Does Postanesthesia Forced-Air Warming Affect Emergence Delirium in Pediatric Patients Receiving Daily Anesthesia?

PURPOSE: To determine if postanesthesia forced-air warming as a nonpharmacologic intervention for emergence delirium (ED)/emergence agitation (EA) decreased the incidence and severity of ED in children aged 18 months to 6 years old. DESIGN: Prospective nonrandomized controlled trial. METHODS: Participants included children aged 18 months to 6 years old receiving general anesthesia within a radiation oncology setting. Status of ED/EA was based on the participants' Pediatric Anesthesia Emergence Delirium (PAED) scale score (two consecutive scores greater than 10 out of 20) or inconsolable agitation behaviors post computed tomography simulation (day 0). Interrater reliability was conducted among the center's perianesthesia care nurses. Participants who scored positive for ED/EA received a forced-air warming blanket for the remainder of treatment with data collection 1 to 14 days postanesthesia. Non-ED/EA participants were followed for 14 days and provided forced-air warming if ED/EA occurred. Data consisted of daily PAED scores and self- or parent-report on the anxiety scale. If the participants received forced-air warming, nurses' clinical observations and parent satisfaction surveys were collected 3 times during the 14-day study period. FINDINGS: A total of 59 participants completed the study (mean age 3.43 years; 60% male; 63% non-Hispanic White); 16 were identified with ED or EA (mean age 3.56 years; 50% male; 69% non-Hispanic White) with an incidence rate of 28%. For the 16 participants with ED/EA, the primary diagnosis consisted of solid tumors and an American Society of Anesthesia Classification III to IV. Prior to the forced-air warming intervention, all 16 participants exhibited inconsolable ED/EA behaviors, including 8 who had PAED scores greater than 10. ED/EA behaviors expressed included inconsolability, confusion, thrashing, and combativeness. Within the 14-day period, 3 participants received forced-air warming on day 1, while the other 13 received an average of 4.23 days of treatment (range 1 to 11 days; mode 1 day; median 4 days). Comparison of PAED scores pre (mean 4.4) and post (mean 1.8) indicated that the use of forced-air warming was statistically significant (P = .001). ED/EA behaviors and PAED scores after the forced-air warming period decreased in all but one participant. Some agitation behaviors were not captured within the PAED score. CONCLUSIONS: Forced-air warming impacted PAED scores and agitation behaviors for studied participants, offering a safe, nonpharmacological nursing intervention that may be an effective tool for helping to manage this baffling condition.

Arcus Experience: Bridging the Data Science Gap for Nurse Researchers.

BACKGROUND: For years, nurse researchers have been called upon to engage with "big data" in the electronic health record (EHR) by leading studies focusing on nurse-centric patient outcomes and providing clinical analysis of potential outcome indicators. However, the current gap in nurses' data science education and training pose a significant barrier. OBJECTIVES: We aimed to evaluate the viability of conducting nurse-led, big-data research projects within a custom-designed computational lab and examine the support required by a team of researchers with little to no big-data experience. METHODS: Four nurse-led research teams developed a research question reliant on existing EHR data. Each team was given its own virtual computational lab populated with raw data. A data science education team provided instruction in coding languages-primarily structured query language and R-and data science techniques to organize and analyze the data. RESULTS: Three research teams have completed studies, resulting in one manuscript currently undergoing peer-review and two manuscripts in progress. The final team is performing data analysis. Four barriers and four facilitators to big-data projects were identified. DISCUSSION: As the data-science learning curve is steep, organizations need to help bridge the gap between what is currently taught in doctoral nursing programs and what is required of clinical nurse researchers to successfully engage in big-data methods. Additionally, clinical nurse researchers require protected research time and a data science infrastructure that supports novice efforts with education, mentorship, and computational lab resources.

Experiences of U.S. Nurses Compared With Nonnurses in the First Year of COVID-19: Findings From a National Registry.

