Pediatric Intensive Care Unit Nurses Research Articles

Beliefs and attitudes of PICU doctors and nurses on parental presence and open visiting policies: an Italian nationwide survey.

The aim of the study is to investigate doctors' and nurses' beliefs and attitudes towards family presence and open visiting policies in Pediatric Intensive Care Units (PICUs) in Italy. A multicentric nationwide study was carried out in all 30 Italian PICUs. All doctors and nurses were asked to complete the Italian version of the Beliefs and Attitudes toward Visitation in ICU Questionnaire (BAVIQ). The questionnaire consists of 20 questions on beliefs and 14 on attitudes towards visiting. The response rate was 89% (925 questionnaires), with 87% of nurses and 94% of doctors responding. Most respondents (85%) believed that visiting has a beneficial effect on the patient and that an open visiting policy can reduce parental anxiety (68%). However, nearly half the respondents believed that an open policy interferes with direct nursing care (45%) and makes them feel checked up on (49%). Multiple logistic regression conducted on the eight most representative items showed that factors associated with beliefs and attitudes opposing open visiting policies were: being a nurse, geographic area (working in PICUs in Central Italy or the South and Islands) and working in a cardiac surgery unit. Age showed a trend of younger professionals being more convinced that an open visiting policy can be beneficial for patients. Most healthcare professionals in Italian PICUs believe that an open visiting policy for families is beneficial for both the patient and his/her family. However, despite an overall positive attitude among PICU staff members, there is still some resistance in Italy, particularly among nurses and in cardiac surgery units.

Early Impressions and Adoption of the AtriAmp for Managing Arrhythmias Following Congenital Heart Surgery.

AtriAmp is a new medical device that displays a continuous real-time atrial electrogram on telemetry using temporary atrial pacing leads. Our objective was to evaluate early adoption of this device into patient care within our pediatric intensive care unit (PICU). This is a qualitative study using inductive analysis of semi-structured interviews to identify dominant themes. The study was conducted in a single-center, tertiary, academic 21-bed mixed PICU. The subjects were PICU multidisciplinary team members (Pediatric Cardiac Intensivists, PICU Nurse Practitioners, PICU nurses and Pediatric Cardiologists) who were early adopters of the AtriAmp (n = 14). Three prominent themes emerged: (1) Accelerated time from arrhythmia event to diagnosis and treatment; (2) Increased confidence in the accuracy of providers' arrhythmia diagnosis; and (3) Improvement in the ability to educate providers about post-operative arrhythmias. Providers also noted some learning curves, but none compromised medical care or clinical workflow. Insights from early adopters of AtriAmp signal the need for simplicity and fidelity in new PICU technologies. Our research suggests that such technologies can be pivotal to the support and growth of multi-disciplinary teams, even among those who do not participate in early implementation. Further research is needed to understand when and why novel technology adoption becomes widespread in high-stakes settings.

Nurses’ Understanding and Practice of Minimal Stimulation in the Pediatric Intensive Care Unit

Background Pediatric patients receiving neurologic and neurosurgical critical care undergo many procedures that result in stimulation of the sympathetic nervous system, which increases their risk of poor outcomes. Nurses typically implement a variety of interventions to minimize such stimulation; however, minimal stimulation has not been specifically defined in the literature or described as a standardized bundle of care. Objective To examine pediatric intensive care unit nurses’ interpretation and practice of minimal stimulation in patients with neurologic and neurosurgical conditions and specifically to triangulate nurses’ descriptions of this practice with related findings in the literature. Methods This was a qualitative, descriptive, exploratory study that used naturalistic inquiry. Results A total of 13 pediatric intensive care unit nurses participated in the study. Three primary themes were identified regarding minimal stimulation: (1) new knowledge and practice, (2) communication, and (3) impact of minimal stimulation. Conclusions The findings of this study help to establish a working definition of the nursing practice of minimal stimulation and provide a basis for future research. More detailed study is needed on the concept of a standardized minimal stimulation bundle and its impact on patient outcomes.

