Impact of COVID-19-related restricted family presence policies on Canadian pediatric intensive care unit clinicians: a qualitative study.

PURPOSE: Pediatric intensive care units (PICUs) worldwide restricted family presence in response to the COVID-19 pandemic. We aimed to explore the experiences and impact of restricted family presence policies on Canadian PICU clinicians. METHODS: We conducted a qualitative study that followed an interpretive phenomenological design. Participants were PICU clinicians providing direct patient care in Canada during periods of COVID-19-related restricted family presence. We purposively sampled for maximum variation among survey participants who consented to be contacted for further research on the same topic. In-depth interviews were conducted remotely via telephone or video-call, audio-recorded, and transcribed. Interviews were inductively coded and underwent thematic analysis. Proposed themes were member-checked by interviewees. RESULTS: Sixteen PICU clinicians completed interviews. Interviewees practiced across Canada, represented a range of disciplines (eight nurses, two physicians, two respiratory therapists, two child life specialists, two social workers) and years in profession (0-34 years). We identified four themes representing the most meaningful aspects of restricted family presence for participants: 1) balancing infection control and family presence; 2) feeling disempowered by hospital and policy-making hierarchies; 3) empathizing with family trauma; and 4) navigating threats to the therapeutic relationship. CONCLUSION: Pediatric intensive care unit clinicians were impacted by restricted family presence policies during the COVID-19 pandemic. These policies contributed to feelings of disempowerment and challenged clinicians' perceived ability to provide the best family-centred care possible. Frontline expertise should be incorporated into the design and implementation of policies to best support family-centred care in any context and minimize risks of moral distress for PICU clinicians.

RéSUMé: OBJECTIF: Les unités de soins intensifs pédiatriques (USIP) du monde entier ont restreint la présence des familles en réponse à la la pandémie de COVID-19. Notre objectif était d'explorer les expériences et l'impact des politiques de restriction de la présence familiale sur les clinicien·nes des USIP canadiennes. MéTHODE: Nous avons mené une étude qualitative qui a suivi un plan phénoménologique interprétatif. Les participant·es étaient des clinicien·nes des USIP qui dispensaient des soins directs aux patient·es au Canada pendant les périodes de présence restreinte des familles en raison de la COVID-19. Nous avons délibérément échantillonné pour obtenir une variation maximale parmi les participant·es à l'enquête qui ont accepté d'être contacté·es pour d'autres recherches sur le même sujet. Des entretiens approfondis ont été menés à distance par téléphone ou par appel vidéo, enregistrés et transcrits. Les entretiens ont été codés de manière inductive et ont fait l'objet d'une analyse thématique. Les thèmes proposés ont été contrôlés par membre par les personnes interrogées. RéSULTATS: Seize cliniciennes et cliniciens des USIP ont passé des entrevues. Les personnes interrogées exerçaient partout au Canada, représentaient un éventail de disciplines (huit infirmiers et infirmières, deux médecins, deux inhalothérapeutes, deux spécialistes du milieu de l'enfant, deux travailleuses et travailleurs sociaux) et d'années d'expérience professionnelle (de 0 à 34 ans). Nous avons identifié quatre thèmes représentant les aspects les plus significatifs de la présence restreinte de la famille pour les participant·es : 1) l'équilibre entre la prévention des infections et la présence de la famille; 2) le sentiment d'être dépossédé·e par les hiérarchies de l'hôpital et de ne pas pouvoir participer à l'élaboration des politiques; 3) le sentiment d'empathie à l'égard des traumatismes familiaux; et 4) la réponse aux menaces qui ont pesé sur la relation thérapeutique. CONCLUSION: Les cliniciens et cliniciennes des unités de soins intensifs pédiatriques ont été touché·es par les politiques de restriction de la présence familiale pendant la pandémie de COVID-19. Ces politiques ont contribué à un sentiment d'impuissance et ont remis en question la capacité perçue des équipes à fournir les meilleurs soins possibles axés sur la famille. L'expertise de première ligne devrait être intégrée à la conception et à la mise en œuvre des politiques afin de mieux soutenir les soins axés sur la famille dans n'importe quel contexte et de minimiser les risques de détresse morale pour les cliniciennes et cliniciens des USIP.