BACKGROUND: Nursing professional organizations and media sources indicated early in the pandemic that the physical and psychological effects of COVID-19 might be distinct and possibly greater in nurses than in other types of healthcare workers (HCWs). OBJECTIVES: Based on survey data collected in Healthcare Worker Exposure Response and Outcomes (HERO), a national registry of U.S. HCWs, this study compared the self-reported experiences of nurses with other HCWs during the first 13 months of the pandemic. METHODS: Nurse responses were compared to responses of nonnurse HCWs in terms of viral exposure, testing and infection, access to personal protective equipment (PPE), burnout, and well-being. Logistic regression models were used to examine associations between nurse and nonnurse roles for the binary end points of viral testing and test positivity for COVID-19. We also examined differences by race/ethnicity and high-risk versus low-risk practice settings. RESULTS: Of 24,343 HCWs in the registry, one third self-identified as nurses. Nurses were more likely than other HCWs to report exposure to SARS-CoV-2, problems accessing PPE, and decreased personal well-being, including burnout, feeling tired, stress, trouble sleeping, and worry. In adjusted models, nurses were more likely than nonnurse HCWs to report viral testing and test positivity for COVID-19 infection. Nurses in high-risk settings were more likely to report viral exposure and symptoms related to well-being; nurses in low-risk settings were more likely to report viral testing and test positivity. Black or Hispanic nurses were most likely to report test positivity. DISCUSSION: Differences were identified between nurses and nonnurse HCWs in access to PPE, physical and mental well-being measures, and likelihood of reporting exposure and infection. Among nurses, testing and infection differed based on race and ethnicity, and type of work setting. Our findings suggest further research and policy are needed to elucidate and address social and occupational disparities.

Design of the Healthcare Worker Exposure Response and Outcomes (HERO) research platform.

BACKGROUND: The SARS CoV-2 virus has caused one of the deadliest pandemics in recent history, resulting in over 170 million deaths and global economic disruption. There remains an urgent need for clinical trials to test therapies for treatment and prevention. DESIGN: An online research platform was created to support a registry community of healthcare workers (HCWs) to understand their experiences and conduct clinical studies to address their concerns. The first study, HERO-HCQ, was a double-blind, multicenter, randomized, pragmatic trial to evaluate the superiority of hydroxychloroquine (HCQ) vs placebo for pre-exposure prophylaxis (PrEP) of COVID-19 clinical infection in HCWs. Secondary objectives were to assess the efficacy of HCQ in preventing viral shedding of COVID-19 among HCWs and to assess the safety and tolerability of HCQ. METHODS: HCWs joined the Registry and were pre-screened for trial interest and eligibility. Trial participants were randomized 1:1 to receive HCQ or placebo. On-site baseline assessment included a COVID-19 nasopharyngeal PCR and blood serology test. Weekly follow-up was done via an online portal and included screening for symptoms of COVID-19, self-reported testing, adverse events, and quality of life assessments. The on-site visit was repeated at Day 30. DISCUSSION: The HERO research platform offers an approach to rapidly engage, screen, invite and enroll into clinical studies using a novel participant-facing online portal interface and remote data collection, enabling limited onsite procedures for conduct of a pragmatic clinical trial. This platform may be an example for future clinical trials of common conditions to enable more rapid evidence generation.

Advancing Opportunities for Clinical Inquiry and Professional Development During a Pandemic.

A notable challenge faced by pediatric hospitals during the COVID-19 pandemic included the need to decrease inpatient census and socially distant non-clinical hospital employees to alternative work arrangements. In doing so, nurses and other clinical care services employees were reassigned to new roles, while others continue to work from home. This paper aims to describe how during the COVID-19 pandemic, a pediatric hospital-based center for nursing research and evidence-based practice used this opportunity to virtually engage staff across the department in topics of clinical inquiry through education sessions, office hours, and individualized/team consultation. Therefore, elevating and increasing the presence of nursing research and evidence-based practice while providing opportunities for the continued professional development of nurses, respiratory therapists, clinical dietitians, child life specialists and employees in neurodiagnostics.

An Educational Intervention to Improve Staff Collaboration and Enhance Knowledge of Fall Risk Factors and Prevention Guidelines.

BACKGROUND: Magnet®-designated hospitals are seeking to reduce the frequency of falls that lead to injury, which is considered a hospital-acquired condition. Patients with cancer are at high risk to fall, due to multiple factors. Synthesis of the literature supports team efforts and shared learning sessions for patient-care staff as part of the fall prevention process. The purpose was to improve collaboration between Registered Nurses (RNs) and Senior Nurse Aides (SNAs), as well as to enhance their knowledge of fall risk factors and evidence-based prevention guidelines for pediatric oncology patients. METHODS: An evidence-based practice project was implemented using a quality improvement pilot based on the Magnet® framework. Oncology RNs and SNAs at a large pediatric hospital were invited to attend one of five educational sessions. Pre-and post-session learning was assessed based on an adapted fall risk knowledge assessment tool. FINDINGS: Thirty participants attended an educational session with 27 (25 RNs and 2 SNAs) matched pre- and post-session assessments. Median post-session assessment scores were statistically significantly higher than pre-session scores (Z =  -3.11, p = 0.001). Overall knowledge scores increased for 63% of participants. DISCUSSION: An educational intervention focused on pediatric oncology nursing enhanced knowledge of patient-care roles and fall prevention efforts, leading to improved fall outcomes. APPLICATION TO PRACTICE: Ensuring that RNs and SNAs fully embrace their shared role in harm prevention is vital when considering the complexity of delivering nursing care in our current healthcare environment.