Sustainable improvement in upstream and downstream outcomes for intubated patients three years after an airway-based educational intervention in a low-resource pediatric intensive care unit

ObjectiveTo determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a low-resource country. DesignQuality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3). SettingPICU of the largest public children's hospital in El Salvador. Patients147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)). InterventionA low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes. Measurements and main resultsThe primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2–55.1 % in Epoch 3 (p = 0.003, z-score −2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15–0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48–2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention. ConclusionsSustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.

Sustainability of a Pediatric Neurointensive Care Unit Model Within a Mixed Pediatric Intensive Care Unit and Its Effect on Nursing Sentiment.

BACKGROUND: Pediatric neurocritical care (PNCC) and pediatric neurointensive care units (neuro-PICU) are growing fields. Although some institutions have established independent neuro-PICUs meeting most Neurocritical Care Society (NCS) standards for neurocritical care units, many centers lack the resources to do so. We describe an alternative neuro-PICU model as a designated unit within a mixed pediatric intensive care unit (PICU) and its effects on nursing sentiment. METHODS: We established a 6-bed neuro-PICU within a 36-bed noncardiac PICU. Charge nurses were tasked with admitting PNCC patients into these beds. For nursing expertise, we used a core group of 12 PNCC specialty nurses and instituted PNCC nursing education to PICU nurses. We observed the number of PNCC patients admitted to neuro-PICU beds and surveyed charge nurses to identify barriers to assigning patients. We surveyed PICU nursing staff to explore sentiment regarding PNCC before and after establishing the neuro-PICU. Nursing criteria were compared with NCS standards. RESULTS: In the 40-month period, our PICU saw 2060 PNCC admissions. Overall, occupied neuro-PICU beds housed PNCC patients 74.1% of the time. The biggest barriers to patient placement were too many competing placement requests, not enough neuro-PICU beds when specialty census was high, and difficulty assigning one nurse to two PNCC patients. In surveys after establishing the neuro-PICU, compared to before, experienced nurses reported being more interested in obtaining Emergency Neurological Life Support certification (94.2% vs 80.6%, P = .0495), and inexperienced nurses reported being more familiar with PNCC clinical pathways (53.5% vs 31.7%, P = .0263). Most NCS criteria related to nursing organization were met. CONCLUSIONS: Focused neuro-PICUs should be developed to complement advances in the field of PNCC. Alternative neuro-PICU models are possible and can increase nursing interest in further education and awareness of clinical pathways, but barriers exist that require institutional commitment to nursing development to sustain the delivery of specialized care to this population.

Attitudes, knowledge and practices concerning delirium among paediatric intensive care unit nurses: a multisite cross-sectional study in Sichuan, China.

Delirium is an acute mental state associated with poor outcomes. The incidence of delirium is high, especially in the paediatric intensive care unit (PICU). It is important for staff, particularly nurses, to understand delirium and implement interventions to prevent it. We performed a survey with the aim of evaluating and analysing the factors influencing the knowledge, attitudes and behaviour of PICU nurses towards delirium. This cross-sectional descriptive study included 215 PICU nurses in 6 PICUs from five teaching hospitals in Sichuan Province, China. An online survey about the knowledge, attitudes and practices related to delirium care was conducted among PICU nurses used a self-made and validated questionnaire. The data were analysed using descriptive statistics; differences between groups were compared using t tests, ANOVA and rank-sum tests. Variables with a significance level of 0.05 in the univariate analysis were entered into the multivariable regression analysis to identify predictors. Only 14.4% of the nurses had a good understanding of delirium, and 40.9% had received relevant training. The mean knowledge score was 9.01 ± 3.86, and the overall passing rate of knowledge was 49.8%. The mean attitude and behaviour scores were 40.95 ± 5.62 and 40.33 ± 8.01, respectively. Among the hospitals, different delirium assessments for children and specific training were performed, explaining approximately 10% of the variability in knowledge scores (F = 6.152), approximately 10% of the variability in attitude/belief scores (F = 5.908), and approximately 17% of the variability in practice scores (F = 10.767). PICU nurses have poor knowledge of delirium, particularly regarding its clinical manifestations, influencing factors and medications used, and they have adequate attitudes and confidence and good behaviour regarding delirium in children. To better prevent delirium, we suggest that PICU departments routinely assess delirium and conduct delirium training for nurses. Not applicable.