A survey of pediatric intensive care unit clinician experience with restricted family presence during COVID-19.

PURPOSE: Limiting family presence runs counter to the family-centred values of Canadian pediatric intensive care units (PICUs). This study explores how implementing and enforcing COVID-19-related restricted family presence (RFP) policies impacted PICU clinicians nationally. METHODS: We conducted a cross-sectional, online, self-administered survey of Canadian PICU clinicians to assess experience and opinions of restrictions, moral distress (Moral Distress Thermometer, range 0-10), and mental health impacts (Impact of Event Scale [IES], range 0-75 and attributable stress [five-point Likert scale]). For analysis, we used descriptive statistics, multivariate regression modelling, and a general inductive approach for free text. RESULTS: Representing 17/19 Canadian PICUs, 368 of 388 respondents (94%) experienced RFP policies and were predominantly female (333/368, 91%), English speaking (338/368, 92%), and nurses (240/368, 65%). The mean (standard deviation [SD]) reported moral distress score was 4.5 (2.4) and was associated with perceived differential impact on families. The mean (SD) total IES score was 29.7 (10.5), suggesting moderate traumatic stress with 56% (176/317) reporting increased/significantly increased stress from restrictions related to separating families, denying access, and concern for family impacts. Incongruence between RFP policies/practices and PICU values was perceived by 66% of respondents (217/330). Most respondents (235/330, 71%) felt their opinions were not valued when implementing policies. Though respondents perceived that restrictions were implemented for the benefit of clinicians (252/332, 76%) and to protect families (236/315, 75%), 57% (188/332) disagreed that their RFP experience was mainly positive. CONCLUSION: Pediatric intensive care unit-based RFP rules, largely designed and implemented without bedside clinician input, caused increased psychological burden for clinicians, characterized as moderate moral distress and trauma triggered by perceived impacts on families.

RéSUMé: OBJECTIF: Limiter la présence de la famille va à l'encontre des valeurs centrées sur la famille des unités de soins intensifs pédiatriques (USIP) canadiennes. Cette étude explore comment la mise en œuvre et l'application des politiques de restriction de la présence familiale liées à la COVID-19 ont eu une incidence sur les cliniciennes et cliniciens des USIP à l'échelle nationale. MéTHODE: Nous avons mené un sondage transversal, en ligne et auto-administré auprès des cliniciens et cliniciennes des USIP canadiennes afin d'évaluer leur expérience et opinions sur les restrictions, la détresse morale (thermomètre de détresse morale, intervalle de 0 à 10) et les impacts sur la santé mentale (échelle d'impact des événements [EIE], intervalle de 0 à 75, et le stress qui peut y être attribué [échelle de Likert à cinq points]). Pour l'analyse, nous avons utilisé des statistiques descriptives, une modélisation de régression multivariée et une analyse inductive générale pour le texte libre. RéSULTATS: Représentant 17/19 USIP canadiennes, 368 des 388 personnes répondantes (94 %) ont vécu des politiques de restriction de la présence familiale et étaient principalement des femmes (333/368, 91 %), anglophones (338/368, 92 %) et infirmières (240/368, 65 %). Le score moyen (écart type [ET]) rapporté de détresse morale était de 4,5 (2,4) et était associé à l'impact différentiel perçu sur les familles. Le score moyen (ET) total de l'EIE était de 29,7 (10,5), ce qui suggère un stress traumatique modéré, 56 % (176/317) des personnes répondantes déclarant une augmentation ou une augmentation significative du stress associé aux restrictions liées à la séparation des familles, au refus d'accès et à la préoccupation pour les impacts familiaux. L'incongruité entre les politiques et les pratiques de restriction des visites familiales et les valeurs des USIP était perçue par 66 % des personnes répondantes (217/330). La plupart (235/330, 71 %) estimaient que leurs opinions n'étaient pas prises en compte lors de la mise en œuvre de politiques. Bien que les répondant·es aient perçu que les restrictions avaient été mises en œuvre dans l'intérêt des cliniciens et cliniciennes (252/332, 76 %) et pour protéger les familles (236/315, 75 %), 57 % (188/332) n'étaient pas d'accord pour dire que leur expérience de la restriction des visites familiales était principalement positive. CONCLUSION: Les règles de restriction de la présence familiale dans les unités de soins intensifs pédiatriques, en grande partie conçues et mises en œuvre sans l'avis du personnel clinique au chevet des patient·es, ont entraîné une augmentation du fardeau psychologique pour le personnel clinique, caractérisée par une détresse morale modérée et un traumatisme déclenché par des répercussions perçues sur les familles.

