Low-value home-based nursing care: A national survey study

AIMS

To explore potential areas of low-value home-based nursing care practices, their prevalence and related influencing factors of nurses and nursing assistants working in home-based nursing care.

DESIGN

A quantitative, cross-sectional design.

METHODS

An online survey with questions containing scaled frequencies on five-point Likert scales and open questions on possible related influencing factors of low-value nursing care. The data collection took place from February to April 2022. Descriptive statistics and linear regression were used to summarize and analyse the results.

RESULTS

A nationwide sample of 776 certified nursing assistants, registered nurses and nurse practitioners responded to the survey. The top five most delivered low-value care practices reported were: (1) 'washing the client with water and soap by default', (2) 'application of zinc cream, powders or pastes when treating intertrigo', (3) 'washing the client from head to toe daily', (4) 're-use of a urinary catheter bag after removal/disconnection' and (5) 'bladder irrigation to prevent clogging of urinary tract catheter'. The top five related influencing factors reported were: (1) 'a (general) practitioner advices/prescribes it', (2) 'written in the client's care plan', (3) 'client asks for it', (4) 'wanting to offer the client something' and (5) 'it is always done like this in the team'. Higher educational levels and an age above 40 years were associated with a lower provision of low-value care.

CONCLUSION

According to registered nurses and certified nursing assistants, a number of low-value nursing practices occurred frequently in home-based nursing care and they experienced multiple factors that influence the provision of low-value care such as (lack of) clinical autonomy and handling clients' requests, preferences and demands. The results can be used to serve as a starting point for a multifaceted de-implementation strategy.

REPORTING METHOD

STROBE checklist for cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nursing care is increasingly shifting towards the home environment. Not all nursing care that is provided is effective or efficient and this type of care can therefore be considered of low-value. Reducing low-value care and increasing appropriate care will free up time, improve quality of care, work satisfaction, patient safety and contribute to a more sustainable healthcare system.

Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial

BACKGROUND

To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0-3 years after cardiac surgery with cardiopulmonary bypass.

METHODS

Multi-center, randomized, double-blinded, controlled trial in four level-3 Pediatric Intensive Care Units (PICU) in the Netherlands and Belgium. Inclusion period; March 2016-July 2020. Children aged 0-3 years, undergoing cardiac surgery with cardiopulmonary bypass were eligible. Patients were randomized to continuous morphine or intermittent IV paracetamol as primary analgesic after a loading dose of 100 mcg/kg morphine was administered at the end of surgery. Rescue morphine was given if numeric rating scale (NRS) pain scores exceeded predetermined cutoff values. Primary outcome was median weight-adjusted cumulative morphine dose in mcg/kg in the first 48 h postoperative. For the comparison of the primary outcome between groups, the nonparametric Van Elteren test with stratification by center was used. For comparison of the proportion of patients with one or more NRS pain scores of 4 and higher between the two groups, a non-inferiority analysis was performed using a non-inferiority margin of 20%.

RESULTS

In total, 828 were screened and finally 208 patients were included; parents of 315 patients did not give consent and 305 were excluded for various reasons. Fourteen of the enrolled 208 children were withdrawn from the study before start of study medication leaving 194 patients for final analysis. One hundred and two patients received intermittent IV paracetamol, 106 received continuous morphine. The median weight-adjusted cumulative morphine consumption in the first 48 h postoperative in the IV paracetamol group was 5 times lower (79%) than that in the morphine group (median, 145.0 (IQR, 115.0-432.5) mcg/kg vs 692.6 (IQR, 532.7-856.1) mcg/kg; P < 0.001). The rescue morphine consumption was similar between the groups (p = 0.38). Non-inferiority of IV paracetamol administration in terms of NRS pain scores was proven; difference in proportion - 3.1% (95% CI - 16.6-10.3%).

CONCLUSIONS

In children aged 0-3 years undergoing cardiac surgery, use of intermittent IV paracetamol reduces the median weight-adjusted cumulative morphine consumption in the first 48 h after surgery by 79% with equal pain relief showing equipoise for IV paracetamol as primary analgesic. Trial Registration Clinicaltrials.gov, Identifier: NCT05853263; EudraCT Number: 2015-001835-20.

Does a Transition to Single-Occupancy Patient Rooms Affect the Incidence and Outcome of In-Hospital Cardiac Arrests?

BACKGROUND

It is proposed that patients in single-occupancy patient rooms (SPRs) carry a risk of less surveillance by nursing and medical staff and that resuscitation teams need longer to arrive in case of in-hospital cardiac arrest (IHCA). Higher incidences of IHCA and worse outcomes after cardiopulmonary resuscitation (CPR) may be the result.

OBJECTIVES

Our study examines whether there is a difference in incidence and outcomes of IHCA before and after the transition from a hospital with multibedded rooms to solely SPRs.

METHODS

In this prospective observational study in a Dutch university hospital, as a part of the Resuscitation Outcomes in the Netherlands study, we reviewed all cases of IHCA on general adult wards in a period of 16.5 months before to 16.5 months after the transition to SPRs.

RESULTS

During the study period, 102 CPR attempts were performed: 51 in the former hospital and 51 in the new hospital. Median time between last-seen-well and start basic life support did not differ significantly, nor did median time to arrival of the CPR team. Survival rates to hospital discharge were 30.0% versus 29.4% of resuscitated patients (p = 1.00), with comparable neurological outcomes: 86.7% of discharged patients in the new hospital had Cerebral Performance Category 1 (good cerebral performance) versus 46.7% in the former hospital (p = .067). When corrected for telemetry monitoring, these differences were still nonsignificant.

CONCLUSIONS

The transition to a 100% SPR hospital had no negative impact on incidence, survival rates, and neurological outcomes of IHCAs on general adult wards.

Nurses' perceptions of the transition to 100% single-occupancy patient rooms in a university hospital in the Netherlands: an uncontrolled before and after study

BACKGROUND

To improve patients' privacy, comfort and infection control, newly built hospitals increasingly offer 100% single-occupancy patient rooms. Our study examines how nurses perceived the transition from a hospital with multi-bedded patient rooms to one with solely single-occupancy patient rooms designed according to principles of a healing environment.

METHODS

In a single-centre, before-after survey study, nurses completed a questionnaire of 21 items in three domains: perceived patient safety and monitoring, nurses' working conditions and patient environment. Before-measurements (n = 217) were compared with two after-measurements in the new hospital, respectively after one (n = 483) and two years (n = 191).