“At Least I Can Push this Morphine”: PICU Nurses’ Approaches to Suffering Among Dying Children

ContextParents of children who die in the pediatric intensive care unit (PICU) carry memories of their child's suffering throughout a lifelong grieving experience. Given their prolonged time at the bedside, PICU nurses are poised to attend to dying children's suffering. ObjectivesWe aimed to explore how PICU nurses identify, assess, and attend to EOL suffering. MethodsInterpretive descriptive qualitative study with thematic analysis of virtual focus groups from a geographically diverse sample of PICU nurses. ResultsNurses participated in five focus groups (N = 19). Most identified as White (89%) females (95%) with a range of 1-24 years of PICU experience and involvement in >10 EOL care cases (89%). Nurses described approaches to suffering within five themes: 1) Identifying and easing perceptible elements; 2) Recognizing and responding to subtleties moment-to-moment; 3) Acclimating to family interdependence; 4) Synchronizing nurse in-the-room insight with systemic complexity; and 5) Accounting for ambiguity. Nurses detailed elements of suffering they could “fix” with straightforward, external interventions (e.g., pain medication). More complex tasks like optimizing care within familial and interprofessional team relationships while navigating psychosocial responses from children and families challenged nurses. Nurses attempted to minimize EOL suffering amidst ambiguity and complexity using internal processes including managing the environment and titrating moment-to-moment care. ConclusionsWhile physical suffering may be remedied with direct nursing care, holistically attending to EOL suffering in the PICU requires both bolstering external processes and strengthening PICU nurses’ internal resources. Improving psychosocial training and optimizing interprofessional care systems could better support dying children and their families.

Improving Pediatric Critical Care Nurses' Practice in Implementing the Full Outline of Unresponsiveness Coma Scale.

Clinical estimation of consciousness is the most fundamental and crucial component of neurological examinations for pediatric patients in the pediatric intensive care unit (PICU). The full outline of unresponsiveness (FOUR) Coma Scale assesses four variables: eye response, motor response, brainstem reflexes, and respiratory pattern. A score of 0 represents non-function in each category, whereas a score of 4 indicates normal functioning. The FOUR Coma Scale is easy to apply and is currently the most widely used scale for assessing consciousness, particularly in intubated children. This study aimed to improve pediatric critical care nurses' practice in implementing the FOUR Coma Scale. A quasi-experimental research design (pre/post-test design) was employed on a convenience sample composed of 45 male and female nurses who participated in the study and provided direct care for critically ill children at the Medical Pediatric Intensive Care Unit affiliated with the Mansoura University Children's Hospital, Mansoura University, Egypt. All the participants completed the FOUR Coma Scale knowledge and practice assessment questionnaire. Majority of the nurses were females and had bachelors' degrees in nursing (94.6% and 71.1%, respectively). Moray Coma Scale was used to assess level of consciousness (LOC) by more than half the number of nurses (55.6%) in the PICU. All PICU nurses had poor knowledge and practice scores in the pre-intervention phase, and this percentage statistically significantly improved in the post-intervention phase (P = .001). The mean score of nurses' knowledge and practice on the FOUR Coma Scale significantly improved after the implementation of instructional intervention.

A survey of knowledge, attitudes, and practices among paediatric intensive care unit nurses for preventing pressure injuries: An analysis of influencing factors.

To explore the knowledge, attitudes and practice (KAP) status of preventing pressure injury among clinical nurses working in paediatric ICU, and to examine factors affecting nurses' KAP. A questionnaire survey was conducted among 1906 paediatric ICU nurses in 18 children's hospitals by convenience sampling method. The survey tools were self-designed general data questionnaire, KAP questionnaire for the prevention of pressure injury and the influencing factors were analysed. A total of 1906 valid questionnaires were collected. The scores of overall KPA, knowledge, attitudes, and practice were 101.24 ± 17.22, 20.62 ± 9.63, 54.93 ± 5.81and 25.67 ± 6.76, respectively. The results of multiple linear regression analysis showed that education background, professional title, age and specialist nurse were the main influencing factor of nurses' knowledge of preventing PI; education background and specialist nurse were the main influencing factors of nurses' attitudes of preventing PI; knowledge, attitudes and education background were the main influencing factors of nurses' practice of preventing PI. Paediatric ICU nurses have a positive attitude towards the prevention of PI, but their knowledge and practice need to be improved. According to different characteristics of nurses, nursing managers should carry out training on the knowledge of prevention of PI to establish a positive attitude, so as to drive the change of nursing practice and improve the nursing practice level of ICU nurses to prevent of PI.

