Post-Intensive Care Syndrome: Educational Interventions for Parents of Hospitalized Children

Parents' experiences of family and daily life after their child's stay in the pediatric intensive care unit: a qualitative descriptive study

INTRODUCTION

The stay of a critically ill child in a pediatric intensive care unit (PICU) is a significant experience for the family. Thus far, little is known regarding the impact of this stay on parents and their healthy children for whom no continuous aftercare services are offered. This study aimed to capture the post-stay experience and needs of parents after this traumatic event so that they could return to family and everyday life.

METHODS

This qualitative descriptive study was conducted in collaboration with four pediatric intensive care units in Switzerland. It included parents whose children had fully recovered after a stay and who did not require continuous medical follow-up. All children were hospitalized in the PICU for at least 48 h. Data were collected through narrative pairs (n = 6) and individual interviews (n = 8). Interviews were audio recorded, transcribed, coded inductively according to Saldaña, and analyzed.

RESULTS

The results showed three related phases that influence each other to restore normality in daily life: Trust and inclusion in the treatment process during the stay (1), processing after the stay (2), and returning to everyday life (3).

CONCLUSION

Follow-up meetings should be available to all parents whose children have been hospitalized in the PICU. In particular, it should also be available to parents whose children have fully recovered and no longer have any medical disabilities.

Humanisation in paediatric intensive care units: A narrative review

OBJECTIVE

To identify findings in the scientific literature relevant to the strategic lines proposed by the Humanising Intensive Care Project in the context of paediatric intensive care units.

DESIGN

Narrative review.

METHODS

A literature search was conducted in the databases PubMed, Scopus, CINHAL, and Cochrane Library. Specific indexing terms and search strategies adapted to each database were designed. The inclusion of publications was based on two criteria: 1) related to the paediatric intensive care unit and 2) addresses at least one of the topics related to the strategic lines of the Humanising Intensive Care Project. Study selection was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the quality of the included studies was assessed using the Mixed Method Appraisal tool.

RESULTS

A total of 100 articles from 19 different countries were included, covering the period between 2019 and 2021. Nineteen different design types were identified. Thirty-two studies were cross-sectional observational studies, while 15 had an experimental approach. The articles were distributed among the seven strategic lines of the Humanising Intensive Care Project.

CONCLUSIONS

Synthesising the knowledge related to humanisation in paediatric intensive care units will allow progress to be made in improving quality in these units. However, there is disparity in the amount of experimental research overall.

IMPLICATIONS FOR CLINICAL PRACTICE

There is a disparity in the available research related to the different strategic lines, and it is necessary to carry out more exhaustive research on topics such as the presence and participation of the family in care or the management of post-paediatric intensive care syndrome.

Improving Health Equity in Living Donor Kidney Transplant: Application of an Implementation Science Framework

BACKGROUND

Interventions to improve racial equity in access to living donor kidney transplants (LDKT) have focused primarily on patients, ignoring the contributions of clinicians, transplant centers, and health system factors. Obtaining access to LDKT is a complex, multi-step process involving patients, their families, clinicians, and health system functions. An implementation science framework can help elucidate multi-level barriers to achieving racial equity in LDKT and guide the implementation of interventions targeted at all levels.

METHODS

We adopted the Pragmatic Robust Implementation and Sustainability Model (PRISM), an implementation science framework for racial equity in LDKT. The purpose was to provide a guide for assessment, inform intervention design, and support planning for the implementation of interventions.

RESULTS

We applied 4 main PRISM domains to racial equity in LDKT: Organizational Characteristics, Program Components, External Environment, and Patient Characteristics. We specified elements within each domain that consider perspectives of the health system, transplant center, clinical staff, and patients.

CONCLUSION

The applied PRISM framework provides a foundation for the examination of multi-level influences across the entirety of LDKT care. Researchers, quality improvement staff, and clinicians can use the applied PRISM framework to guide the assessment of inequities, support collaborative intervention development, monitor intervention implementation, and inform resource allocation to improve equity in access to LDKT.