RESULTS

Nurses considered the single rooms in the new hospital worse for visibility and monitoring but this had improved somewhat after two years. In either setting, the majority perceived working conditions (walking distances and designated rest area) as unfavourable. The patient environment in the new hospital was generally perceived as much better than in the former hospital.

CONCLUSION

The transition to solely single-occupancy patient rooms was largely considered positive by nurses in terms of patient environment. However, monitoring of patients and working conditions remain a concern. When designing new hospitals, attention should be paid to optimal working conditions for nurses. To improve monitoring of patients, we recommend the use of remote-sensoring.

Mobility level and factors affecting mobility status in hospitalized patients admitted in single-occupancy patient rooms

BACKGROUND

Although stimulating patients' mobility is considered a component of fundamental nursing care, approximately 35% of hospitalized patients experience functional decline during or after hospital admission. The aim of this study is to assess mobility level and to identify factors affecting mobility status in hospitalized patients admitted in single-occupancy patient rooms (SPRs) on general wards.

METHODS

Mobility level was quantified with the Johns Hopkins Highest Level of Mobility Scale (JH-HLM) and EQ-5D-3L. GENEActiv accelerometer data over 24 h were collected in a subset of patients. Data were analyzed using generalized ordinal logistic regression analysis. The STROBE reporting checklist was applied.

RESULTS

Wearing pajamas during daytime, having pain, admission in an isolation room, and wearing three or more medical equipment were negatively associated with mobilization level. More than half of patients (58.9%) who were able to mobilize according to the EQ-5D-3L did not achieve the highest possible level of mobility according to the JH-HLM. The subset of patients that wore an accelerometer spent most of the day in sedentary behavior (median 88.1%, IQR 85.9-93.6). The median total daily step count was 1326 (range 22-5362).

CONCLUSION

We found that the majority of participating hospitalized patients staying in single-occupancy patient rooms were able to mobilize. It appeared, however, that most of the patients who are physically capable of walking, do not reach the highest possible level of mobility according to the JH-HLM scale. Nurses should take their responsibility to ensure that patients achieve the highest possible level of mobility.

Reasons Patients With Primary Progressive Multiple Sclerosis Contact Their Specialist Nurses

BACKGROUND

Questions asked by patients with primary progressive multiple sclerosis (PPMS) during patient-initiated MS nurse consultations may contain salient information that can help health care providers understand their needs, which, in turn, can help tailor counseling and treatment.

METHODS

Records of all patients with PPMS visiting the MS center of a large teaching hospital in the Netherlands between January 2007 and January 2021 were studied retrospectively. Number and type (scheduled or patient initiated) of MS nurse consultations, reasons for consultations (in prespecified categories), and frequency of subsequent referrals were registered. Association between factors (living with partner, Expanded Disability Status Scale score, comorbidities, age, sex) and number of patient-initiated consultations was studied using negative binomial regression analysis.

RESULTS

In total, 98 patients with PPMS were included, with 720 MS nurse consultations during follow-up (median duration, 8.1 years), of which 274 (38%) were patient initiated. Patients had a broad spectrum of reasons to contact MS nurses. The most common categories were treatment (36%) and micturition and defecation (31%). Patients living without a partner (incidence rate ratio, 2.340; 95% CI, 1.057-5.178) and male patients (incidence rate ratio, 1.890; 95% CI, 0.925-3.861) consulted MS nurses more frequently. The MS nurses made 146 referrals (20% of all contacts); 59 were after patient-initiated consultation (22%). The most frequent referrals were to neurologists, urologists, and rehabilitation specialists.

CONCLUSIONS

Multiple sclerosis nurses have a pivotal role in PPMS care, especially for patients living without a partner and male patients. Recurring questions about (new) treatment options illustrate the pressing need for highly effective treatment. Micturition and defecation problems are also a considerable concern and warrant close monitoring.

The self-regulation skills instrument in transplantation (SSIt): Development and measurement properties of a self-report self-management instrument

OBJECTIVE

To develop a self-management instrument for organ transplant recipients that incorporates self-regulations skills and to determine its measurement properties.

METHODS

The instrument includes concepts from social cognitive models: problem awareness, attitude, self-efficacy, motivation, social support, goal setting, goal pursuit, skills and goal affect. The measurement properties were evaluated based on the COSMIN guidelines. Face and content validity were determined through patient assessment, Three-Step Test-Interview and expert assessment using the Content Validity Index. Structural validity and reliability were tested using exploratory factor analysis and Cronbach's alpha. Construct validity was tested by comparing subscales with the Health Education Impact Questionnaire (heiQ).

RESULTS

After face and content validity assessment 47 items were entered into the exploratory factor analysis. The analysis showed two meaningful factors, with internal consistency of 0.90 and 0.89. Spearman correlations between the subscales and heiQ were moderate (0.55; 0.46). The final version consists of 21 items, divided into two scales: 'Setbacks' and 'Successes'.

CONCLUSIONS

The Self-regulation skills instrument in transplantation (SSIt) is a valid and reliable instrument to asses necessary skills for self-management after transplantation and may be useful for other patients as well.

PRACTICE IMPLICATIONS

Insight into self-regulation competencies can help healthcare professionals to tailor self-management support.

Implementation of a nursing oral health care protocol in a university teaching hospital: A cluster-randomized stepped-wedge design

INTRODUCTION

Providing oral care is an essential part of basic nursing care but receives little priority in daily practice, with a risk of adverse events. Also, nurses report many barriers to adequate provision of oral care, such as time restraints, insufficient materials, fear of causing pain, lack of knowledge and a negative attitude towards providing oral care.

METHODS

We performed a cluster-randomized, stepped-wedge study to explore the effect of the the implementation of a new nursing evidence-based oral care protocol on nurses' knowledge, attitude and protocol adherence. The study population included both nursing students, graduated nurses and patients in selected wards. The implementation strategy included oral and written information, instruction videos and reminders. Nurses' knowledge and attitude towards oral care were assessed at baseline and after the implementation of the protocol with a validated 47-item questionnaire with a score range of 0-100. Secondarily, nurses' protocol adherence to teeth brushing, measured in Activities of Daily Living (ADL) dependent patients, was evaluated. The Standards for Reporting Implementation Studies (StaRI) Statement was used.

RESULTS

At baseline, the questionnaire was completed by 226 nurses; after implementation by 283. Knowledge had significantly improved from 68.8 to 72.3. Nurses' attitude improved not significantly. Protocol adherence was assessed in 73 ADL-dependent patients at baseline, in 51 after implementation. Adherence to teeth brushing significantly decreased in patients with permanent teeth. Also, adherence to both teeth brushing and usage of soap decreased in patients with (partial) dentures.