Attitudes toward Thanatophobia: comparative analysis between pediatric intensive care units (PICUs) nurses, nurse interns and student nurses

Background: Thanatophobia refers to the anxiety related to fear of death. Nurses who care for critically ill children and their families may encounter death and dying recurrently, which can be emotionally challenging and distressing. Thanatophobia reported to significantly influence the emotional well-being and quality of life of healthcare professionals, especially those working in PICUs. Methods: A comparative study aimed to investigate and compare the attitudes toward death and dying patients among 176 participants included pediatric intensive care units (PICUs) nurses, nurse interns, and student nurses and to explore the relationship between various factors such as work experience, palliative care training, and personal experience with dying patients utilizing a quantitative descriptive correlation cross sectional research design and convenience sampling technique. Data was collected using a two part online self-reported questionnaire survey with the first section included sociodemographic data and second section was the thanatophobia scale by Merrill, Lorimor, Thornby and Woods (1998). Data was analyzed using the Statistical Software (JMP).

Evaluating the knowledge and attitudes towards radiation protection in portable radiological examinations among nurses in pediatric intensive care units

This study aims to assess the knowledge and attitudes towards radiation protection among nurses in pediatric intensive care units (PICUs), where portable radiological examinations are frequently conducted. In this study, we employed a descriptive cross-sectional research design using a 17-item self-administered questionnaire. The study comprised 160 nurses, mostly female (91%), with an even split in educational background between diploma and bachelor’s degree holders. The majority had 1–5 years (39%) and 6–10 years (33%) of experience, while only a small fraction (6.2%) had undergone training in radiation protection. The overall scores of knowledge and attitudes were 2.9 ± 1.4 out of 7 and 3.1 ± 0.9 out of 4, respectively. A statistically significant variation in knowledge scores was noted between those with a Bachelor’s degree (3.2 ± 1.4) and a Diploma (2.7 ± 1.3) (p = 0.044). A positive correlation between knowledge and attitude scores was statistically validated (Spearman’s rho = 0.19, p = 0.014), and training in radiation protection was identified as a significant factor affecting these scores (estimate = –1.38, p = 0.025). The study reveals a poor level of knowledge and a good attitude towards radiation protection among PICU nurses in the Jizan Region. This emphasizes the need for targeted educational interventions and training programs in radiation safety to enhance the quality of care in pediatric radiological procedures.

The 2022-2023 Pediatric Respiratory Illness Surge: Survey of Acute and Critical Care Resource Use.

A surge of pediatric respiratory illnesses beset the United States in late 2022 and early 2023. This study evaluated within-surge hospital acute and critical care resource availability and utilization. The study aimed to determine pediatric hospital acute and critical care resource use during a respiratory illness surge. Between January and February 2023, an online survey was sent to the sections of hospital medicine and critical care of the American Academy of Pediatrics, community discussion forums of the Children's Hospital Association, and PedSCCM-a pediatric critical care website. Data were summarized with median values and interquartile range. Across 35 hospitals with pediatric intensive care units (PICU), increase in critical care resource use was significant. In the month preceding the survey, 26 (74%) hospitals diverted patients away from their emergency department (ED) to other hospitals, with 46% diverting 1-5 patients, 23% diverting 6-10 patients, and 31% diverting more than 10 patients. One in 5 hospitals reported moving patients on mechanical ventilation from the PICU to other settings, including the ED (n = 2), intermediate care unit (n = 2), cardiac ICU (n = 1), ward converted to an ICU (n = 1), and a ward (n = 1). Utilization of human critical care resources was high, with PICU faculty, nurses, and respiratory therapists working at 100% capacity. The respiratory illness surge triggered significant hospital resource use and diversion of patients away from hospitals. Pediatric public health emergency-preparedness should innovate around resource capacity.

