Early Rehabilitation in Critically ill Children: A Two Center Implementation Study.

OBJECTIVES: To implement an early rehabilitation bundle in two Canadian PICUs. DESIGN AND SETTING: Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2). PATIENTS: All children under 18 years old admitted to the PICU were eligible for the intervention. INTERVENTIONS: A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement. CONCLUSIONS: A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project.

OBJECTIVES: To develop and implement a tool to improve daily patient goal setting, team collaboration and communication. DESIGN: Quality improvement implementation project. SETTING: Tertiary-level PICU. PATIENTS: Inpatient children less than 18 years old requiring ICU level care. INTERVENTION: A "Glass Door" daily goals communication tool located in the door front of each patient room. MEASUREMENTS AND MAIN RESULTS: We used Pronovost's 4 E's model to implement the Glass Door. Primary outcomes were uptake of goal setting, healthcare team discussion rate around goals, rounding efficiency, acceptability and sustainability of the Glass Door. The total implementation duration from engagement to evaluation of sustainability was 24 months. Goal setting increased significantly from 22.9% to 90.7% ( p < 0.01) patient-days using the Glass Door compared to a paper-based daily goals checklist (DGC). One-year post implementation, the uptake was sustained at 93.1% ( p = 0.04). Rounding time decreased from a median of 11.7 minutes (95% CI, 10.9-12.4 min) to 7.5 minutes (95% CI, 6.9-7.9 min) per patient post-implementation ( p < 0.01). Goal discussions on ward rounds increased overall from 40.1% to 58.5% ( p < 0.01). Ninety-one percent of team members perceive that the Glass Door improves communication for patient care, and 80% preferred the Glass Door to the DGC for communicating patient goals with other team members. Sixty-six percent of family members found the Glass Door helpful in understanding the daily plan and 83% found it helpful in ensuring thorough discussion among the PICU team. CONCLUSIONS: The Glass Door is a highly visible tool that can improve patient goal setting and collaborative team discussion with good uptake and acceptability among healthcare team members and patient families.

An Unusual Vascular Track for Neonatal Peripherally Inserted Central Catheter: A Case Report.

Peripherally inserted central catheterization is a common procedure in neonatal intensive care units. However, in preterm low birthweight newborns, achieving good vascular access can be a challenge. We describe our experience in achieving peripherally inserted central catheterization in a preterm baby through an unusual vascular tract. The line inserted through one of the superficial abdominal veins traversed the epigastric vein, the internal thoracic vein, the superior vena cava, and successfully reached the cavoatrial junction. The line was confirmed radiologically and used safely and effectively for almost 20 days.

Outcome of Late-onset Neonatal Sepsis at a Tertiary Hospital in Oman.

OBJECTIVES: We sought to determine the prevalence, pattern of causative organisms, and mortality of newborns with culture-proven late-onset sepsis (LOS) and to determine and compare the risk factors linked to late-onset gram-positive and late-onset gram-negative sepsis in Sultan Qaboos University Hospital (SQUH). METHODS: We conducted a cross-sectional retrospective study of data obtained between 1 January 2007 and 31 December 2014 (eight years) from infants in the neonatal intensive care unit (NICU) at SQUH. Infants born in SQUH (inborn) and other institutions (outborn) with positive blood cultures were included in the study. RESULTS: The total number of live births and admissions during the study period were 26 289 and 3559, respectively. The total number of infants identified with LOS were 125 of whom 69 (55.2%) were gram-positive, 52 (41.6%) were gram-negative, and four (3.2%) were due to Candida species (spp.). The majority of infants (n = 113, 90.4%) were inborn; 69 (55.2%) were males and 56 (44.8%) were females. The prevalence of LOS among inborn admissions was 4.3 per 1000 live births. Most infections occurred in very low birth weight infants (n = 81, 64.8%). Eleven (8.8%) infants died due to gram-negative sepsis. Klebsiella pneumoniae followed by Pseudomonas aeruginosa were the leading cause of death. Maternal intrapartum antibiotics were the only independent risk factor correlating with gram-negative organisms in multivariate analysis (p = 0.003). CONCLUSIONS: LOS poses a burden in the NICU, which could be due to the increasing survival of premature babies. The main contributing organisms to LOS are gram-positive bacteria. Klebsiella spp. is a major cause of mortality in LOS. The use of intrapartum antibiotic prophylaxis in mothers might explain the positive correlation of maternal antibiotics as a risk factor with gram-negative infections.