CONCLUSION

Nurses' knowledge and attitude of oral care increased somewhat after the implementation of a new nursing evidence-based protocol. After implementation, there was an unexplained decreased adherence to oral care in ADL-dependent patients.

The influence of intensive care treatment in infancy on cortisol levels in childhood and adolescence

BACKGROUND

Infants admitted to the intensive care unit experience numerous early-life stressors, which may have long-term effects on hypothalamic-pituitary-adrenal axis functioning.

AIMS

To determine the effects of intensive care treatment and related exposure to stress, pain, and opioids in infancy on cortisol levels in childhood and adolescence.

STUDY DESIGN

Cross-sectional study.

SUBJECTS

Children and adolescents aged 8 to 18 years with a history of intensive care treatment in infancy and healthy controls. The intensive care treatment cohort consisted of four subgroups with varying levels of exposure to stress, pain, and opioids in infancy. They received either mechanical ventilation, extracorporeal membrane oxygenation, major surgery, or excochleation of a giant congenital melanocytic nevus.

OUTCOME MEASURES

Between-group differences in stress reactivity to a study visit consisting of pain threshold testing and an MRI examination and diurnal cortisol levels, as measured in saliva.

RESULTS

After adjustment for age, sex, and gestational age, the diurnal cortisol output (AUCg) in the overall intensive care group (N = 76) was 18 % (approximately 1000 nmol/L) (95 % CI [-31 %, -3 %], P = 0.022) lower than that in the control group (N = 67). Cortisol awakening response, diurnal decline, and stress reactivity neither differed significantly between the overall intensive care group and control group, nor between the intensive care subgroups and control group.

CONCLUSION

Children and adolescents with a history of intensive care treatment in infancy have similar cortisol profiles to those of healthy controls, except for an 18 % lower diurnal cortisol output. The clinical relevance of this reduction is yet to be determined.

Hospitalized Patients' Sleep Quality Compared Between Multioccupancy Rooms and Single-Patient Rooms

OBJECTIVES

To evaluate patients' sleep quality in a former hospital with two-and four-bedded rooms compared to a new hospital that incorporated evidence-based design features, including exclusively single-patient rooms (SPRs).

BACKGROUND

Hospitalized patients often report poor sleep quality due to both patient-related factors and hospital environmental factors. It is unclear if staying in an SPR in a hospital designed as a healing environment is associated with better sleep quality.

METHODS

In a before-after study, sleep quality, duration, and efficiency over 72 hr were measured with a sleep diary, GENEActiv accelerometer, and the Richards-Campbell Sleep Questionnaire (RCSQ) with scores ranging from 0 to 100, with higher scores reflecting better sleep. Participants were either staying alone in the former hospital with two-and four-bedded rooms (Group 1), sharing a room with one to three fellow patients (Group 2), or staying alone in a newly designed hospital with 100% SPRs (Group 3).

RESULTS

We included 17 patients in Group 1, 32 patients in Group 2, and 56 patients in Group 3. Univariable linear mixed model analysis, controlling for night number, revealed that the RCSQ total score was lowest in Group 2 compared to the other two groups. In the multivariable analysis, the RCSQ score was also the lowest in Group 2, with a significant effect from covariate "use of night medication."

CONCLUSION

Self-reported sleep quality of hospitalized patients in a hospital with 100% SPRs designed as a healing environment was slightly better than that of patients staying in multioccupancy rooms with fellow patients.

Integrative nursing in Europe - A competency profile for nursing students validated in a Delphi-study

BACKGROUND

Integrative nursing is a framework for providing holistic care and includes complementary therapies and non-pharmacological interventions. There is no common European approach on how to educate healthcare professionals on complementary therapies and non-pharmacological interventions for symptom management. Nurses report a lack of formal education as the main barrier to applying integrative nursing.

OBJECTIVES

The aim of this study is to develop and validate integrative nursing learning outcomes in a competency profile for bachelor nursing students.

METHODS

A two-round Delphi study was conducted with experts on integrative nursing and/or nurse education from eight European countries. The expert panelists rated their level of agreement with learning outcomes in relation to "Knowledge, Skills, Responsibility and Autonomy" on a nine-point Likert scale (1 = strongly disagree/9 = strongly agree) and were invited to add comments in an open text field. The Rand manual's description of levels of appropriateness was used, and experts' suggestions were analyzed thematically and used for reformulating or adding learning outcomes.

RESULTS

In the first round, 19 out of 23 experts participated, versus 18 in the second round. In all, thirty-five learning outcomes within the three areas Knowledge, Skills and Responsibility/Autonomy were rated. After two Delphi rounds, twenty-four included learning outcomes were classified as appropriate, with median levels of appropriateness between 7 and 9; none had been classified as inappropriate. The learning outcomes include general knowledge about selected complementary therapies and non-pharmacological interventions, safety, national rules and regulations, communication and ethical skills and competencies for self-care actions and for applying simple evidence-based complementary therapies and non-pharmacological interventions in nursing practice.

CONCLUSIONS

The competency profile consist of validated competencies; the high degree of consensus from the expert panelists makes the learning outcomes relevant for structuring a teaching module for nursing students about integrative nursing.

Barriers and facilitators for implementation of automated home medication dispensers in home care from Dutch professionals' perspective: a qualitative study

INTRODUCTION AND AIMS

Present-day home care needs to be more efficiently organized in view of the ageing of the population and the current nursing shortages. Ensuring safe medication use is part of the challenge. The number of required visits could be reduced if automated home medication dispensers (AHMD) are adequately implemented. However, the barriers and facilitators for implementation are unknown. We aimed to explore determinants (barriers, facilitators or both) for implementing AHMD in home care, from home care nurses' perspective.

METHODS

Semistructured interviews were conducted with home care nurses. Determinants were identified through thematic content analysis. The first four transcripts were coded inductively. Then, a code tree was developed based on the Tailored Implementation for Chronic Diseases checklist, consisting of seven domains. Each code/determinant was then labelled as a barrier, facilitator or both.

RESULTS

Fifteen home care nurses were interviewed. The most relevant domains were innovation factors, individual health professional factors and patient factors. The most mentioned barrier was the required unplanned visits when patients do not withdraw medication within the scheduled time limit (alarm). According to our respondents, carefully assessing patients' eligibility (e.g. learnability) and properly instructing and guiding them will help prevent these alarms from happening. Next to these determinants, motivating patients to start using an AHMD and professionals having sufficient knowledge and confidence were the most mentioned facilitators.

