Pediatric Delirium: Early Identification of Barriers to Optimize Success of Screening and Prevention

Nurses' Experiences of the Prerequisites for Implementing Family-Centered Care to Prevent Pediatric Delirium

PURPOSE

The aim of this study was to describe nurses' experiences of the prerequisites for implementing family-centered care to prevent pediatric delirium.

DESIGN

The research employed a qualitative, descriptive study design.

METHODS

A total of 10 nurses working in the pediatric intensive care unit at 1 university hospital participated in the study. The quality data were collected using individual semistructured interviews, and the data were then analyzed by inductive content analysis.

RESULTS

The prerequisites for implementing family-centered care to prevent delirium among pediatric patients consisted of 30 subcategories that were grouped into 11 generic categories. The generic categories were further grouped into 5 main categories: (1) an environment that supports family presence, (2) psychosocial support for the family, (3) individual family involvement, (4) family participation in shared decision-making, and (5) nurses' professional competence.

CONCLUSIONS

According to the nurses' experiences, the implementation of a family-centered approach to preventing delirium in pediatric patients requires creating a supportive environment for families, providing psychosocial support, encouraging family involvement in decision-making, and ensuring that all nurses have the necessary skills.

Nursing experiences and knowledge of paediatric delirium: Analysing knowledge-practice gaps

BACKGROUND

Delirium commonly occurs in paediatric patients with acute critical illness and negatively affects clinical outcomes. Variations in delirium knowledge levels and its management have been noted among nurses.

AIMS

This study investigated nurses' experiences and knowledge levels regarding paediatric delirium. Additionally, we aimed to assess the gap between knowledge levels and practical experiences with paediatric delirium.

STUDY DESIGN

This cross-sectional descriptive study conveniently sampled paediatric nurses from a university hospital in South Korea between September 2022 and March 2023. Nursing experiences with paediatric delirium and delirium knowledge levels were measured using structured survey questionnaires. Delirium knowledge was scored 0 to 47, and higher scores indicated higher levels of delirium-related knowledge. Data were analysed using descriptive statistics and presented as mean, standard deviation, frequency and percentage.

RESULTS

A total of 127 paediatric nurses participated in this study; 40.2% had experience with 1-5 delirium cases in the previous year, and 86.6% (n = 110) had never used assessment tools for paediatric delirium assessment. The mean total delirium knowledge score was 34.45 ± 5.4; the mean scores of knowledge regarding aetiology, signs and symptoms and nursing management of delirium were 8.93 ± 1.31, 13.24 ± 2.81 and 12.3 ± 2.7, respectively. Interventions associated with a lower level of delirium-related knowledge and a lower performance rate included avoiding restraint use and maintaining hydration and electrolyte levels. Interventions associated with a higher level of delirium-related knowledge but a lower rate of performance comprised providing orientation, offering emotional support, allowing participants to stay with family members and administering medications to manage delirium.

CONCLUSIONS

Although nurses working in paediatric units exhibited high rate of delirium nursing care, there was the gap between their delirium-related knowledge and practice. Nurses need to be aware of the insufficient part of delirium care, and paediatric delirium education should be reinforced.

RELEVANCE TO CLINICAL PRACTICE

Preventing, assessing and systematically managing paediatric delirium is crucial, and considering the study results, delirium education among nurses is needed.

A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU

Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.

Implementation and effectiveness of a delirium care protocol in Thai critically ill children

BACKGROUND

Delirium in critically ill children can result in long-term morbidity. Our main objectives were to evaluate the effectiveness of a new protocol on the reduction, prevalence, and duration of delirium and to identify associated risk factors.

METHODS

The effectiveness of the protocol was evaluated by a chart review in all critically ill children aged 1 month to 15 years during the study period. A Cornell Assessment of Pediatric Delirium score ≥9 was considered positive for delirium. Data on delirium prevalence and duration from the pre-implementation and post-implementation phases were compared. Univariate and multivariate analyses were used to identify the risk factors of delirium.

RESULTS

A total of 120 children was analyzed (58 children in the pre-implementation group and 62 children in the post-implementation group). Fifty children (41.7%) screened positive for delirium. Age less than 2 years, delayed development, use of mechanical ventilation, and pediatric intensive care unit (PICU) stay >7 days were significantly associated with delirium. The proportion of children screened positive was not significantly different after the implementation (before, 39.7% vs. after, 43.5%; P=0.713). Subgroup analyses revealed a significant reduction in the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery.

CONCLUSIONS

The newly implemented protocol was able to reduce the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. More studies should be conducted to reduce delirium to prevent long-term morbidity after PICU discharge.

