Caregiving for Interstage Infants: A Continuous Process of Compromise During the Pandemic.

Background: Infants born with single ventricle heart disease require in-home medicalized care during the interstage period (time between the first and second staged heart surgery). These caregivers rely on extended family, friends, and hired caretakers to provide respite time. However, the coronavirus pandemic removed these families' options due to stay-at-home and social distancing directives. We explored the caregivers' experiences during the interstage period, including impacts on their lifestyle, as they managed their infants' critical needs during the coronavirus disease 2019 pandemic. Method: In-person or telephonic interviews of 14 caregivers interviewed once or twice were conducted between November 2019 and July 2020. Constructivist Grounded Theory methodology guided both data collection and analysis for the inductive and abductive exploration of caregivers' experiences. Results: Data analysis led to the development of 2 concepts: Accepting and adapting to a restrictive home environment and Reconciling what is and what is yet to come. Refinement of the relationship between the 2 concepts led to the development of a theory grounded in the words and experiences of the participants called: A Continuous Process of Compromise. Conclusions: Our findings increase understanding of caregivers' experiences related to psychosocial and lifestyle impacts and the need for additional support during the interstage period.

Developing a sense of self-reliance: caregivers of infants with single-ventricle heart disease during the interstage period.

BACKGROUND: Caring for infants after the first-stage palliative surgery for single-ventricle heart disease bring challenges beyond the usual parenting responsibilities. Current studies fail to capture the nuances of caregivers' experiences during the most critical "interstage" period between the first and second surgery. OBJECTIVES: To explore the perceptions of caregivers about their experiences while transitioning to caregiver roles, including the successes and challenges associated with caregiving during the interstage period. METHODS: Constructivist Grounded Theory methodology guided the collection and analysis of data from in person or telephonic interviews with caregivers after their infants underwent the first-stage palliative surgery for single-ventricle heart disease, and were sent to home for 2-4 months before returning for their second surgery. Symbolic interactionism informed data analyses and interpretation. RESULTS: Our sample included 14 parents, who were interviewed 1-2 times between November, 2019 and July, 2020. Most patients were mothers (71%), Latinx (64%), with household incomes <$30K (42%). Data analysis led to the development of a Grounded Theory called Developing a Sense of Self-Reliance with three categories: (1) Owning caregiving responsibilities despite grave fears, (2) Figuring out how "to make it work" in the interstage period, and (3) Gaining a sense of self-reliance. CONCLUSIONS: Parents transitioned to caregiver roles by developing a sense of self-reliance and, in the process, gained self-confidence and decision-making skills. Our study responded to the key research priority from the AHA Scientific Statement to address the knowledge gap in home monitoring for interstage infants through qualitative research design.

Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit.

OBJECTIVE: Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. DESIGN: A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. PATIENTS: Pediatric patients with congenital or acquired cardiac disease. SETTING: Twenty-four-bed cardiothoracic intensive care unit in a tertiary children's hospital. INTERVENTIONS: Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. RESULTS: There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001). CONCLUSION: The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.

Having to Be the One: Mothers Providing Home Care to Infants With Complex Cardiac Needs.

BACKGROUND: Early diagnosis of complex congenital heart disease and advances in surgical interventions have resulted in remarkable improvements in prognoses and hospital survival. Although studies have provided insight into children's experiences with complex congenital heart disease after hospitalization, few have addressed parents' experiences providing care for infants with complex congenital heart disease who are discharged home with complex care needs after surgical palliation. OBJECTIVES: To describe the perceptions and lived experiences of mothers of infants who were discharged from the hospital after surgery for complex congenital heart disease but were then readmitted to the hospital. METHODS: Data collection and analysis for this pilot study were guided by grounded theory. From February through October 2017, interviews were conducted with 10 mothers about their experiences caring for their infants at home after surgery for complex congenital heart disease. RESULTS: Analyses led to development of 1 category, "having to be the one," which had 3 properties: having no choice but to provide complex care at home, handling unexpected roles, and grappling with the possibility of death. CONCLUSIONS: The category of "having to be the one" highlighted mothers' experiences providing medicalized care at home to their infants after complex cardiac surgery while managing other responsibilities, such as employment, busy households, and parenting other school-age children. The role of the caregiver is vital but demanding. Mothers' caregiving at home may be enhanced by nursing interventions such as routine screening for infant distress plus assessment for alterations in family coping or relational challenges that threaten family function.