Is Pediatric Intensive Care Trauma-Informed? A Review of Principles and Evidence

Pediatric critical illness and injury, along with the experience of recovering from critical illness are among the most potentially traumatic experiences for children and their families. Additionally, children often come to the Pediatric Intensive Care Unit (PICU) with pre-existing trauma that may sensitize them to PICU-related distress. Trauma-informed care (TIC) in the PICU, while under-examined, has the potential to enhance quality of care, mitigate trauma-related symptoms, encourage positive coping, and provide anticipatory guidance for the recovery process. This narrative review paper first describes the need for TIC in the PICU and then introduces the principles of TIC as outlined by the American Academy of Pediatrics: awareness, readiness, detection and assessment, management, and integration. Current clinical practices within PICU settings are reviewed according to each TIC principle. Discussion about opportunities for further development of TIC programs to improve patient care and advance knowledge is also included.

A citation analysis and scoping systematic review of the operationalization of the Practical, Robust Implementation and Sustainability Model (PRISM)

Background

The Practical, Robust Implementation and Sustainability Model (PRISM) was developed in 2008 as a contextually expanded version of the broadly used Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. PRISM provides researchers a pragmatic and intuitive model to improve translation of research interventions into clinical and community practice. Since 2008, the use of PRISM increased across diverse topics, populations, and settings. This citation analysis and scoping systematic review aimed to assess the use of the PRISM framework and to make recommendations for future research.

Methods

A literature search was conducted using three databases (PubMed, Web of Science, Scopus) for the period of 2008 and September 2020. After exclusion, reverse citation searches and invitations to experts in the field were used to identify and obtain recommendations for additional articles not identified in the original search. Studies that integrated PRISM into their study design were selected for full abstraction. Unique research studies were abstracted for information on study characteristics (e.g., setting/population, design), PRISM contextual domains, and RE-AIM outcomes.

Results

A total of 180 articles were identified to include PRISM to some degree. Thirty-two articles representing 23 unique studies integrated PRISM within their study design. Study characteristics varied widely and included studies conducted in diverse contexts, but predominately in high-income countries and in clinical out-patient settings. With regards to use, 19 used PRISM for evaluation, 10 for planning/development, 10 for implementation, four for sustainment, and one for dissemination. There was substantial variation across studies in how and to what degree PRISM contextual domains and RE-AIM outcomes were operationalized and connected. Only two studies directly connected individual PRISM context domains with RE-AIM outcomes, and another four included RE-AIM outcomes without direct connection to PRISM domains.

Conclusions

This is the first systematic review of the use of PRISM in various contexts. While there were low levels of ‘integrated’ use of PRISM and few reports on linkage to RE-AIM outcomes, most studies included important context domains of implementation and sustainability infrastructure and external environment. Recommendations are provided for more consistent and comprehensive use of and reporting on PRISM to inform both research and practice on contextual factors in implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01234-3.

Parental experience of transition from a pediatric intensive care unit to a general ward: A Qualitative Study

AIM

To explore parental experience in transitioning from a pediatric intensive care unit to a general ward and to investigate parental involvement in caring for their critical illness children.

BACKGROUND

Parents have a major responsibility in caring for seriously ill children, but nursing staff fail to meet the expectations of parents regarding nursing care. Few studies have investigated the challenges and needs of Chinese parents during the transition from pediatric intensive care unit to general ward.

METHODS

Semi-structured interviews were conducted with 24 parents of children with critical illness in a pediatric hospital in Shanghai, mainland China to explore their views. Transcripts were entered into NVivo. Framework analysis was used to analyze the qualitative data.

RESULTS

Four themes were identified by data analysis: changes in the child during post pediatric intensive care unit periods; experiencing a wide range of emotions; factors involved in the transition; and suggestions for improving transitional care.

CONCLUSIONS

Due to the unmet needs of parents, a more flexible visiting policy and social media support were highly desirable. Getting accurate information, establishing family integrated care, and strengthening ward-based critical support services were also listed as important needs of parents caring for critically ill children.