CONCLUSION

An overview of 78 determinants from nurses' perspective for implementation of AHMD in home care was established. This should form the basis for developing strategies for implementing AHMD in home care. Further research is recommended to investigate the perceived determinants from the patients', relatives' and informal caregivers' perspectives, and to prioritize the determinants from all perspectives.

Reference values of diaphragmatic dimensions in healthy children aged 0-8 years

Diaphragmatic thickness (Tdi) and diaphragm thickening fraction (dTF) are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children are scarce. We determined reference values of Tdi and dTF using ultrasound in healthy children aged 0-8 years old and assessed their reproducibility. In a prospective, observational cohort, Tdi and dTF were measured on ultrasound images across four age groups comprising at least 30 children per group: group 1 (0-6 months), group 2 (7 months-1 year), group 3 (2-4 years) and group 4 (5-8 years). Ultrasound images of 137 healthy children were included. Mean Tdi at inspiration was 2.07 (SD 0.40), 2.09 (SD 0.40), 1.69 (SD 0.30) and 1.72 (SD 0.30) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at expiration was 1.64 (SD 0.30), 1.67 (SD 0.30), 1.38 (SD 0.20) and 1.42 (SD 0.20) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at inspiration and mean Tdi at expiration for groups 1 and 2 were significantly greater than those for groups 3 and 4 (both p < 0.001). Mean dTF was 25.4% (SD 10.4), 25.2% (SD 8.3), 22.8% (SD 10.9) and 21.3% (SD 7.1) for group 1, 2, 3 and 4, respectively. The intraclass correlation coefficients (ICC) representing the level of inter-rater reliability between two examiners performing the ultrasounds was 0.996 (95% CI 0.982-0.999). ICC of the inter-rater reliability between the raters in 11 paired assessments was 0.989 (95% CI 0.973-0.995).   Conclusion: Ultrasound measurements of Tdi and dTF were highly reproducible in healthy children aged 0-8 years.    Trial registration: ClinicalTrials.gov identifier (NCT number): NCT04589910. What is Known: • Diaphragmatic thickness and diaphragm thickening fraction are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children to compare these with are scarce. What is New: • We determined normal values of diaphragmatic thickness and diaphragm thickening fraction using ultrasound in 137 healthy children aged 0-8 years old. The diaphragmatic thickness of infants up to 1 year old was significantly greater than that of children from 2 to 8 years old. Diaphragmatic thickness decreased with an increase in body surface area. These normal values in healthy children can be used to assess changes in respiratory muscle thickness in mechanically ventilated children.

COMFORTneo scale: a reliable and valid instrument to measure prolonged pain in neonates?

OBJECTIVE

We studied the reliability and validity of the COMFORTneo scale, designed to measure neonatal prolonged pain.

STUDY DESIGN

This prospective observational study evaluated four clinimetric properties of the COMFORTneo scale from NICU nurses' assessments of neonates' pain. Intra-rater reliability was determined from three video fragments at two time points. Inter-rater reliability and construct validity were determined in five neonates per nurse with the COMFORTneo and numeric rating scales (NRS) for pain and distress. Pain scores using N-PASS were correlated with COMFORTneo scores to further evaluate construct validity.

RESULT

Intra-rater reliability: Twenty-two nurses assessed pain twice with an intraclass correlation coefficient (ICC) of 0.70. Inter-rater reliability: The ICC for 310 COMFORTneo scores together with 62 nurses was 0.93. Construct validity: Correlation between COMFORTneo and NRS pain, distress, and N-PASS was 0.34, 0.72, and 0.70, respectively.

CONCLUSION

The COMFORTneo can be used to reliably and validly assess pain in NICU patients.

Falls Incidence Compared Between a Multibedded Ward Hospital and a 100% Single-Occupancy Room Hospital: An Uncontrolled Before-After Study

BACKGROUND

Single-occupancy patient rooms in hospitals have become popular because of the privacy they offer. A downside, however, is the lack of social control from other patients, which might increase the risk of falls and undetected delirium.

AIM

To study whether the incidence of falls in single-occupancy patient rooms differs from that in multibedded patient rooms. Secondary aims were to establish differences in the context of falls and differences in delirium incidence.

METHODS

An uncontrolled observational before-after study was performed during 16 months before and 16 after moving to a hospital with 100% single-occupancy patient rooms. Fall data were retrieved from the hospital incident reporting system. The Delirium Observation Screening Scale (DOSS) was retrieved from the hospital electronic patient data system. Main outcomes were the number of falls per 1,000 patient days, assessed with a Poisson regression analysis, and delirium incidence in fallers.

RESULTS

The incidence of falls was not significantly different between the before period (1.39 falls/1,000 patient days) and the after period (1.38 falls/1,000 patient days; p = .924). In the after period, falls in the bathroom were significantly more frequent than in the before period, respectively, 17.2% and 9.4% (p = .003). In both periods, one quarter of the patients who fell had been assessed for delirium. In the before period, 57/73 (78%) of those were suspected for delirium (DOSS ≥ 3) versus 37/55 (67%) in the after period (p = .225).

CONCLUSIONS

In this study, we observed no change in incidence of falls after moving to a hospital with 100% single-occupancy bed rooms.

Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study

AIMS AND OBJECTIVES

To identify the prevalence and determinants of medication administration errors (MAEs).

BACKGROUND

Insight into determinants of MAEs is necessary to identify interventions to prevent MAEs.

DESIGN

A prospective observational study in two Dutch hospitals, a university and teaching hospital.

METHODS

Data were collected by observation. The primary outcome was the proportion of administrations with one or more MAEs. Secondary outcomes were the type, severity and determinants of MAEs. Multivariable mixed-effects logistic regression analyses were used for determinant analysis. Reporting adheres to the STROBE guideline.

RESULTS

MAEs occurred in 352 of 2576 medication administrations (13.7%). Of all MAEs (n = 380), the most prevalent types were omission (n = 87) and wrong medication handling (n = 75). Forty-five MAEs (11.8%) were potentially harmful. The pharmaceutical forms oral liquid (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.25), infusion (OR 1.73, CI 1.02-2.94), injection (OR 3.52, CI 2.00-6.21), ointment (OR 10.78, CI 2.10-55.26), suppository/enema (OR 6.39, CI 1.13-36.03) and miscellaneous (OR 6.17, CI 1.90-20.04) were more prone to MAEs compared to oral solid. MAEs were more likely to occur when medication was administered between 10 a.m.-2 p.m. (OR 1.91, CI 1.06-3.46) and 6 p.m.-7 a.m. (OR 1.88, CI 1.00-3.52) compared to 7 a.m.-10 a.m. and when administered by staff with higher professional education compared to staff with secondary vocational education (OR 1.68, CI 1.03-2.74). MAEs were less likely to occur in the teaching hospital (OR 0.17, CI 0.08-0.33). Day of the week, patient-to-nurse ratio, interruptions and other nurse characteristics (degree, experience, employment type) were not associated with MAEs.