"I want to be there. I have to be there.": Parents' perceived barriers and facilitators to bedside presence in the pediatric intensive care unit.

Introduction: Parental presence at the bedside during a stressful pediatric intensive care unit (PICU) admission may improve child comfort, reduce parental anxiety, and enable family engagement. We performed this study to identify factors that parents perceive impact their capability, opportunity, and motivation to be at the bedside in PICU. Methods: We conducted a qualitative descriptive study using semi-structured interviews based on the Theoretical Domains Framework (TDF). We included parents of children admitted to the PICU for at least 24 h at IWK Health in Nova Scotia, Canada. Interviews were coded independently by two researchers using a directed content approach based on the TDF. We generated themes and subthemes, with the subthemes identified as factors impacting parental presence, and assigned TDF domains to each of the subthemes. Results: Fourteen primary caregivers (8 mother figures, 6 father figures) participated in 11 interviews. The factors associated with parental presence were captured by 6 themes: Understanding the Medicalized Child; Maintaining the Parent Role; Life Beyond the Hospital; Parental Intrinsic Responses and Coping; Support Structures; and The PICU Environment. Fifty-two barriers and enablers were identified within 13 TDF domains; 10 TDF domains were determined to be relevant to parental presence, which may be used to guide design of future interventions. Participants emphasized the importance of self-care to enable them to remain physically at their child's bedside and to be engaged in their care. Conclusions: Parents perceive multiple factors within 6 themes act as barriers or enablers to presence with their critically ill child in the PICU. Guided by relevant TDF domains, interventions may be designed to optimize presence, particularly engaged presence, which may improve health-related outcomes of children and their parents.

"We Aren't Meant to Go Through the Hardest Parts of Our Lives Alone": Family Experience With Restricted PICU Presence During the COVID-19 Pandemic.

CONTEXT: PICUs across Canada restricted family presence (RFP) in response to the COVID-19 pandemic from allowing two or more family members to often only one family member at the bedside. The objective of this study was to describe the experiences and impact of RFP on families of critically ill children to inform future policy and practice. HYPOTHESIS: RFP policies negatively impacted families of PICU patients and caused moral distress. METHODS AND MODELS: National, cross-sectional, online, self-administered survey. Family members of children admitted to a Canadian PICU between March 2020 and February 2021 were invited to complete the survey. RFP-attributable distress was measured with a modified distress thermometer (0-10). Closed-ended questions were reported with descriptive statistics and multivariable linear regression assessed factors associated with RFP-attributable distress. Open-ended questions were analyzed using inductive content analysis. RESULTS: Of 250 respondents who experienced RFP, 124 (49.6%) were restricted to one family member at the bedside. The median amount of distress that families attributed to RFP policies was 6 (range: 0-10). Families described isolation, removal of supports, and perception of trauma related to RFP. Most families (183, 73.2%) felt that policies were enforced in a way that made them feel valued by PICU clinicians, which was associated with less RFP-attributable distress. Differential impact was seen where families with lower household income indicated higher RFP-attributable distress score (2.35; 95% CI, 0.53-4.17; p = 0.03). Most respondents suggested that future policies should allow at least two family members at the bedside. INTERPRETATIONS AND CONCLUSIONS: Families of children admitted to PICUs during the COVID-19 pandemic described increased distress, trauma, and removal of supports due to RFP policies. Vulnerable families showed an increased odds of higher distress. Healthcare professionals played an important role in mitigating distress. Allowance of at least two family members at the bedside should be considered for future policy.

Outcomes associated with family presence at the bedside of critically ill children in the pediatric intensive care unit: a scoping review protocol.