Non-pharmacological interventions to prevent and manage delirium in critically ill children in neonatal and paediatric intensive care units (NICU/PICU): a scoping review protocol

INTRODUCTION

Delirium is one of the most common forms of acute cerebral dysfunction in critically ill children leading to increased morbidity and mortality. Prevention, identification and management of delirium is an important part of paediatric and neonatological intensive care. This scoping review aims to identify and map evidence on non-pharmacological interventions for paediatric delirium prevention and management in paediatric and neonatal intensive care settings.

METHODS AND ANALYSIS

This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches will be performed in the databases Medline (via PubMed), CINAHL, Cochrane Library, Ovid (Journals), EMBASE and Web of Science (01/2000-current). Two reviewers will independently review retrieved studies, and relevant information will be extracted using data extraction forms. The results will be presented in tabular format and accompanied by a narrative summary.

INCLUSION CRITERIA

The review will include references that describe or evaluate non-pharmacological interventions to prevent or manage paediatric delirium. Conference abstracts, editorials, opinion papers and grey literature will be excluded.

ETHICS AND DISSEMINATION

Due to the nature of research involving humans or unpublished secondary data, approval of an ethics committee are not required. The dissemination of findings is planned via professional networks and publication in an open-access scientific journal.

Updates and Clinical Implications of Pediatric Delirium

Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to critical care units and is associated with increased mortality, morbidity, length of stay, and care costs. Multiple pediatric critical care societies recommend the implementation of screening practices using validated delirium tools. Delirium remains underrecognized because of suboptimal screening and protocol implementation in pediatric critical care units nationally and internationally. The mainstay of delirium prevention and management is nonpharmacologic, focusing on normalizing a patient's environment, sleep/wake cycles, nutritional status, and activity levels.

Clinical application of 'Sophia Observation withdrawal Symptoms-Paediatric Delirium' screening tool in Danish version: A feasibility study

AIMS AND OBJECTIVES

The aims of the present study were investigating the feasibility of: (1) using the Danish version of Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) screening tool in clinical practice and (2) comparing SOS-PD performance to a child psychiatrist's assessment using the diagnostic criteria as a reference standard.

BACKGROUND

Critically ill children risk developing delirium potentially causing discomfort and suffering. Intensive care delirium has a fluctuating course complicating detection. Systematic screening during and after intensive care is central to manage paediatric delirium.

DESIGN AND METHODS

We used a descriptive and comparative design. First aim: Bedside nurses were asked to evaluate their experience of using the SOS-PD. Second aim: We compared the SOS-PD performance with the child psychiatrist assessment in 50 children aged 4 weeks to 18 years.

RESULTS

Nurses found the Danish version of the SOS-PD applicable and easy to use. Of the 50 children included, 13 were diagnosed with delirium by the child psychiatrist. Consistency was found between the SOS-PD score and the child psychiatrist's assessment (88%). We found three false-negative and three false-positive SOS-PD cases. The false-negative cases could be explained by the differences in time periods for the assessments. SOS-PD assessments covered the past 4 h, whereas the psychiatric assessments covered the past 24 h. We assume the false-positive cases represent an acceptable inconsistency between the two assessment methods.

CONCLUSIONS

The Danish version of the SOS-PD appeared suitable for identifying paediatric delirium. Our results emphasised the importance of assessment at least once during each nursing shift to ensure delirium detection around the clock due to the fluctuating course of delirium.

RELEVANCE TO CLINICAL PRACTICE

Implementing the Danish SOS-PD may increase awareness of this critical disorder by improving systematic identification of paediatric delirium in clinical practice paving the way for improved delirium prevention and management.

Rol de enfermería frente al delirium en unidad de cuidado intensivo pediátrico: Scoping Review

Introducción: El manejo integral de delirium tiene componentes de diferente índole y el rol de enfermería frente a éste puede ser difuso. Objetivo: Identificar en la literatura disponible los cuidados de enfermería no farmacológicos para niños hospitalizados en Unidad de Cuidado Intensivo Pediátrica que presenten delirium. Materiales y métodos: Se realizó una búsqueda estratégica en Web Of Science, Medline, Science Direct, Scielo, Biblioteca Virtual en Salud, LILACS y Open Grey utilizando los términos “nursing care”, “child OR children”, “delirium”, y “Pediatric Intensive Care Unit”. La extracción y análisis de los datos se dio por medio de una matriz. Resultados: Se identificaron 12 artículos que cumplían con los criterios de inclusión y se clasificaron en 4 categorías según la intervención principal desarrollada en el estudio: Abordaje investigativo, intervenciones de confort, intervenciones integrales, e intervenciones educativas. Discusión: El cuidado de enfermería frente al delirium comprende medidas preventivas o curativas que parten del paciente como centro y se extienden hasta su entorno y su familia. Las intervenciones de enfermería pueden estar interrelacionadas de manera que se sustentan y complementan entre ellas. Algunas actividades de cuidado pueden considerarse un indicador de calidad de la atención en salud. Conclusiones: Para abordar integralmente el delirium pediátrico es necesario incidir sobre los factores individuales, ambientales y estructurales que contribuyen a su aparición. El cuidado de enfermería frente al delirium constituye una forma de proteger y promover el bienestar y el desarrollo inmediato y futuro de los niños.