CONCLUSIONS

This study identified a high MAE prevalence. Identified determinants suggest that focusing interventions on complex pharmaceutical forms and error-prone administration times may contribute to MAE reduction.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can be used to develop targeted interventions to improve patient safety.

No association between thickening fraction of the diaphragm and extubation success in ventilated children

Introduction

In mechanically ventilated adults, thickening fraction of diaphragm (dTF) measured by ultrasound is used to predict extubation success. Whether dTF can also predict extubation success in children is unclear.

Aim

To investigate the association between dTF and extubation success in children. Second, to assess diaphragm thickness during ventilation and the correlation between dTF, diaphragm thickness (Tdi), age and body surface.

Method

Prospective observational cohort study in children aged 0-18 years old with expected invasive ventilation for >48 h. Ultrasound was performed on day 1 after intubation (baseline), day 4, day 7, day 10, at pre-extubation, and within 24 h after extubation. Primary outcome was the association between dTF pre-extubation and extubation success. Secondary outcome measures were Tdi end-inspiratory and Tdi end-expiratory and atrophy defined as <10% decrease of Tdi end-expiratory versus baseline at pre-extubation. Correlations were calculated with Spearman correlation coefficients. Inter-rater reliability was calculated with intraclass correlation (ICC).

Results

Fifty-three patients, with median age 3.0 months (IQR 0.1-66.0) and median duration of invasive ventilation of 114.0 h (IQR 55.5-193.5), were enrolled. Median dTF before extubation with Pressure Support 10 above 5 cmH₂O was 15.2% (IQR 9.7-19.3). Extubation failure occurred in six children, three of whom were re-intubated and three then received non-invasive ventilation. There was no significant association between dTF and extubation success; OR 0.33 (95% CI; 0.06-1.86). Diaphragmatic atrophy was observed in 17/53 cases, in three of extubation failure occurred. Children in the extubation failure group were younger: 2.0 months (IQR 0.81-183.0) vs. 3.0 months (IQR 0.10-48.0); p = 0.045. At baseline, pre-extubation and post-extubation there was no significant correlation between age and BSA on the one hand and dTF, Tdi- insp and Tdi-exp on the other hand. The ICC representing the level of inter-rater reliability between the two examiners performing the ultrasounds was 0.994 (95% CI 0.970-0.999). The ICC of the inter-rater reliability between the raters in 36 paired assessments was 0.983 (95% CI 0.974-0.990).

Conclusion

There was no significant association between thickening fraction of the diaphragm and extubation success in ventilated children.

Effect of a Pharmacy-based Centralized Intravenous Admixture Service on the Prevalence of Medication Errors: A Before-and-After Study

OBJECTIVES

Intravenous admixture preparation errors (IAPEs) may lead to patient harm. The primary aim of this study was to assess the effect of a pharmacy-based centralized intravenous admixture service (CIVAS) on IAPEs.

METHODS

We conducted a before-and-after study in 3 clinical wards before CIVAS implementation and in the CIVAS unit 18 months after implementation. Intravenous admixture preparation error data were collected by disguised observation. The primary outcome was the proportion of admixtures with 1 or more IAPEs. Secondary outcomes were the type and potential severity of IAPEs, noncompliance to hygiene procedures, and nursing staff satisfaction with the CIVAS. The primary outcome was analyzed using a multivariable mixed-effects logistic regression model.

RESULTS

One or more IAPEs were identified in 14 of 543 admixtures (2.6%) in the CIVAS unit and in 148 of 282 admixtures (52.5%) in the clinical wards (odds ratio, 0.02; 95% confidence interval, 0.004-0.05). The most common IAPE types were wrong solvent or diluent (n = 95) and wrong volume of infusion fluid (n = 45). No potentially harmful IAPEs occurred in the CIVAS unit as opposed to 22 (7.8%) in the clinical wards. Disinfection procedures were better adhered to in the CIVAS unit. Overall nurse satisfaction with the CIVAS increased from a median of 70 (n = 166) 5 months after intervention to 77 (n = 115) 18 months after intervention ( P < 0.001) on a 100-point scale.

CONCLUSIONS

Centralized intravenous admixture service performed notably better than the clinical wards with regard to IAPEs and noncompliance to hygiene procedures. Nurses were satisfied with the CIVAS. Hence, the implementation of CIVAS is an important strategy to improve medication safety in hospitals.

Educational courses on non-pharmacologic complementary interventions for nurses across Europe: The INES mapping pilot study

BACKGROUND

Pharmacological interventions still form the mainstay of the management of pain, anxiety, sleep problems and discomfort. In Europe, an estimated 100 million people use complementary non-pharmacological interventions (NPIs) for these conditions. In their pre-registration education, nurses do not generally learn about the various types of NPIs and how patients and health care professionals can include NPIs complementary to their standard care. Some nursing schools in Europe offer elective courses on NPIs, often relying on individual initiatives. Little is publicly available about the content of these programmes and how they relate to the current nursing curriculum for EU countries.

OBJECTIVES

This pilot study aims to explore and map the field of nursing education with regard to complementary NPIs for nurses in Europe.

DESIGN

A web-based open-access questionnaire administered through the online survey tool LimeSurvey® was designed by the authors.

PARTICIPANTS

The questionnaire was sent to a purposive sample of 49 experts on nurse education and complementary NPIs from 16 European countries. All levels of education were eligible for inclusion.

METHODS

The questionnaire consisted of 35 items regarding course content, teaching material, teaching methods and methods of assessment. In addition, respondents were invited to perform a strengths, weaknesses, opportunities and threats (SWOT) analysis in relation to their education programme. Qualitative data was analyzed using a directive content analysis approach.

RESULTS

Between January and May 2020, thirty-one completed questionnaires from ten different countries were returned (response rate 63.3%). Massage, meditation, mindfulness and relaxation are the most taught interventions. Anxiety, stress, chronic pain, depression and sleep problems are the most common symptoms addressed.

CONCLUSIONS

Currently, a consistent and European approach to education for nurses on complementary NPIs and integrative nursing is lacking. Although taught at regular nursing educational institutes, the courses discussed here are not yet embedded in mainstream education for nurses.