The Experience of Pain and Pain Tool Preferences of Hospitalized Youth.

BACKGROUND: An accurate holistic pediatric pain assessment is necessary for quality pain management. Evidence continues to be published indicating inadequacies in pediatric pain management. It is important for clinicians to consider the pain assessment process while caring for youth. AIM: The purpose of this study was to understand the pain experience through focused interviews and to explore how youth use, interpret and understand self-report pain assessment tools including their tool preferences. DESIGN: A qualitative descriptive study using a research developed semi-structured interview guide was conducted with 40 hospitalized youth, 10-17 years (M: 13yr; S.D. 2.4); 21 (52.5%) female on a medical inpatient unit. Interview questions focused on: current pain experience; pain related symptoms; evaluation of pain treatment and preferences for select pain assessment tools: 0-10 Numeric Rating Scale, The Oucher, Faces Pain Scale-Revised, and Adolescent Pediatric Pain Tool (APPT). SETTING: Large tertiary and quaternary care pediatric hospital located in northeastern United States. PARTICIPANTS/SUBJECTS: Hospitalized youth, 10-17 years of age. RESULTS: Analysis of transcribed interviews yielded 3 themes: My Pain Now, Pain Treatment Expectations, and Telling Healthcare Providers about My Pain. Additionally, pain tools preference, assessment frequency, and discussion of how behavior, activity level, and pain expression was different for each youth. APPT was the preferred pain assessment tool. Descriptive words such as sharp, throbbing, and aching were identified most often. Youth identified that activity and pain level often do not match. CONCLUSIONS: Because pain is multi-dimensional, assessing each dimension (quality, location, intensity, and meaning) is key to thorough assessment. Results provide insight into youth preferences influencing clinical practice such as offering options for interventions and having a voice in the pain management process. All nurses caring for children should discuss available pain tools preferably before the child is in pain and assure the child knows how to use the tool.

Safety of a 1-Day Polyethylene Glycol 3350 Bowel Preparation for Colonoscopy in Children.

OBJECTIVES: Electrolyte-free polyethylene glycol powder (PEG-3350) has been widely used for colonoscopy preparation (prep); however, limited safety data on electrolyte changes exists with 1-day prep regimens. The primary aim of this study was to determine the proportion of patients with significant serum chemistry abnormalities before and at the time of colonoscopy. Secondary aims included evaluation of prep tolerance and bowel cleansing efficacy. METHODS: We performed a prospective descriptive observational study of pediatric patients scheduled for outpatient colonoscopy who received our standard 1-day, weight-based 4 g/kg PEG-3350 prep with a single stimulant laxative dose and had serum chemistry testing within 60 days before and at the time of colonoscopy. A standardized bowel cleanliness tool (Aronchick scale) was completed by the endoscopist. RESULTS: One hundred fifty-five patients had serum electrolytes data pre- and postprep. Comparison of each patient's chemistries demonstrated statistical equivalence with the 1 exception of blood urea nitrogen levels (P = 0.56). Hypokalemia was detected postprep in 37 subjects (24%), but none had a serum level <3.3 mmol/L, which was deemed to be of no clinical significance. Five patients were hypoglycemic post prep; 3 were 7 years or younger (P = 0.02). The colon cleanliness rating was excellent or good in 77% and suboptimal in 23% of patients. CONCLUSIONS: A 1-day, weight-based PEG-3350 bowel prep in children appears safe. Changes in electrolyte levels and renal function were not clinically significant. Children of 7 years or younger seem to be at a higher risk of hypoglycemia compared with older children.

Pain Assessment of Children with Autism Spectrum Disorders.

