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McAlinden B, Pool N, Harnischfeger J, Waak M, Campbell M. 'Baby Liberation' - Developing and implementing an individualised, developmentally-supportive care bundle to critically unwell infants in an Australian Paediatric Intensive Care Unit. Early Hum Dev 2024; 190:105944. [PMID: 38290275 DOI: 10.1016/j.earlhumdev.2024.105944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/21/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Infants requiring high acuity care within a Paediatric Intensive Care Unit are at multifactorial risk of neurological injury to the immature brain, resulting in long-term developmental difficulties. In 2020, Queensland Children's Hospital implemented an individualised family-centred developmental care program, 'Baby Liberation', to address an identified service gap for critically unwell infants, aimed at optimising early neuroprotective strategies and minimising risk of suboptimal developmental outcomes. AIM To implement Baby Liberation for infants admitted to a quaternary paediatric intensive care referral centre. Secondary aims were to describe environmental changes, enablers and limitations related to implementation. STUDY DESIGN A single-centre, prospective implementation pilot study investigated the feasibility of implementing Baby Liberation. Subjects included infants less than six months of age admitted to Queensland Children's Hospital Paediatric Intensive Care Unit. OUTCOME MEASURES Primary measures comprised data collected during the implementation period, including number of eligible patients and number of developmental care plans provided. Environmental audit data were collected pre and post implementation to inform secondary outcomes. RESULTS Baby Liberation was feasibly implemented into the Queensland Children's Hospital Paediatric Intensive Care Unit. During implementation, 181 individualised care plans were provided to 313 eligible infants (57.8 %). Environmental audits showed improvements in all areas of developmental care, with greatest improvements noted in pain and stress management (+95 %) and staff support and development (+83.3 %). CONCLUSION Implementation of Baby Liberation was feasible within a large quaternary paediatric intensive care unit and has potential to be expanded into other clinical areas providing acute infant care.
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Affiliation(s)
- Bronagh McAlinden
- Physiotherapy Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia.
| | - Natasha Pool
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Jane Harnischfeger
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Michaela Waak
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Miranda Campbell
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia; Occupational Therapy and Music Therapy Department, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
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Schults JA, Charles KR, Harnischfeger J, Ware RS, Royle RH, Byrnes JM, Long DA, Ullman AJ, Raman S, Waak M, Lake A, Cooke M, Irwin A, Tume L, Hall L. Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections. Aust Crit Care 2024; 37:34-42. [PMID: 38142148 DOI: 10.1016/j.aucc.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections. OBJECTIVE The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions. METHODS A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models. RESULTS Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use. CONCLUSIONS Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.
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Affiliation(s)
- Jessica A Schults
- Metro North Health, Herston Infectious Disease Institute, Queensland, Australia; The University of Queensland, School of Nursing Midwifery and Social Work, Australia; The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Queensland, Australia.
| | - Karina R Charles
- The University of Queensland, School of Nursing Midwifery and Social Work, Australia; The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Jane Harnischfeger
- The University of Queensland, School of Nursing Midwifery and Social Work, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Ruth H Royle
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Joshua M Byrnes
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Australia
| | - Debbie A Long
- The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Queensland, Australia
| | - Amanda J Ullman
- The University of Queensland, School of Nursing Midwifery and Social Work, Australia; The University of Queensland, Children's Health Research Centre, Australia; Menzies Health Institute Queensland, Griffith University, Queensland, Australia; Children's Health Queensland Hospital and Health Service, Queensland, Australia
| | - Sainath Raman
- The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Michaela Waak
- The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Anna Lake
- The University of Queensland, Children's Health Research Centre, Australia
| | - Marie Cooke
- School of Nursing & Midwifery, Griffith University, Australia
| | - Adam Irwin
- The University of Queensland, Centre for Clinical Research, The University of Queensland, Queensland, Australia; Infection Management and Prevention Service, Queensland Children's Hospital, Queensland, Australia
| | - Lyvonne Tume
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK; Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Lisa Hall
- Metro North Health, Herston Infectious Disease Institute, Queensland, Australia; School of Public Health, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