Pain assessment & management decision-making in pediatric critical care

PurposeThe aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed. Design and methodsA qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes. ResultsThree major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made. ConclusionsVariation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. “Assume pain present” was identified as a concept and documentation practice that may guide decisions; further research is needed. Practice implicationsDevelopment of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation.

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice. To describe how PICU nurses are assessing and managing pain for children who require NMB. A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither. A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent. These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Overcoming patient safety concerns and integrating early mobility into pediatric intensive care unit nursing practice

PurposeEarly Mobilization (EM) in Pediatric Intensive Care Units (PICU) is safe, feasible and improves outcomes for PICU patients, yet patient safety concerns persist among nurses which limits EM adoption. The purpose of this study was to explore how nurses incorporate EM into practice and balance their concerns for patient safety with the benefits of EM. Design & methodsThis focused ethnographic study included 15 in-depth interviews with 10 PICU nurses. Data were analyzed using thematic analysis. ResultsTwo major categories were found which describe the clinical judgement and decision-making of PICU nurses regarding EM. The nurses' concerns for patient safety was the first major category. This included patient-level factors: hemodynamic stability, devices attached, patient's strength, and risk for falls and size. In the second major category, these safety concerns were overcome by applying a multiple step process which resulted in nurses performing EM despite their concerns. That process included: gaining comfort through experience, performing patient safety checks, working with therapists, learning from adverse events, and understanding existing evidence about the benefits of EM. ConclusionsThe overarching theme was nurses' determination to preserve patient safety while ensuring patients could receive the benefits of EM. This theme describes the decisions, behaviors and processes that nurses enact to become more comfortable with EM despite their concerns for patient safety and potential adverse events while performing mobility activities. Practice implicationsCreating opportunities for nurses to participate in EM may increase their willingness to overcome safety concerns and engage in these activities.

Transferring critical pediatric patients from emergency department to intensive care: A quality improvement initiative

BackgroundTransfer of care, moving hospitalized patients between care areas, is a critical point of vulnerability for healthcare organizations. Patient information handoff is an essential activity occurring frequently in hospital environments. Poor communication has been linked with adverse events and poor patient outcomes. This evidence-based quality project aimed to enhance the handoff process between the Emergency Department (ED) and Pediatric Intensive Care Unit (PICU) by standardizing transfer of care steps. This was accomplished through customizing a reporting tool to contain all the information the receiving department deemed necessary for safe patient care. MethodsA customized situation, background, assessment, recommendation (SBAR) form handoff tool was developed for ED to PICU transfers. This SBAR tool included information that PICU nurses identified as critical to transfer of care. Nurse perceptions were surveyed pre- and post-implementation. Patient safety event reports were tracked to evaluate events related to transfer of care before and after the practice change. FindingsAn increased number of PICU nurses agreed the customized handoff tool was complete and organized. Additionally, more nurses agreed that handoff gave all information needed to safely care for critically ill patients transferred from the ED. Lastly, bedside patient checks increased, and patient safety events related to transfer of care decreased. DiscussionThis project demonstrated that implementation of a standardized transfer of care process coupled with a customized handoff tool increased PICU nurse perceptions that handoff was organized, and all information needed to safely care for critically ill patients was conveyed. Application to practiceTransfer of care processes between the ED and PICU should be standardized. The use of customized tools may improve information exchange between nurses and ensure that all vital patient information is communicated.

Competency Assessment of Pediatric Intensive Care Nurses

One of the biggest challenges that clinical nurse educators at the unit level face today is measuring the ongoing competency of nursing staff members to ensure provision of high-quality, evidence-based care. Pediatric nursing leaders at an urban, level I trauma teaching institution in the southwestern United States used a shared governance approach to create a standardized competency assessment tool for pediatric intensive care unit nurses. Donna Wright’s competency assessment model was used as a framework to guide the tool’s development. The adoption of the standardized competency assessment tool was aligned with the organization’s institutional goals and enabled clinical nurse educators to comprehensively evaluate staff members on a regular basis. This standardized competency assessment system for pediatric intensive care nurses is more effective than use of a practice-based, task-oriented assessment method and has improved nursing leaders’ ability to staff the pediatric intensive care unit safely.