OBJECTIVE: The objective of this review is to identify the outcomes of family presence at the bedside of critically ill children in pediatric intensive care units (PICUs) that have been reported in the literature. INTRODUCTION: PICU admission is traumatic for critically ill children and their family members, and family presence may alleviate negative outcomes. Family presence may change with family member, patient, health care provider, and institutional circumstances. Prior to designing studies to assess the outcomes of family presence at the bedside, or to conducting a systematic review of the literature, a scoping review is needed to systematically identify and map the outcomes for stakeholders. INCLUSION CRITERIA: This review will include literature addressing outcomes of family presence at the bedside in the PICU on the patient, family members, and health care providers. Emotional, social, psychological, and physiological outcomes will be considered, including outcomes on the provision of PICU care. METHODS: A systematic search will be undertaken across four databases and several sources of gray literature. The review will not be restricted by language, and will be limited to sources published after 1960. The search strategy was designed using text words from titles and abstracts of relevant studies. Title and abstract screening, followed by full text assessment of sources against inclusion criteria, will be completed in duplicate. Data will be extracted by two independent reviewers using a data extraction tool developed by the study team. Data will be presented in tabular format to address findings related to the review objectives.

Total Daily Production and Periodicity of Melatonin Metabolite in Critically Ill Children.

OBJECTIVES: To determine whether total daily 6-sulfatoxymelatonin excretion and diurnal variation of melatonin secretion was maintained during the early phase of PICU admission through examination of the melatonin urinary metabolite, 6-sulfatoxymelatonin. DESIGN: Exploratory prospective, observational study. SETTING: Twelve-bed medical-surgical PICU of a Children's Hospital. PATIENTS: Fifty children 3 months to 18 years old enrolled within 24 hours of PICU admission with access for urinary sampling. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Urine samples were collected at 4-hour intervals for 24 hours and stored at -80C. 6-sulfatoxymelatonin was determined in duplicate by direct enzyme-linked immunosorbent assay. Patients were heterogeneous for diagnosis, had a mean age of 8.1 years (SD = 6.1 yr), and median (interquartile range) Pediatric Risk of Mortality III of 10 (4-13). Mean (SD) total daily 6-sulfatoxymelatonin production was 30.0 µg (25.6 µg) for the first 24 hours, which did not differ significantly from the means on days 2 (p = 0.56) or 3 (p = 0.29), and was similar to literature controls. Mean 6-sulfatoxymelatonin production for the population fit a periodic function well, with a reliable amplitude of 326 ng/hr and peak excretion from 04:00 to 08:00 (F = 4.4, p = 0.01), even when 6-sulfatoxymelatonin was corrected for body weight (F = 3.4, p = 0.03) and when sedation was included in the model (F = 3.95, p = 0.004). There was no significant correlation between lighting and 6-sulfatoxymelatonin excretion at any time period (R values: 0.11-0.25, p = 0.10-0.94). Mean 6-sulfatoxymelatonin excretion did not fit the model for a periodic function well for the subpopulations studied (sepsis [n = 18, F = 1.1, p = 0.32], respiratory failure requiring deep sedation [n = 10, F = 0.4, p = 0.66], and neurologic injury [n = 7, F = 0.6, p = 0.55]). CONCLUSIONS: Total daily and diurnal variation of 6-sulfatoxymelatonin excretion is heterogeneously maintained early in pediatric critical illness. However, this may not hold true for specific diagnostic categories.

Parental Presence at the Bedside of Critically Ill Children in a Unit With Unrestricted Visitation.