OBJECTIVE: Pain assessment of individuals with autism spectrum disorder (ASD) is largely unexplored. The core deficits of ASD may interfere with this population's ability to effectively use traditional pain assessment tools. Accurate pain assessment is essential to providing quality care. The objective was to illuminate barriers to pain assessment in children with an ASD, describe novel methods to communicate about their pain experience, and identify vocabularies that hold meaning with respect to pain to better understand pain from their context. METHODS: Qualitative descriptive study using semistructured interviews including interactive electronic technology to enhance communication. Subjects included children aged 6 to 17 years with ASD experiencing acute pain after a surgical procedure at a large urban tertiary children's hospital. RESULTS: Based on the analysis of 40 interviews, participants consisted of 34 (85%) male, 29 (72.5%) non-Hispanic white with mean age 11.75 ± 3.36 years (range: 6-17). All subjects were able to describe and locate their pain but required a variety of approaches. Assessment preferences included minimal time spent focusing on pain and simplistic language and actions using terms familiar to each subject. Notably, subjects were able to reliably demonstrate understanding of graded response and seriation. Parent involvement was essential, both in helping interpret the child's needs and providing trusted support. CONCLUSIONS: Some children with ASD require an alternate interactive approach to pain assessment. Individualized consideration and estimation of pain assessment methods for use in this population may provide more meaningful interactions, ultimately guiding better pain management interventions.

Polyethylene glycol powder solution versus senna for bowel preparation for colonoscopy in children.

OBJECTIVES: Safety and effectiveness of large-volume polyethylene glycol-based solution (PEG-ES) have been documented, but the taste and volume can be barriers to successful colonoscopy preparation. Efficacy and safety of small-volume electrolyte-free (PEG-P) preparation (Miralax) for colonoscopy preparation have been rarely studied, although presently used at many pediatric centers. The primary objective of the present study was to determine whether PEG-P results in a more efficacious and safe colonoscopy preparation as compared with senna. METHODS: The study design was prospective, randomized, and single-blinded. Patients ages 6 to 21 years were randomized to a 2-day clean-out regimen of PEG-P at a dose of 1.5 g/kg divided twice per day for 2 days versus senna 15 mL daily (ages 6-12) or 30 mL daily (ages 12-21) for 2 days. Both preparations required 1 day of clear liquids whereas senna preparation required an additional day of full liquid diet. A blinded endoscopist graded the quality of preparation with a standardized cleanliness tool (Aronchick scale). Serum chemistry panels were obtained. Patients or parents rated symptoms and ease of preparation. The anticipated number of subjects was 166; however, the interim analysis demonstrated inferiority of senna preparation. RESULTS: Thirty patients were evaluated in the present study. Of the patients in the PEG-P arm, 88% (14/16) received an excellent/good score compared with 29% (4/14), with the senna preparation (P = 0.0022). Both preparations were well-tolerated by patient-graded ease of preparation. Demographics and laboratory values did not differ significantly across the 2 groups. No serious adverse events were noted. CONCLUSIONS: PEG-P is an effective colonoscopy preparation whereas senna preparation was insufficient. Both were well-tolerated and appear safe in a pediatric population.

Finding the evidence to change practice for assessing pain in children who are cognitively impaired.

We report on a quality improvement project whose purpose was to systematically review behavioral pain assessment tools for children who are cognitively impaired, with the goal of identifying a valid and reliable tool for clinical practice. In addition, we sought to partner with parents and/or caregivers to expand their role in pain assessment. The project team conducted an extensive synthesis of the literature to examine the availability and quality of published pain assessment tools for use with children with cognitive impairment (CI) or developmental disability. Once completed, we identified 2 of the available 10 tools to test in the clinical setting. Data from this quality improvement project provided evidence to support the adoption of the revised Faces, Legs, Activity, Cry, and Consolability pain assessment tool for children with CI into clinical practice.

Optimizing the assessment of pain in children who are cognitively impaired through the quality improvement process.

Pain assessment in children with cognitive impairment (CI) is challenging. A quality improvement (QI) project involving evidence-based review of pain assessment tools, feedback from the Family Advisory Council, trialing of selected tools within clinical settings including obtaining feedback from nurses, and parents caring for nonverbal children with developmental delay was reported. Synthesized evidence supported the adoption of revised Faces, Legs, Activity, Cry, and Consolability pain assessment tool into clinical practice. Results of postimplementation audit and challenges of staff nurse involvement in the QI process were also discussed. The 24-month-long QI process and its impact on changing practice were described in detail.