IMPLICATIONS FOR NURSING MANAGEMENT

A profound understanding of parental experiences during the transitional period can help nursing staff to assess the effects on children and their families, improve ward-based intensive care, support parental participation, and improve visitation policies. Based on these findings, nurse managers can develop reasonable intervention programs in order to improve nursing quality and patient outcomes.

Socio-Ecologic Perspective: Barriers Complicating Post-Intensive Care Syndrome Mitigation

Objective:Post-intensive care syndrome (PICS) is a phenomenon whereby survivors of an intensive care unit (ICU) admission subsequently experience issues with physical, cognitive, or mental health status persisting beyond the acute hospitalization. Risk factors for developing PICS include prolonged mechanical ventilation with sedation and immobility. PICS is a devastating illness that negatively alters the life path of many individuals with tremendous economic impact. Methods: This qualitative study employed a grounded theory approach to understand the systemic barriers blocking mitigation and treatment of PICS in all seven ICUs across Essex County, New Jersey (NJ) through semi-scripted interviews conducted with 11 members of the healthcare teams with at least one from each site. Thematic analysis was performed with open, axial, and selective coding. Results: Applying socio-ecologic viewpoint to data illustrate significant barriers on both an interpersonal and organizational level that decrease the operationalization of PICS mitigation measures as identified by healthcare providers. Of those interviewed, eight (73%) were physicians and the remaining were nurses. Significant thematic issues included understanding the risk factors of PICS but feeling powerless to institute mitigation efforts; experiencing lack of enthusiasm due to the absence of institutionalized mitigation protocols; noting frustration about closing the gap between academic recommendations and the ability to operationalize these appropriately; and feeling unable to effectuate meaningful change. Conclusion: Providing education to the target population and healthcare provider stakeholders regarding the barriers against PICS mitigation can alter the status quo.

Evaluating the Feasibility and Efficacy of a Pediatric Intensive Care Unit Diary

As the progress of critical care medicine has improved the survival rate of critically ill patients, comorbidities and long-term health care have attracted people's attention. The terms "post-intensive care syndrome" (PICS) and "PICS-family" (PICS-F) have been used in non-neurocritical care populations, which are characterized by the cognitive, psychiatric, and physical sequelae associated with intensive care hospitalization of survivors and their families. An intensive care unit (ICU) diary authored by the patient's family members may alleviate the psychological distress of the patient and his or her family. This quality improvement project focused on the development and implementation of the pediatric intensive care unit (PICU) diary in the pediatric critical care setting. The project aims to evaluate the feasibility and the potential efficacy of the PICU diary, measured through parental acceptance and satisfaction. Seventeen families of critically ill children admitted to the PICU received the PICU diary during the implementation period. Twenty-four parents completed the weekly follow-up, and 15 subsequently completed the diary entry evaluation. The use of the diary in the PICU setting is feasible and considered beneficial by families of critically ill children.

Racial/Ethnic Differences in Stress, Coping, and Distress Among Mothers With a Child in the ICU

BACKGROUND

Having a child in the intensive care unit (ICU) is a stressful event that can cause negative mental health outcomes for parents, but little is known about the experience of parental stress among members of racial/ethnic minority groups.

OBJECTIVE

To examine the stress and coping process in a racially/ethnically diverse sample of mothers of a child who was acutely admitted to an ICU.

METHODS

Participants (N = 103) completed a cross-sectional self-report survey; 86.4% completed it within a week of their child's ICU admission. Analysis of variance was used to examine racial/ethnic differences in perceived ICU-related stressors, coping behaviors, and distress level. Linear regression was used to examine the moderating effects of race/ethnicity on the relationships between stressors, coping behaviors, and distress.

