzed, with a crude prevalence of 16%. Factors such as the reason for admission, the use of respiratory support, and the reason for application of PR were linked to the hours of use of PR. IMPLICATIONS FOR CLINICAL PRACTICE: Knowing the prevalence of PR use will make professionals aware that it is still necessary to implement policies that avoid its use to prevent the side effects they have in pediatric patients.

Perspectives of BrinquEinstein healthcare professionals on the implementation of therapeutic play in pediatrics. / Perspectivas dos profissionais de saúde do BrinquEinstein sobre a implementação do brinquedo terapêutico na pediatria.

The benefits of therapeutic play (TP) in pediatrics are widely reported in the literature, however its use by health professionals is still limited. The objective was to understand how professionals belonging to the BrinquEinstein group evaluate the process of systematic implementation of TP in hospital pediatric units. Exploratory study, with a qualitative approach, developed in the pediatric and intensive care units of extra-large general hospital in São Paulo. The sample consisted of 13 professionals from different categories belonging to BrinquEinstein. Data was collected through individual semi-structured and audio-recorded interviews, being analyzed based on the Inductive Thematic Analysis proposed by Braun and Clark. From the analysis of the interviews, five themes emerged: experiencing a transforming process; the benefits that strengthen the path; the facilities that encourage the walk; the barriers that challenge the process; the future prospects. For the interviewed professionals, it is essential that the use of TP becomes a routine practice in different contexts of the child´s healthcare, in which managers and institutions play a fundamental role in its implementation.

Os benefícios do brinquedo terapêutico (BT) em pediatria são amplamente divulgados na literatura, entretanto, seu uso pelos profissionais de saúde ainda é limitado. Objetivou-se compreender como os profissionais que pertencem ao grupo BrinquEinstein e avaliam o processo de implementação sistemática do BT em unidades pediátricas hospitalares. Realizou-se estudo exploratório, de abordagem qualitativa, nas unidades pediátrica e de terapia intensiva de um hospital geral de extraporte, na cidade de São Paulo. Participaram 13 profissionais de diferentes categorias pertencentes ao BrinquEinstein. Os dados foram coletados por meio de entrevista semiestruturada individual e audiogravada, sendo analisados a partir da Análise Temática Indutiva proposta por Braun e Clark. Da análise das entrevistas, emergiram cinco temas: vivenciando um processo transformador; os benefícios que fortalecem o caminho; as facilidades que impulsionam a caminhada; as barreiras que desafiam o processo; e as perspectivas futuras. Para os profissionais entrevistados, é imprescindível que o uso do BT se torne uma prática rotineira nos diferentes contextos de atendimento à saúde da criança, sendo que gestores e instituições têm papel fundamental na sua implementação.

Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study).

BACKGROUND: The objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV). METHODS: Thirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients' level of comfort. NIV failure was considered to be a requirement for endotracheal intubation. RESULTS: A total of 457 patients were included, with a median age of 3.3 months (IQR 1.3-16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230-1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009-1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS. CONCLUSIONS: Sedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

The elements of end-of-life care provision in paediatric intensive care units: a systematic integrative review.

BACKGROUND: Deaths in paediatric intensive care units (PICUs) are not uncommon. End-of-life care in PICUs is generally considered more challenging than other settings since it is framed within a context where care is focused on curative or life-sustaining treatments for children who are seriously ill. This review aimed to identify and synthesise literature related to the essential elements in the provision of end-of-life care in the PICU from the perspectives of both healthcare professionals (HCPs) and families. METHODS: A systematic integrative review was conducted by searching EMBASE, CINAHL, MEDLINE, Nursing and Allied Health Database, PsycINFO, Scopus, Web of Science, and Google Scholar databases. Grey literature was searched via Electronic Theses Online Service (EthOS), OpenGrey, Grey literature report. Additionally, hand searches were performed by checking the reference lists of all included papers. Inclusion and exclusion criteria were used to screen retrieved papers by two reviewers independently. The findings were analysed using a constant comparative method. RESULTS: Twenty-one studies met the inclusion criteria. Three elements in end-of-life care provision for children in the PICUs were identified: 1) Assessment of entering the end-of-life stage; 2) Discussion with parents and decision making; 3) End of life care processes, including care provided during the dying phase, care provided at the time of death, and care provided after death. CONCLUSION: The focus of end-of-life care in PICUs varies depending on HCPs' and families' preferences, at different stages such as during the dying phase, at the time of death, and after the child died. Tailoring end-of-life care to families' beliefs and rituals was acknowledged as important by PICU HCPs. This review also emphasises the importance of HCPs collaborating to provide the optimum end-of-life care in the PICU and involving a palliative care team in end-of-life care.