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Schults JA, Charles K, Harnischfeger J, Erikson S, Burren J, Waak M, Blackwood B, Tume LN, Long D. Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice. Aust Crit Care 2022:S1036-7314(22)00090-X. [PMID: 36038459 DOI: 10.1016/j.aucc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES We aimed to (i) describe current weaning and extubation practices in children (protocols to identify weaning candidates, spontaneous breathing trials, and other aspects of care such as sedation weaning) and (ii) understand responsibilities for ventilation weaning decisions across Australia and New Zealand (ANZ). METHODS A cross-sectional survey of ANZ intensive care units who routinely intubate and ventilate children (<18 years) was conducted. We worked with the Australian and New Zealand Intensive Care Society Paediatric Study Group to identify units and potential respondents (senior nurse representative per unit) and to administer questionnaires. Survey questions (n = 35) examined current protocols, practices, unit staffing, and decision-making responsibilities for ventilation weaning and extubation. Open-ended questions examined respondents' experiences of weaning and extubation. RESULTS A senior nursing respondent from 18/22 intensive care units (82%) completed the survey. Across units, most used sedation assessment tools (88%), and less often, sedation weaning tools (55%). Spontaneous awakening protocols were not used; one unit (5%) reported the use of a spontaneous breathing protocol. Two respondents reported that ventilation weaning protocols (11%) were in use, with 44% of units reporting the use of extubation protocols. Weaning and extubation practices were largely perceived as medically driven, with qualitative data demonstrating a desire from most respondents for greater shared decision-making. CONCLUSION In ANZ, ventilation weaning and extubation practices are largely medically driven with variation in the use of protocols to support mechanical ventilation weaning and extubation in children. Our findings highlight the importance of future research to determine the impact of greater collaboration of the multidisciplinary team on weaning practices.
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Affiliation(s)
- Jessica A Schults
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Metro North Hospital and Health Service, Queensland, Australia; Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Queensland, Australia.
| | - Karina Charles
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Queensland, Australia
| | - Jane Harnischfeger
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Simon Erikson
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Juerg Burren
- University Children's Hospital Zurich, Switzerland
| | - Michaela Waak
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; Centre for Children's Health Research, the University of Queensland, Queensland, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Northern Ireland, UK
| | - Lyvonne N Tume
- School of Health & Society, University of Salford, Manchester, UK; Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Debbie Long
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
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Waak M, Gibbons K, Sparkes L, Harnischfeger J, Gurr S, Schibler A, Slater A, Malone S. Real-time seizure detection in paediatric intensive care patients: the RESET child brain protocol. BMJ Open 2022; 12:e059301. [PMID: 36691237 PMCID: PMC9171209 DOI: 10.1136/bmjopen-2021-059301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/19/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Approximately 20%-40% of comatose children with risk factors in intensive care have electrographic-only seizures; these go unrecognised due to the absence of continuous electroencephalography (EEG) monitoring (cEEG). Utility of cEEG with high-quality assessment is currently limited due to high-resource requirements. New software analysis tools are available to facilitate bedside cEEG assessment using quantitative EEG (QEEG) trends. The primary aim of this study is to describe accuracy of interpretation of QEEG trends by paediatric intensive care unit (PICU) nurses compared with cEEG assessment by neurologist (standard clinical care) in children at risk of seizures and status epilepticus utilising diagnostic test statistics. The secondary aims are to determine time to seizure detection for QEEG users compared with standard clinical care and describe impact of confounders on accuracy of seizure detection. METHODS AND ANALYSIS This will be a single-centre, prospective observational cohort study evaluating a paediatric QEEG programme utilising the full 19 electrode set. The setting will be a 36-bed quaternary PICU with medical, cardiac and general surgical cases. cEEG studies in PICU patients identified as 'at risk of seizures' will be analysed. Trained bedside clinical nurses will interpret the QEEG. Seizure events will be marked as seizures if >3 QEEG criteria occur. Post-hoc dedicated neurologists, who remain blinded to the QEEG analysis, will interpret the cEEG. Determination of standard test characteristics will assess the primary hypothesis. To calculate 95% (CIs) around the sensitivity and specificity estimates with a CI width of 10%, the sample size needed for sensitivity is 80 patients assuming each EEG will have approximately 9 to 18 1-hour epochs. ETHICS AND DISSEMINATION The study has received approval by the Children's Health Queensland Human Research Ethics Committee (HREC/19/QCHQ/58145). Results will be made available to the funders, critical care survivors and their caregivers, the relevant societies, and other researchers. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ANZCTR) 12621001471875.