Development of a non-pharmacologic delirium management bundle in paediatric intensive care units

BACKGROUND

Non-pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU).

AIM

To explore expert opinions and generate informed consensus decisions regarding the content of a non-pharmacologic delirium bundle to manage delirium in PICU patients.

STUDY DESIGN

A two-round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated.

RESULTS

We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9-point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0-2, 3-5, and 6-18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence.

CONCLUSIONS

Based on expert consensus, we developed an age-specific non-pharmacologic delirium bundle of interventions to manage delirium in PICU patients.

RELEVANCE TO CLINICAL PRACTICE

An age-specific Non-Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium.

Implementation of a Delirium Bundle for Pediatric Intensive Care Patients

BACKGROUND AND OBJECTIVE

Delirium represents the most common form of acute cerebral dysfunction in critical illness. The prevention, recognition, and treatment of delirium must become the focus of modern pediatric intensive care, as delirium can lead to increased morbidity and mortality. The aim of this study is to evaluate the impact of a delirium bundle consisting of mainly non-pharmacological measures.

MATERIAL AND METHODS

This is a pre-/post-implementation study in an interdisciplinary pediatric intensive care unit of a tertiary care university hospital. In the pre-implementation period, pediatric intensive care delirium was monitored using the Sophia Observation withdrawal Symptoms and Pediatric Delirium scale. After introduction of a delirium bundle consisting of non-pharmacological prevention and treatment measures a period of 4 months was interposed to train the PICU staff and ensure that the delirium bundle was implemented consistently before evaluating the effects in the post-implementation period. Data collection included prevalence of delirium and withdrawal, length of PICU stay, duration of mechanical ventilation, and cumulative dose of sedatives and analgesics.

RESULTS

A total of 792 critically ill children aged 0-18 years were included in this study. An overall delirium prevalence of 30% was recorded in the pre-implementation group and 26% in the post-implementation group (p = 0.13). A significant reduction in the prevalence of pediatric delirium from was achieved in the subgroup of patients under 5 years of age (27.9 vs. 35.8%, p = 0.04) and in patients after surgery for congenital heart disease (28.2 vs. 39.5%, p = 0.04). Young age, length of PICU stay, and iatrogenic withdrawal syndrome were found to be risk factors for developing delirium.

CONCLUSIONS

Based on a validated delirium monitoring, our study gives new information regarding the prevalence of pediatric delirium and the characteristics of intensive care patients at risk for this significant complication. Especially young patients and patients after surgery for congenital heart disease seem to benefit from the implementation of non-pharmacological delirium bundles. Based on our findings, it is important to promote change in pediatric intensive care-toward a comprehensive approach to prevent delirium in critically ill children as best as possible.

A systematic review of the impact of intensive care admissions on post discharge cognition in children

Understanding how hospitalization affects cognitive development is crucial to safeguard children's cognition; however, there is little research evaluating the associations between NICU or PICU hospitalization and survivors' cognition. The objective of this study is to identify and characterize the associations between a neonatal or pediatric ICU hospitalization and the short- and long-term cognition of survivors. The databases Cochrane Library, Medline, EBSCO, Embase, and Google Scholar and the journals JAMA Pediatrics, Journal of Pediatrics, Pediatrics, Archives of Disease in Childhood, Academic Pediatrics, Pediatric Critical Care Medicine and Child Development were searched until April 2021. Retrieved article references were analyzed. Included articles investigated cognition as an outcome of ICU hospitalization in non-preterm neonatal or pediatric patients. Case studies and studies analyzing diagnosis or treatment interventions were excluded. Four prospective cohort or case-control studies and two retrospective cohort studies were included, totaling 2172 neonatal and 42368 pediatric patients. Quality assessment using the BMJ Criteria and Cochrane Collaboration's Risk-of-Bias tool displayed good results. Significant negative associations were found between neonatal cognition and length-of-ICU-stay at 9- (p<0.001) and 24 months (p<0.01), and between pediatric cognition and length-of-ICU-stay at discharge (p<0.001). Additional weeks on the neonatal ICU increased odds of impairment at 9- (OR 1.08, 95%CI 1.034-1.112) and 24 months (OR 1.11, 95%CI 1.065-1.165).Conclusion: There is a significant negative correlation between NICU and PICU hospitalization and the short- and long-term cognitive status. Future research must identify patient- and hospital-related risk factors and develop management strategies. What is Known: • Cognitive development relies on the presence of stimulating factors and absence of risk factors, and is hypothesized to be directly and indirectly affected by hospitalization in the short and long term. • No research examines the relation between survivor cognition post-discharge of a general pediatric hospitalization, and scarcely more of a neonatal or pediatric intensive care hospitalization. What is New: • NICU and PICU hospitalization is independent risk factors for survivor impaired cognition in the short and in the long term with a dose-response effect. High risk patients for cognitive impairment should be identified and appropriately followed-up. • Patients with an ICU hospitalization of over 2.5 days and two or more of the following factors should be considered high risk: increased mortality risk, invasive interventions, neurological or oncological diagnosis, postnatal complications or decreased maternal mental health status.