Repositioning Guidelines to Decrease Pressure Injury in the Pediatric Intensive Care Unit: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement (QI) project was to develop and implement repositioning guidelines that reduce pressure injury (PI) in hemodynamically unstable pediatric intensive care unit (PICU) patients. PARTICIPANTS AND SETTING: All PICU patient ages 0 to 36 months who required sedation for invasive mechanical ventilation and had a Braden Q score ≤ 18 were eligible for inclusion. The project was implemented in 116 patients preimplementation and 100 postimplementation. Their median t age was 5 months (interquartile range 2-13 months). The QI project setting was an academic hospital PICU with a Level I trauma center located in the Mid-Atlantic Region of the United States. APPROACH: A pre-post observational design was used to compare the at-risk population for 21 weeks before (August-December 2018) and after (August-December 2019) implementing repositioning guidelines. Turn attempts were undertaken every 2 hours. Repositioning attempts were defined as (1) full (30°); (2) partial (15°); (3) unable to turn owing to hemodynamic instability; or (4) noncompliance. The primary outcome was incidence of Stage II or higher PI. OUTCOMES: We found a significant reduction in the incidence of PI before and after implementation of the repositioning intervention (16.4% vs 2.0%, P = .0003). IMPLICATIONS FOR PRACTICE: A structured intervention for repositioning hemodynamically unstable PICU patients has the potential to significantly lower PI incidence in a group of hemodynamically unstable children.

Staffing Models: Making Increased Acuity Safe in the Pediatric ICU.

Traditional staffing models rely on the productivity metric of hours per patient day, lacking the ability to adequately capture the nursing workload. Acuity-based staffing considers the patient population's acuity for appropriate nursing workload. Using process improvement methodology, a pediatric ICU transitioned to an acuity-based staffing model resulting in an 11.3% ( P < 0.05) reduction in the acuity per nursing assignment and a decrease in reportable safety events by 61.3% ( P < 0.05).

Humanisation in paediatric intensive care units: A narrative review.

OBJECTIVE: To identify findings in the scientific literature relevant to the strategic lines proposed by the Humanising Intensive Care Project in the context of paediatric intensive care units. DESIGN: Narrative review. METHODS: A literature search was conducted in the databases PubMed, Scopus, CINHAL, and Cochrane Library. Specific indexing terms and search strategies adapted to each database were designed. The inclusion of publications was based on two criteria: 1) related to the paediatric intensive care unit and 2) addresses at least one of the topics related to the strategic lines of the Humanising Intensive Care Project. Study selection was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the quality of the included studies was assessed using the Mixed Method Appraisal tool. RESULTS: A total of 100 articles from 19 different countries were included, covering the period between 2019 and 2021. Nineteen different design types were identified. Thirty-two studies were cross-sectional observational studies, while 15 had an experimental approach. The articles were distributed among the seven strategic lines of the Humanising Intensive Care Project. CONCLUSIONS: Synthesising the knowledge related to humanisation in paediatric intensive care units will allow progress to be made in improving quality in these units. However, there is disparity in the amount of experimental research overall. IMPLICATIONS FOR CLINICAL PRACTICE: There is a disparity in the available research related to the different strategic lines, and it is necessary to carry out more exhaustive research on topics such as the presence and participation of the family in care or the management of post-paediatric intensive care syndrome.