Nurse Practitioners' Self-Efficacy and Behavior in Supporting Self-Management of Patients With a Progressive, Life-Threatening Illness and Their Relatives: A Nationwide, Cross-Sectional Online Survey

This study aimed at investigating nurse practitioners' self-efficacy and behavior in supporting self-management of patients with a progressive, life-threatening illness and their relatives. We adapted an existing validated instrument for this purpose, amongst other things by adding a seventh subscale "attention for relatives," and administered it in a nationwide, cross-sectional online survey among Dutch nurse practitioners. We analyzed associations between self-reported self-efficacy and behavior using Pearson correlations and paired sample t tests. Associations between self-efficacy and behavior with nurse practitioners' characteristics were examined using linear regression models. Most nurse practitioners (n = 327; 26% complete responses) were women (93%). Subscale and total scores for nurse practitioners' self-efficacy were moderately positively correlated with those for their behavior in self-management support. Subscale and total scores were statistically significantly higher for their self-efficacy than for their behavior. Increased work experience with patients with a progressive, life-threatening illness was associated with higher scores on self-efficacy and behavior in self-management support. We conclude that nurse practitioners are confident in their ability to support self-management; yet, they do not always use these competencies in practice.

Cost-effectiveness of central automated unit dose dispensing with barcode-assisted medication administration in a hospital setting

BACKGROUND

Central automated unit dose dispensing (cADD) with barcode-assisted medication administration (BCMA) has been shown to reduce medication administration errors (MAEs). Little is known about the cost-effectiveness of this intervention.

OBJECTIVE

To estimate the cost-effectiveness of cADD with BCMA compared to usual care.

METHODS

An economic evaluation was conducted alongside a prospective before-and-after effectiveness study in a Dutch university hospital. The primary effect measure was the difference between the rate of MAEs before and after implementation of cADD with BCMA, obtained by disguised observation in six clinical wards and subsequent extrapolation to the entire hospital. The cost-analysis was conducted from a hospital perspective with a 12-month incremental costing approach. The total costs covered the pharmaceutical service, nurse medication handling, wastage, and materials related to cADD. The primary outcome was the cost-effectiveness ratio expressed as costs per avoided MAE, obtained by dividing the annual incremental costs by the number of avoided MAEs. The secondary outcome was the cost-effectiveness ratio expressed as costs per avoided potentially harmful MAE (i.e. MAEs with the potential to cause harm).

RESULTS

The intervention was associated with an absolute MAE reduction of 4.5% and a reduction of 2.7% for potentially harmful MAEs. Based on 2,260,870 administered medications in the entire hospital annually, a total of 102,210 MAEs and 59,830 potentially harmful MAEs were estimated to be avoided. The intervention was associated with an increased incremental cost of €1,808,600 annually. The cost-effectiveness ratio was €17.69 per avoided MAE and €30.23 per avoided potentially harmful MAE.

CONCLUSIONS

The implementation of cADD with BCMA was associated with a reduced rate of medication errors, including harmful ones, at higher overall costs. The costs per avoided error are relatively low, and therefore, this intervention could be an important strategy to improve patient safety in hospitals.

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.

Aromatherapy massage seems effective in critically ill children: an observational before‐after study

Children treated in a pediatric intensive care unit (PICU) are at risk of distress and pain. This study investigated if aromatherapy massage can reduce children's distress and improve comfort. This observational before‐after study was performed in a 22‐bed PICU in Cape Town, South Africa. The aromatherapy massage consisted of soft massaging using the “M‐technique” and a 1% blend of essential oils of Lavender (Lavandula angustifolia), German Chamomile (Matricatia recutita) and Neroli (Citrus aurantium) mixed with a grapeseed carrier oil. All present children were eligible, except those who had recently returned, were asleep or deemed unstable. The primary outcome was distress measured with the COMFORT‐Behavior scale (COMFORT‐B). Secondary outcomes were heart rate, oxygen saturation (SatO₂), the Numeric Rating Scale (NRS)‐Anxiety and pain assessed by the NRS‐Pain scale. Outcomes variables were evaluated with Wilcoxon signed‐rank test and multiple regression analysis. The intervention was applied to 111 children, fifty‐one of whom (45.9%) were younger than three years old. The group median COMFORT‐B score before intervention was 15 (IQR 12–19), versus 10 (IQR 6–14) after intervention. Heart rate and NRS‐Anxiety were significantly lower after the intervention (P < 0.001). Multiple regression analysis showed that interrupted massages were less effective than the uninterrupted massages. Parental presence did not influence the outcome variables. We did not find a significant change on the NRS‐Pain scale or for SatO₂. Aromatherapy massage appears beneficial in reducing distress, as measured by the COMFORT‐B scale, heart rate and the NRS‐Anxiety scale, in critically ill children. Thus, the potential of aromatherapy in clinical practice deserves further consideration.

The Effect of Ibuprofen Exposure and Patient Characteristics on the Closure of the Patent Ductus Arteriosus in Preterm Infants

Spontaneous closure of the ductus arteriosus depends on gestational age (GA) and might be delayed in preterm infants, resulting in patent ductus arteriosus (PDA). Ibuprofen can be administered to enhance closure, but the exposure‐response relationship between ibuprofen and the closure of PDA remains uncertain. We investigated the influence of patient characteristics and ibuprofen exposure on ductus closure. A cohort of preterm infants with PDA and treated with ibuprofen was analyzed. Ibuprofen exposure was based on a previously developed population pharmacokinetic study that was in part based on the same study population. Logistic regression analyses were performed with ductus closure (yes/no) as outcome, to analyze the contribution of ibuprofen exposure and patient characteristics. In our cohort of 263 preterm infants (median GA 26.1 (range: 23.7–30.0) weeks, birthweight 840 (365–1,470) g) receiving ibuprofen treatment consisting of 3 doses that was initiated at a median postnatal age (PNA_start) of 5 (1–32) days, PDA was closed in 55 (21%) patients. Exposure to ibuprofen strongly decreased with PNA_start. Overall, the probability of ductus closure decreased with PNA_start (odds ratio (OR): 0.7, 95% CI: 0.6–0.8) and Z‐score for birthweight (Z_{Birthweight‐for‐GA}; OR: 0.8, 95% CI: 0.6‐1.0), and increased with GA (OR: 1.5, 95% CI: 1.1–1.9). For patients with PNA_start < 1 week, concentrations of ibuprofen, GA, and Z_{Birthweight‐for‐GA} predicted probability of ductus closure. During a window of opportunity for ductus closure within the first days of life, probability of closure depends on GA, Z_{Birthweight‐for‐GA}, and ibuprofen exposure. Increased, yet unstudied dosages might increase the effectivity of ibuprofen beyond the first week of life.