RESULTS

Mothers across racial group experienced similar stressors during the acute phase of their child's ICU admission. African American mothers reported greater overall use of coping behaviors, particularly avoidance coping, and experienced higher levels of distress than did Hispanic or non-Hispanic White mothers. Hispanic mothers experienced the least distress. The interaction of race/ethnicity and emotion-focused coping moderated the stress and coping process.

CONCLUSIONS

Racial and ethnic diversity in sampling should be a priority in future studies of the stress and coping process of mothers with a child in an ICU. Critical care nurses should minimize known stressors for these mothers and encourage and support their preferred coping behaviors, recognizing that these may differ across racial/ethnic groups.

Development and validation of a novel informational booklet for pediatric long-term ventilation decision support

OBJECTIVES

To provide accessible, uniform, comprehensive, and balanced information to families deciding whether to initiate long-term ventilation (LTV) for their child, we sought to develop and validate a novel informational resource.

METHODS

The Ottawa Decision Support Framework was followed. Previous interviews with 44 lay and 15 professional stakeholders and published literature provided content for a booklet. Iterative versions were cognitive tested with six parents facing decisions and five pediatric intensivists. Ten parents facing decisions evaluated the booklet using the Preparation for Decision Making Scale and reported their decisional conflict, which was juxtaposed to the conflict of 21 parents who did not read it, using the Decisional Conflict Scale. Twelve home ventilation program directors evaluated the booklet's clinical sensibility and sensitivity, using a self-designed six-item questionnaire. Data presented using summary statistics.

RESULTS

The illustrated booklet (6th-grade reading level) has nine topical sections on chronic respiratory failure and invasive and noninvasive LTV, including the option to forgo LTV. Ten parents who read the booklet rated it as helping "Quite a bit" or more on all items of the Preparation for Decision Making Scale and had seemingly less decisional conflict than 21 parents who did not. Twelve directors rated it highly for clinical sensibility and sensitivity.

CONCLUSIONS

The LTV booklet was rigorously developed and favorably evaluated. It offers a resource to improve patient/family knowledge, supplement shared decision-making, and reduce decisional conflict around LTV decisions. Future studies should validate it in other settings and further study its effectiveness.

Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit

Introduction

Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population.

Methods

We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission.

Results

Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff.

Conclusions

Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

A Randomized Controlled Trial Comparing Two Self-Administered Educational Strategies for Patients With Knee Osteoarthritis

OBJECTIVE

The objective of this study was to assess the efficacy of self-administered patient educational tools in improving knowledge and behaviors for the management of knee osteoarthritis.

METHODS

We conducted a randomized clinical trial in patients with knee osteoarthritis to assess the efficacy of providing a video for entertainment education, in combination with two booklets, compared with providing the booklets alone. We evaluated changes in scores on a patient knowledge questionnaire, the Decisional Conflict Scale, the Arthritis Self-Efficacy Scale, and the Effective Consumer Scale between baseline and same day, 3 months, and 6 months post intervention. We used linear regression models to explore associations between demographic characteristics and outcomes, testing for interactions.

RESULTS

Two hundred nineteen participants were randomly assigned to receive the video + booklets (n = 109) or the booklets alone (n = 110). The mean age of participants was 64.6 (±8.3) years. At 6 months, statistically significant improvements were observed in knowledge and decisional conflict scores for both groups, and statistically significant improvements in the behavior to participate in their health care were observed in the video + booklets group. The video + booklets group was more knowledgeable immediately post intervention than the booklet group (mean difference 0.39 [95% confidence interval 0.02-0.76]). No other significant changes in outcomes were observed at 6 months between the two groups. The video + booklets combination was associated with decreased decisional conflict in Spanish speakers and increased self-efficacy in those with less than a high school education.

CONCLUSION

Although both education strategies were associated with improved knowledge and reduced decisional conflict at 6 months, receiving the video + booklets in combination, compared with receiving the booklets alone, proved to be more effective in changing behaviors and appeared to have some advantages for Spanish speakers and those who were less educated.