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Affiliation(s)
- Michaela Waak
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Centre for Children's Health Research, Brisbane, Queensland, Australia
- The University of Queensland, Saint Lucia, Queensland, Australia
| | - Louise Sparkes
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
- Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Jane Harnischfeger
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Sandra Gurr
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Andreas Schibler
- St Andrew's War Memorial Hospital, Spring Hill, Queensland, Australia
| | - Anthony Slater
- Queensland Children's Hospital Paediatric Intensive Care Unit, South Brisbane, Queensland, Australia
| | - Stephen Malone
- The University of Queensland, Saint Lucia, Queensland, Australia
- Neurosciences, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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Waak M, Harnischfeger J, Ferguson A, Gibbons K, Nguyen KH, Long D. Every child, every day, back to play: the PICUstars protocol - implementation of a nurse-led PICU liberation program. BMC Pediatr 2022; 22:279. [PMID: 35562671 PMCID: PMC9102243 DOI: 10.1186/s12887-022-03232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As admissions to paediatric intensive care units (PICU) rise and mortality rates decline, the focus is shifting from survival to quality of survivorship. There is paucity of internationally accepted guidelines to manage complications like over-sedation, delirium, and immobility in the paediatric setting. These have a strong adverse impact on PICU recovery including healthcare costs and long-term functional disability. The A2F bundle (ABCDEF), or ICU Liberation, was developed to operationalise the multiple evidence-based guidelines addressing ICU-related complications and has been shown to improve clinical outcomes and health-care related costs in adult studies. However, there is little data on the effect of ICU Liberation bundle implementation in PICU. METHODS PICU-STARS will be a single centre before-and-after after trial and implementation study. It is designed to evaluate if the multidimensional, nurse-led ICU Liberation model of care can be applied to the PICU and if it is successful in minimising PICU-related problems in a mixed quaternary PICU. In a prospective baseline measurement, the present practises of care in the PICU will be assessed in order to inform the adaptation and implementation of the PICU Liberation bundle. To assess feasibility, implementation outcomes, and intervention effectiveness, the implementation team will use the Consolidated Framework for Implementation Research (CIFR) and process assessment (mixed methods). The implementation process will be evaluated over time, with focus groups, interviews, questionnaires, and observations used to provide formative feedback. Over time, the barriers and enablers for successful implementation will be analysed, with recommendations based on "lessons learned." All outcomes will be reported using standard descriptive statistics and analytical techniques, with appropriate allowance for patient differentials in severity and relevant characteristics. DISCUSSION The results will inform the fine-tune of the Liberation bundle adaptation and implementation process. The expected primary output is a detailed adaptation and implementation guideline, including clinical resources (and investment) required, to adopt PICU-STARS in other children's hospitals. PATIENT AND PUBLIC INVOLVEMENT STATEMENT The authors thank the PICU education and Liberation Implementation team, and our patients and families for their inspiration and valuable comments on protocol drafts. Results will be made available to critical care survivors, their caregivers, relevant societies, and other researchers. TRIAL REGISTRATION ACTRN, ACTRN382863 . Registered 19/10/2021 - Retrospectively registered. STUDY STATUS recruiting.
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Affiliation(s)
- M Waak
- Child Health Research Centre, The University of Queensland, 62 Graham Street, South Brisbane, Queensland, 4101, Australia. .,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia.
| | - J Harnischfeger
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - A Ferguson
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - K Gibbons
- Child Health Research Centre, The University of Queensland, 62 Graham Street, South Brisbane, Queensland, 4101, Australia
| | - K H Nguyen
- Centre for Applied Health Economics, School of Medicine and Griffith Health Institute, Griffith University, Brisbane, QLD, 4131, Australia.,Centre for Health Service Research, Faculty of Medicine, University of Queensland, QLD, Herston, 4006, Australia
| | - D Long
- Child Health Research Centre, The University of Queensland, 62 Graham Street, South Brisbane, Queensland, 4101, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia.,School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
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Charles K, Harnischfeger J, Erikson S, Burren J, Waak M, Blackwood B, Tume L, Long D, Anne Schults J. Bi-national survey of ventilation weaning and extubation practices in children. Aust Crit Care 2022. [DOI: 10.1016/j.aucc.2022.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Long D, Flatley C, Williams T, Harnischfeger J, McEniery J, Aitken L. Occurrence, management and outcome of fever in critically ill children. Aust Crit Care 2016. [DOI: 10.1016/j.aucc.2015.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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