Quality improvement intervention to stimulate early mobilization of critically ill children

BACKGROUND

Immobility during hospital stay is associated with muscle weakness, delirium, and delayed neurocognitive recovery. Early mobilization of critically ill adults improves their physical functioning and shortens the duration of mechanical ventilation. However, comparable research in children is lacking.

AIMS

To determine the effects of the implementation of an early mobilization (EM) program on mobility activities for critically ill children and to explore barriers and facilitators and clinical outcomes before and after implementation.

STUDY DESIGN

A prospective single-centre before-and-after study.

METHODS

This study was conducted in a PICU of a large tertiary hospital. Children aged from 3 months to 18 years, with an expected stay of ≥3 days were eligible to participate. In the "before" phase, participants received usual care; in the "after" phase we implemented a multicomponent, multidisciplinary EM protocol. The primary outcome was a change in the process outcome "mobilization activities". Secondary outcomes were PICU staff opinions on mobilization (survey), safety, process measures, involvement of parents and physical therapist, and clinical outcomes (sedative use and prevalence of delirium).

RESULTS

A total of 113 children were included; 55 before and 58 after, with a median age of 31 months (IQR: 10-103) and 35 months (IQR: 7-152), respectively. The number of mobilization activities (per patient per day) had significantly increased from 5 (IQR: 2-7) to 6 (IQR: 4-8) (U = 272185.0; p < .001). PT consultations for mobilization had significantly increased from 23.6% (13/55) to 46.5% (27/58) (X²  = 6.48; p = .011). In both phases, no mobilization-related adverse events were documented. The survey showed that PICU staff found EM of critically ill children useful and feasible. In the after phase, PICU staff rated the perceived benefit of the support of the physical therapist during mobilization activities significantly higher than in the before phase (X²  = 34.80; p < .001).

CONCLUSIONS

Implementation of a structured EM program for critically ill children is feasible and safe.

RELEVANCE TO CLINICAL PRACTICE

It is suggested to start the implementation of a structed EM program with the idendentification of local barriers and facilitators by an interdisciplinary PICU team. Further, an increased presence of physiotherapists on the PICU would improve mobilisation levels, and facilitate mobilisation in critically ill children. Also, they can support and advice PICU nurses and parents in mobilising children.

Nurse-led self-management support after organ transplantation-protocol of a multicentre, stepped-wedge randomized controlled trial

BACKGROUND

Recipients of an organ transplantation face a number of challenges and often need to change their health behaviour. Good self-management skills are essential for optimal clinical outcomes. However, few interventions are available to support post-transplant self-management. To fill this gap, we developed a self-management support intervention offered by nurse practitioners. The primary aim of the study is to implement and test the effectiveness of the ZENN intervention in promoting self-management skills among heart, kidney liver and lung transplant recipients in comparison to standard care. The secondary aim is to assess the self-management support skills of nurse practitioners who will deliver the intervention.

METHODS

This multi-centre stepped-wedge randomized controlled trial will take place from September 2020 until May 2023. All departments will commence with inclusion of patients in the control period. Each department will be randomly assigned to a start date (step in the wedge) to commence the experimental period. Patients in the control period will receive standard care and will be asked to complete questionnaires at baseline (T0), 6 months (T1) and 12 months (T2), to assess self-management, self-regulation, quality of life and adherence. During the experimental period, patients will receive standard care plus the ZENN intervention and receive the same set of questionnaires as participants in the control period. Nurse practitioners will complete a baseline and follow-up questionnaire to assess differences in self-management support skills. Video recordings of outpatient clinic consultations during the control and experimental periods will determine the differences in nurses' needs-thwarting and needs-supporting skills between the control and experimental period.

DISCUSSION

The ZENN intervention could be a useful approach to support patients' self-management skills after organ transplantation and thus promote clinical outcomes as well as avoid adverse events.

TRIAL REGISTRATION

Dutch Trial Register NL8469 . Registered on March 19, 2020.

Four-in-One: A Comprehensive Checklist for the Assessment of Pain, Undersedation, Iatrogenic Withdrawal and Delirium in the PICU: A Delphi Study

OBJECTIVES

Children's pain, undersedation, iatrogenic withdrawal syndrome and delirium often have overlapping symptoms, which makes it difficult to decide why a child in the PICU is not comfortable. Validated assessment tools for these conditions are available, but regular assessment with multiple instruments may be too time-consuming. Therefore, we aimed to develop a new holistic instrument-the mosaIC checklist-that incorporates the assessment of the four conditions.

MATERIALS AND METHODS

We conducted a two-rounds international Delphi study among experts working in PICUs worldwide to find cues that in combination or separately are relevant for the four conditions.

RESULTS

In the first Delphi round, 38 of the 48 enrolled participants (79%) completed a questionnaire; in the second round 32 of 48 (67%). Eventually, 46 cues in eight categories (e.g., facial, vocal/verbal, body movements, sleep /behavioral state, posture/muscle tone, agitation, physiological and contextual) were found relevant. Thirty-three (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for iatrogenic withdrawal syndrome (76%) and 28 (61%) for pediatric delirium. Thirteen cues (28%) were considered relevant for all four conditions; 11's (24%) for only one condition.

CONCLUSION

This Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. Application of the mosaIC checklist could help determine what condition is most likely to cause a child's discomfort-and at the same time help reduce the PICU staff's registration burden.

COVID-19 lockdown impacts the wellbeing of parents with infants on a Dutch neonatal intensive care unit

PURPOSE

Parents of infants admitted to a neonatal intensive care unit (NICU) experience additional stress due to restrictions on their presence and visits by other family members during the COVID-19 pandemic. Our study aims to describe how this impacted parents and how NICU staff could support them.

DESIGN AND METHODS

This was a cross-sectional study in which 25 parents (16 mothers, 9 fathers) of infants admitted to our NICU during the first COVID-19 lockdown completed online questionnaires with socio-demographic questions, the Parental Stressor Scale:NICU (PSS:NICU) and questions related to COVID-19.

RESULTS

Being separated from, and not being able to hold their infant at all times were among the most important PSS:NICU stressors. Parents experienced additional stress because other family members were not allowed to visit. They indicated that NICU staff could support them by clearly explaining the reasons for visitor restrictions and by ensuring that they felt heard. Most parents supported the restrictions, but also mentioned that less strict measures would really help them.

CONCLUSIONS

Parents who participated in this study found it very stressful that they could not be with their infant together with their partner and other family members. Furthermore, parents recommended the hospital management to continuously reconsider whether particular restrictions could be lifted in case of a new lockdown. Together with clear communication, this would result in less parenteral stress.