Effects of a Multifaceted Pediatric Delirium Education Program for Pediatric Intensive Care Unit Nurses on their Delirium Knowledge, Self-confidence in Delirium Nursing, and Delirium Assessment Accuracy: A One Group Pretest-Posttest Design

Purpose : This study aimed to identify the effects of a multifaceted pediatric delirium education program for pediatric intensive care unit (PICU) nurses on their delirium knowledge, confidence in delirium nursing, and delirium evaluation accuracy.Methods : This study used a one-group pretest-posttest design. The participants were 50 nurses in two units of the PICU at S General Hospital in Seoul. All participants took a 1-hour lecture with case-based practice for the first two weeks, and received feedback as they applied the program to clinical practice over the next two weeks. Test measures were completed before and after the four week intervention period for all participants. The delirium evaluation accuracy was measured using the Korean version of the Cornell Assessment of Pediatric Delirium. Data were analyzed using the chi-square and paired t-tests.Results : After the Pediatric Delirium Education Program, nurses’ delirium knowledge (&lt;i&gt;x&lt;/i&gt;&lt;sup&gt;2&lt;/sup&gt; =11.65, &lt;i&gt;p&lt;/i&gt; =.001), confidence in delirium nursing (t=9.71, &lt;i&gt;p&lt;/i&gt;＜.001), and delirium evaluation accuracy (t=6.07, &lt;i&gt;p&lt;/i&gt;＜.001) improved significantly.Conclusions : Pediatric delirium education programs for PICU nurses were effective. For active application of the program in clinical practice in the future, various cases of childhood delirium and specific strategies for each subject must be developed. To achieve this, long-term intervention and research for multiple organizations are required.

Outgrowing the Pediatric Intensive Care Unit: Adults With a Pediatric Medically Complex Condition.

With more than 20 years of experience as pediatric and adult critical care nurses, we have observed an increase in the number of medically complex children who are living into adulthood and a troubling lack of adult intensive care unit (ICU) systems and processes for these patients.Medical advances have resulted in a significant decline in the mortality rate in the pediatric ICU (PICU), from 15% in 1980 to 4% in 2006. However, an unintended consequence is that more children experience significant morbidity. In fact, more than 50% of all PICU admissions are children with medical complexity.1,2 Families caring for a child who is chronically critically ill have special care requirements. Nurses in the PICU have extensive experience with pediatric-onset conditions such as congenital heart defects, sickle cell disease, neurodegenerative diseases, chromosomal abnormalities, and muscular dystrophies. They are also familiar with growth and development and have expertise in providing developmentally appropriate care. In addition, PICU nurses are trained in the principles of family- and patient-centered care, which include communicating and collaborating with family caregivers about the processes of care to a much greater extent than usually done in an adult ICU. Certified child life specialists are also available in the PICU to provide specific tools to assist in meeting the needs of the family, including siblings. When medically complex children become adults, many of them transition to adult ICUs that may not be ready for them. As a result, approximately 2% of PICU admissions (range 0%-9%) are adults who have had complex medical needs as children.3,4 However, as the number of medically complex children reaching adulthood continues to grow, the “PICU for adults” model is not sustainable.At this time, many adult ICUs are not prepared for patients with pediatric conditions. Creating an environment in which adult and pediatric health care professionals work collaboratively is essential to providing quality care to these patients and families. Systems need to be developed and expanded to provide complex care in the adult ICU. A proactive, interdisciplinary approach including specialized training for the adult ICU team is needed to sustain a high level of quality care and to support the transition to adult care. Staff in the PICU can help to prepare families for the transition as well as provide education and support to the adult ICU team. Issues to consider include differences in anatomy and physiology of pediatric patients, the unique developmental needs of this population, expansion of specialized services (ie, child life specialists), dedicated sleep areas for parents, and involving parents in decisions and patient care.

Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention.

To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. Mixed-methods study. Tertiary-care pediatric intensive care unit (PICU). Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.