Post-intensive care syndrome: A concept analysis

OBJECTIVE

Post-intensive care syndrome is a term used to describe new or worsening multidimensional impairments in physical, psychological cognitive and social status arising from critical illness and persisting beyond hospital discharge. It is associated with high morbidity among patients discharged from intensive care units. However, due to its complexities, which encompass physical, psychological, cognitive and social impairments, the exact nature of this condition has not been fully conceptualized. The aim of this analysis therefore was to define the concept of post-intensive care syndrome. This conceptual clarity provides a general definition that is essential for practitioners and researchers to gain a comprehensive understanding of the syndrome and provide for accurate measurement of its incidence and prevalence.

DESIGN

The Walker and Avant approach to concept analysis guided this investigation.

DATA SOURCE

An electronic search of the literature using PubMed, CINHAL, PsycArticles, Academic search complete, Science Direct, MEDLINE and Health Source databases informed the analysis. The search included both quantitative and qualitative studies related to post-intensive care syndrome published in English between 2010 and 2020.

RESULTS

Of the 3948 articles identified, 24 ultimately met the inclusion criteria. Analysis identified the defining attributes of post-intensive care syndrome as: (1) new or worsening multidimensional impairments; (2) physical dysfunction; (3) psychological disorder; (4) cognitive impairment; (5) failed social reconstruction; and (6) persistent impaired multidimensional symptoms extending beyond intensive care and hospital discharge. Antecedents were divided into two categories: pre-existing and those related to the intensive care admission. Consequences were identified as both positive (for example the establishment of coping processes) and adverse (for example decreased quality of life and caregiver burden).

CONCLUSION

Post-intensive care syndrome affects more than half of patients discharged from intensive care units. This operational definition and conceptual understanding of this syndrome will help improve understanding and inform the design of preventative strategies to improve long-term consequences of the syndrome. Future research and standardized instrument development will serve to better understand the scope and characteristics of this syndrome and inform the development of possible preventative interventions.

Post-Intensive-Care Syndrome for the Pediatric Neurologist

The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.

Gross motor developmental dysfunctional outcomes in infantile and toddler pediatric intensive care unit survivors

Background

Increasing studies have focused on motor function/dysfunction in PICU survivors; however, most studies have focused on adults and older children. This study investigated gross motor developmental function outcomes in infantile and toddler pediatric intensive care unit (PICU) survivors and the factors associated with gross motor developmental functions.

Methods

This observational study was conducted in the PICU of the First Hospital of Jilin University between January 2019 and March 2019. Thirty-five eligible patients were divided into the dysfunctional (n = 24) or non-dysfunctional (n = 11) group according to the results of the Peabody Developmental Motor Scales, Second Edition (PDMS-2). Baseline gross motor function for all participants before PICU admission was measured via the Age and Stages Questionnaires, Third Edition (ASQ-3). The PDMS-2 was used to evaluate gross motor development function before PICU discharge.

Results

The gross motor developmental dysfunction incidence was 68.6%. Linear correlation analysis showed that the gross motor quotient (GMQ) was positively correlated with the pediatric critical illness score (PCIS, r = 0.621, P < 0.001), and negatively correlated with length of PICU stay (r = − 0.556, P = 0.001), days sedated (r = − 0.602, P < 0.001), days on invasive mechanical ventilation (IMV; r = − 0.686, P < 0.001), and days on continuous renal replacement therapy (CRRT; r = − 0.538, P = 0.001). Linear regression analysis showed that IMV days (β = − 0.736, P = 0.001), sepsis (β = − 18.111, P = 0.003) and PCIS (β = 0.550, P = 0.021) were independent risk factors for gross motor developmental dysfunction.

Conclusions

Gross motor developmental dysfunction in infantile and toddler PICU survivors is more common and may be exacerbated by experiences associated with longer IMV days and increasing illness severity combined with sepsis.

Trial registration

The trial ‘Early rehabilitation intervention for critically ill children’ has been registered at http://www.chictr.org.cn/showproj.aspx?proj=23132. Registration number: ChiCTR1800020196.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.