Cardiac surgical nurses' use of atrial electrograms to improve diagnosis of arrhythmia.

BACKGROUND: The practice standard for electrocardiographic monitoring in hospitals recommends use of atrial electrograms after cardiac surgery to help diagnose cardiac arrhythmias. OBJECTIVES: To determine whether use of atrial electrograms significantly improves nurses' ability to diagnose cardiac arrhythmias and to assess nurses' perceptions of the ease of obtaining and interpreting electrograms, the frequency of use of atrial electrograms, and the correlation between nurses' experience with the technique and arrhythmia scores. METHODS: In total, 282 nurses completed a test consisting of 5 electrocardiographic rhythms for which use of atrial electrograms might improve interpretation. A standardized educational session on obtaining and interpreting atrial electrograms was given to 165 nurses who had not previously received such education. In a second test, the same rhythms were provided along with atrial electrograms to 261 nurses. Overall changes in total test scores and individual changes in interpreting rhythms were analyzed. Demographic information, perceptions of the ease of obtaining and interpreting atrial electrograms, and the frequency of use were collected. Correlation between scores on the second test and nurses' years of experience in interpreting atrial electrograms was determined. RESULTS: Use of atrial electrograms significantly increased overall arrhythmia interpretation scores. Nurses rated obtaining atrial electrograms as easy and interpreting the findings as moderately easy. Despite this reported ease, 57.1% of nurses obtained atrial electrograms less than monthly and only 3.4% obtained them daily. Correlation between experience with atrial electrograms and arrhythmia test scores was not significant. CONCLUSIONS: Nurses' use of atrial electrograms improves diagnoses of cardiac arrhythmias.

Hand hygiene adherence is influenced by the behavior of role models.

OBJECTIVE: Proper hand hygiene (HH) reduces nosocomial infections. Therefore, factors that influence HH behavior of healthcare workers are of great interest. We hypothesized that strict HH adherence by supervisor role models would improve the HH behavior of junior staff. DESIGN: Prospective observational study. SETTING: Pediatric and cardiac intensive care units of a tertiary care children's hospital. SUBJECTS: Two critical care fellows and four nurse orientees. INTERVENTIONS: First, we observed and recorded HH adherence of the fellows and nurse orientees and their respective supervising attending physician or nurse preceptor during daily patient care. Subsequently, we paired the same fellows and nurse orientees with a different supervisor who maintained strict HH adherence, and again noted HH adherence. We used measures of HH opportunities and HH adherence consistent with guidelines set by the Centers for Disease Control and Prevention and Association for Professionals in Infection Control and Epidemiology. MEASUREMENTS AND MAIN RESULTS: HH adherence by fellows and nurse orientees at baseline was 22% of 200 HH opportunities, and improved to 56% of 234 opportunities as a result of role modeling--an average increase of 34% points (95% confidence interval, 18.7-51; p < 0.01 by linear regression), representing a HH adherence rate greater than 1.5 times that of the baseline. The control senior practitioners' HH adherence rate was 20% of 180 opportunities compared with the study senior practitioners' HH adherence of 94% of 187 opportunities--an average difference of 72% points higher compared with the control senior practitioners (95% confidence interval, 56-88.3; p < 0.01 by linear regression). CONCLUSIONS: HH adherence of junior practitioners improved under the supervision of adherent role models. These results suggest that HH behavior of senior practitioners plays a crucial influence on other staff. Senior healthcare practitioners should consider the important role they may play in reinforcing or weakening a culture of patient safety and proper HH.