Auricular Acupressure Adjunct Treatment for Opioid Tapering: A Randomized Pilot Feasibility Study.

PURPOSE: Opioid medications are necessary in the treatment of critically ill infants; however. prolonged use may lead to withdrawal syndrome. The purpose of this study was to assess feasibility of delivering an acupressure protocol for the treatment of iatrogenic withdrawal in a pediatric cardiac intensive care unit as well as impact and acceptance of acupressure as an adjunct treatment. DESIGN: Randomized pilot feasibility trial. METHODS: Acupressure stickers were applied and rotated to one ear every 1-3 days until withdrawal symptoms improved. RESULTS: There were no serious adverse events, with only one reported incident of skin irritation. Recruiting benchmarks were exceeded. Weaning phases were significantly shorter in the acupressure group (medians 6.0 vs 22.0 respectively, p = .025, d = 0.90) and the control group used skin-to-skin contact as a comfort measure significantly more than the acupressure group (42.9% vs 6.3%, p = .18). Acupressure was accepted by parents, with an overall 96.2% rating their experience as positive, as measured by the Parent Client Satisfaction Questionnaire. The majority of health care providers (n = 19) were supportive, with 71.9% agreeing or completely agreeing acupressure is an acceptable adjunct for the treatment of withdrawal symptoms; 26.8% were neutral, as measured by the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure. CONCLUSIONS: Acupressure was found to be safe, feasible, and accepted by health care providers in a pediatric cardiac intensive care setting. CLINICAL IMPLICATIONS: These findings support future research with larger sample sizes to improve clinical treatment of infants physically dependent on sedative medications.

The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children.

OBJECTIVES: Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence. DESIGN AND SETTING: Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU. PATIENTS: Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled. MEASUREMENTS AND MAIN RESULTS: An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis. CONCLUSIONS: The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

OBJECTIVE: To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. DESIGN AND SETTING: A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. PATIENTS: A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. INTERVENTIONS: None. MEASUREMENTS: Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. RESULTS: A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0). CONCLUSIONS: The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Development and testing of an advanced practice clinical advancement program within an academic medical center.

BACKGROUND: Faculty advanced practice registered nurses (APRNs) and physician assistants (PAs) employed by Vanderbilt University Medical Center (VUMC) have historically participated in rank promotion tracks for recognition of professional accomplishments in education, practice, and research. However, there has not been a clinical advancement program for nonfaculty practitioners. Satisfaction, engagement, and health surveys indicated VUMC APRNs and PAs were seeking opportunities for professional growth and development. Many health care organizations have incorporated clinical advancement programs as key recruitment and retention strategies. With a growing number of nonfaculty APRNs and PAs, VUMC began to explore the development, implementation, and evaluation of a clinical advancement program. PURPOSE: A VUMC Clinical Advancement Task Force was created to explore, develop, implement, and evaluate an advanced practice clinical advancement pilot. METHODS: Two teams were selected to participate in a 6-month pilot. Presurveys and postsurveys were conducted, and postpilot focus groups were held with participating practitioners. A 9-square tool was developed as a rubric for evaluating the practitioner's progress. Applications, leader assessments, and recommendations were housed in a secure database for a selected advancement committee to evaluate. RESULTS: Of 23 participants, 47% indicated satisfaction with professional development opportunities, when compared with 84% postpilot. Postpilot focus groups further improved the tool and the process for the program. IMPLICATIONS FOR PRACTICE: Opportunities for advancement/professional development positively influence APRN and PA perceptions of job satisfaction. This program could be tested with other APRN and PA teams for impact on job satisfaction, engagement, and retention.