OBJECTIVES: To determine the percentage of time that critically ill children have a parent at the bedside and to identify extrinsic factors that are associated with percent of time with parental presence at the bedside. DESIGN: Prospective cohort study. SETTING: PICU in a single tertiary care children's hospital. SUBJECTS: Primary two parents of all children admitted to the PICU on 12 preselected days during a 1-year period from 2014 to 2015. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: A total of 111 observations of 108 unique PICU admissions and families were performed. Children had at least one parent present a mean of 58.2% (SD, 34.6%) of the time. Mothers spent more time at the bedside (56.3% [SD, 31.0%]) than fathers (37.3% [SD, 29.5%]) (p = 0.0001). Percent of time with parental presence at the bedside was positively correlated with age (rs = 0.23; p = 0.02) and negatively associated with Pediatric Risk of Mortality III score (rs = -0.26; p = 0.01). Percent of time with parental presence at the bedside was lower for children who were mechanically ventilated (42.8% [SD, 35.5%]) than not (64.5% [SD, 32.2%]) (p = 0.01) and whose parent(s) were single (45.5% [SD, 27.5%]) or cohabitating/common-law (35.7% [SD, 26.4%]) compared with parents who were married (64.2% [SD, 34.2%]) or separated/divorced (68.3% [SD, 28.8%]) (p = 0.02). Percent of time with parental presence at the bedside was higher for children with chronic illnesses (63.4% [SD, 32.9%] vs 50.1% [SD, 35.8%] without; p = 0.04), when there was a bed in the patient room (61.4% [SD, 34.0%] vs 32.5% [SD, 28.3%] without; p = 0.01), and when parents slept in the patient room (90.3% [SD, 11.2%]) compared with their own home (37.6% [SD, 34.4%]) (p < 0.0001). Percent of time with parental presence at the bedside was not correlated with day of PICU stay, number of siblings, previous PICU admission, isolation status, or nursing ratio. CONCLUSIONS: Children had a parent present at the bedside approximately 60% of the time. The parents of younger, sicker children may benefit from supportive interventions during PICU admission. Further research is needed to examine both extrinsic and intrinsic factors affecting parental presence at the bedside.

Hyperosmolar hyperglycemic state without ketosis in a toddler with type 1 diabetes.

We present a thin toddler whose initial presentation with type 1 diabetes was hyperglycemic hyperosmolar syndrome without diabetic ketoacidosis after ingestion of copious quantities of high-sugar beverages. Increasing consumption of high-sugar beverages may make this presentation of type 1 diabetes mellitus more common. Emergency care physicians must be aware of this potential clinical constellation in the very young, as management differs significantly from that accepted for diabetic ketoacidosis in children.

Identifying significant and relevant events during pediatric transport: a modified Delphi study.

OBJECTIVES: Children must often be transported to dedicated pediatric centers to receive specialized medical and surgical care, which places them at risk for significant deterioration and life-threatening events. Studies designed to identify and mitigate these events have been limited by variability in the selection and definition of significant events. The objective of this study was to identify and evaluate indicators that represent significant events during the transport of pediatric patients and are relevant to future research initiatives in transport medicine. DESIGN: We conducted a modified Delphi study consisting of four iterations. SETTING: The expert panel included Canadian, interdisciplinary healthcare providers with transport experience. INTERVENTIONS: In the first Delphi iteration, experts suggested indicators for consideration and evaluated proposed indicators from the literature and introduced by the study steering committee. In subsequent iterations, respondents reevaluated all indicators that had not yet achieved a priori-defined consensus; group comments and aggregate scores for each indicator from previous iterations were provided. MEASUREMENTS AND MAIN RESULTS: The expert panel consisted of 16 physicians and 17 nonphysician healthcare providers from 10 Canadian institutions. In total, the panel evaluated 57 indicators, including 26 not previously presented in the literature. The expert panel determined 52 were significant and relevant to future studies in pediatric transport. The final indicator list includes trigger tools (interventions, physiological markers, and laboratory values) and team member safety and process issues. CONCLUSIONS: Using a systematic, modified Delphi approach, we developed an inclusive list of indicators for application to pediatric transport-related quality improvement and clinical research projects.

Transient blindness as the primary symptom of acute hyponatremia post surgery.

Hyponatremia is a common electrolyte abnormality among children and adults. Visual disturbance associated with hyponatremia has been described in the past; however, all of these cases presented primarily with other classical signs and symptoms of hyponatremia, such as seizures, gastrointestinal upset, lethargy, or headache. We present a child who developed blindness on post-operative day #6 after resection of a brain tumour. Computed tomography of the head showed no new bleed, mass lesion, edema, or occipital lobe pathology. Laboratory evaluation revealed acute hyponatremia (115 mmol/L). No other obvious symptoms of hyponatremia were present prior to its identification. As her hyponatremia was gradually corrected, her blindness completely resolved. This is the first reported patient with acute hyponatremia to present primarily with blindness; a "precondition" of chronically increased intracranial pressure (first hit) compounded by acute hyponatremia (second hit) may have induced reversible visual loss. Checking electrolytes should be the standard of care for neurosurgical patients with acute visual disturbance or other unexplained symptoms. It is a simple measure that quickly identifies a dangerous but reversible condition.