Delirio en niños críticamente enfermos

El delirio en pacientes críticos es una condición médica que afecta tanto a adultos como a niños; en ambas poblaciones implica graves complicaciones como estancia hospitalaria prolongada, alto riesgo de muerte y deterioro cognitivo a largo plazo, así como mayores costos económicos en cuanto a la prestación de servicios de salud. La principal dificultad de esta condición en la población pediátrica es su adecuado reconocimiento, ya que puede presentarse en edades muy tempranas, incluso en niños lactantes, cuando sus signos y síntomas pueden confundirse o superponerse con otras patologías, tales como el síndrome de abstinencia. En consecuencia, en estos casos el uso de herramientas diagnósticas puede ser una labor compleja que implica múltiples dificultades.Antes de 2011 no había muchos estudios que abordaran la evaluación del delirio en niños. Sin embargo, ese mismo año se estableció la primera escala desarrollada específicamente para el monitoreo de pacientes en unidades de cuidado intensivo pediátrico, lo que llevó a un aumento significativos del número de casos de delirio en niños menores de 5 años críticamente enfermos; esta situación hizo que los pediatras se interesaran más en estudiar esta importante patología.La presente reflexión, basada en una revisión de la literatura, busca actualizar el amplio espectro fisiopatológico del delirio en niños críticamente enfermos y, de esta forma, mejorar su tamizaje, diagnóstico e intervenciones terapéuticas tempranas en todas las edades pediátricas, incluso en menores de 5 años.

State of the science in pediatric ICU delirium: An integrative review

Delirium is a complication of critical illness associated with poor outcomes. Although widely studied in adults, comparatively little is understood about delirium in pediatric intensive care units (ICUs). The purpose of this integrative review is to determine the extent and nature of current evidence, identify gaps in the literature, and outline future areas for investigation of pediatric ICU delirium. Eligible articles included research reports of delirium in pediatric ICU samples published in English since 2009. After an extensive literature search and consideration for inclusion/exclusion criteria, 22 articles were chosen for review. Delirium was highly prevalent in the ICU. Delirium episodes developed early in hospitalization, lasted several days, and consisted of hypoactive or mixed motor subtypes. Frequently identified independent risk factors included young age, developmental delay, mechanical ventilation, and benzodiazepine exposure. Pediatric delirium was independently associated with increased length of stay, costs, and mortality. The long-term cognitive, psychological, and functional morbidities associated with pediatric delirium remain largely unknown. Few researchers have implemented interventions to prevent or manage delirium. There was little evidence for the efficacy or safety of pharmacological management. Multicomponent delirium bundles may significantly decrease delirium incidence. Key quality issues among studies included variation in delirium screening, low levels of evidence (i.e., observational studies), and limited ability to determine intervention efficacy in quasi-experimental designs. Although the quantity and quality of pediatric delirium research has rapidly increased, further studies are needed to understand the long-term effects of pediatric delirium and determine the efficacy and safety of interventions for prevention and management.

Assessment of delirium in children admitted into the Intensive Care Unit: psCAM-ICU Tool

Background: Delirium has been identified as a risk factor for the mortality of critically ill patients, generating great social and economic impacts, since patients require more days of mechanical ventilation and a prolonged hospital stay in the intensive care unit (ICU), thus increasing medical costs. Objective: To describe the prevalence and characteristics of delirium episodes in a sample of 6-month to 5-year-old children who are critically ill. Methods: Cohort study at a Pediatric Intensive Care Unit (PICU) in Bogotá (Colombia). Participants were assessed by the Preschool Confusion Assessment Method for the ICU (psCAM-ICU) within the first twenty-four hours of hospitalization. Results: One quarter of the participants (25.8%) presented some type of delirium. Among them, two sub-types of delirium were observed: 62.5% of the cases were hypoactive and 37.5% hyperactive. Moreover, from them, six were male (75%) and 2 female (25%). Primary diagnosis was respiratory tract infection in 62.55% of the patients, while respiratory failure was diagnosed in the remaining 37.5%. Conclusions: The implementation of delirium monitoring tools in critically ill children provides a better understanding of the clinical manifestation of this phenomenon and associated risk factors in order to contribute to the design of efficient intervention strategies.