PRACTICE IMPLICATIONS

Hospital management should be cautious on restricting the presence of parents and other family members and scale restrictions back whenever possible.

Neonatal Pain, Opioid, and Anesthetic Exposure; What Remains in the Human Brain After the Wheels of Time?

OBJECTIVE

To evaluate possible negative long-term effects of neonatal exposure to pain, opioids and anesthetics in children and adolescents.

STUDY DESIGN

We studied five unique groups of children recruited from well-documented neonatal cohorts with a history of neonatal exposure to pain, opioids or anesthetics at different points along the continuum from no pain to intense pain and from no opioid exposure to very high opioid exposure in the presence or absence of anesthetics. We evaluated children who underwent major surgery (group 1 and 2), extracorporeal membrane oxygenation (group 3), preterm birth (group 4) and prenatal opioid exposure (group 5) in comparison to healthy controls. Neuropsychological functioning, thermal detection and pain thresholds and high-resolution structural and task-based functional magnetic resonance imaging during pain were assessed. In total 94 cases were included and compared to their own control groups.

RESULTS

Children and adolescents in groups 3 and 5 showed worse neuropsychological functioning after high opioid exposure. A thicker cortex was found in group 1 (pain, opioid and anesthetic exposure) in only the left rostral-middle-frontal-cortex compared to controls. We found no differences in other brain volumes, pain thresholds or brain activity during pain in pain related brain regions between the other groups and their controls.

CONCLUSIONS

No major effects of neonatal pain, opioid or anesthetic exposure were observed in humans 8-19 years after exposure in early life, apart from neuropsychological effects in the groups with the highest opioid exposure that warrants further investigation. Studies with larger sample sizes are needed to confirm our findings and test for less pronounced differences between exposed and unexposed children.

Quantifying the pharmacodynamics of morphine in the treatment of postoperative pain in preverbal children

While the pharmacokinetics of morphine in children have been studied extensively, little is known about the pharmacodynamics of morphine in this population. Here, we quantified the concentration‐effect relationship of morphine for postoperative pain in preverbal children between 0 and 3 years of age. For this, we applied item response theory modeling in the pharmacokinetic/pharmacodynamic analysis of COMFORT‐Behavior (COMFORT‐B) scale data from 2 previous clinical studies. In the model, we identified a sigmoid maximal efficacy model for the effect of morphine and found that in 26% of children, increasing morphine concentrations were not associated with lower pain scores (nonresponders to morphine up‐titration). In responders to morphine up‐titration, the COMFORT‐B score slowly decreases with increasing morphine concentrations at morphine concentrations >20 ng/mL. In nonresponding children, no decrease in COMFORT‐B score is expected. In general, lower baseline COMFORT‐B scores (2.1 points on average) in younger children (postnatal age <10.3 days) were found. Based on the model, we conclude that the percentage of children at a desirable COMFORT‐B score is maximized at a morphine concentration between 5 and 30 ng/mL for children aged <10 days, and between 5 and 40 ng/mL for children >10 days. These findings support a dosing regimen previously suggested by Krekels et al, which would put >95% of patients within this morphine target concentration range at steady state. Our modeling approach provides a promising platform for pharmacodynamic research of analgesics and sedatives in children.

Effectiveness of Simulation Training and Assessment of PICU Nurses' Resuscitation Skills: A Mixed Methods Study from the Netherlands

PURPOSE

The quality of resuscitation and effective leadership are decisive for the outcome of a resuscitation. Nurses are usually the first responders upon cardiac arrest. Therefore, we started the "proficiency check" project, which aims to improve nurses' resuscitation and teamwork skills. This article describes the effectiveness of the proficiency check and nurses' experiences with it.

DESIGN AND METHODS

This study was done among intensive care nurses working on a pediatric ICU (PICU) in the Netherlands. It was designed as a mixed-methods study combining a quantitative and a qualitative approach. Quantitative data were obtained through a pre-posttest comparison of nurses' resuscitation and teamwork skills, in a simulation setting. Qualitative data on nurses' experiences were collected through semi-structured individual interviews.

RESULTS

Both resuscitation and teamwork skills improved significantly. In 39 nurses (32%), the improvement of both resuscitation and teamwork skills after the intervention was large (effect size >0.8). The experiences of nurses regarding the proficiency check were diverse: on the positive side, increased knowledge and confidence were reported, whereas negative experiences related, among other things, to stress and anxiety.

CONCLUSIONS

Resuscitation and teamwork skills of PICU nurses can be enhanced by the 'proficiency check' studied here. This simulation-based training can be further improved by incorporating the nurses' experiences.

PRACTICE IMPLICATIONS

A simulation-based assessment for resuscitation may play an important role in a PICU, and possibly for other skills and in other settings as well. Particular attention should be paid to the stress that many nurses experience due to skills assessment.

Professional Assessment Tool for Team Improvement: An assessment tool for paediatric intensive care unit nurses' technical and nontechnical skills

BACKGROUND

Cardiorespiratory arrests are rare in paediatric intensive care units, yet intensive care nurses must be able to initiate resuscitation before medical assistance is available. For resuscitation to be successful, instant decision-making, team communication, and the coordinating role of the first responsible nurse are crucial. In-house resuscitation training for nurses includes technical and nontechnical skills.

OBJECTIVES

The aim of this study was to develop a valid, reliable, and feasible assessment instrument, called the Professional Assessment Tool for Team Improvement, for the first responsible nurse's technical and nontechnical skills.

METHODS

Instrument development followed the COnsensus-based Standards for the selection of health Measurement Instruments guidelines and professionals' expertise. To establish content validity, experts reached consensus via group discussions about the content and the operationalisation of this team role. The instrument was tested using two resuscitation assessment scenarios. Inter-rater reliability was established by assessing 71 nurses in live scenario sessions and videotaped sessions, using intraclass correlation coefficients and Cohen's kappa. Internal consistency for the total instrument was established using Cronbach's alpha. Construct validity was assessed by examining the associations between raters' assessments and nurses' self-assessment scores.

RESULTS

The final instrument included 12 items, divided into four categories: Team role, Teamwork and communication, Technical skills, and Reporting. Intraclass correlation coefficients were good in both live and videotaped sessions (0.78-0.87). Cronbach's alpha was stable around 0.84. Feasibility was approved (assessment time reduced by >30%).

CONCLUSIONS

The Professional Assessment Tool for Team Improvement appears to be a promising valid and reliable instrument to assess both technical and nontechnical skills of the first responsible paediatric intensive care unit nurse. The ability of the instrument to detect change over time (i.e., improvement of skills after training) needs to be established.

Towards Evidence-Based Weaning: a Mechanism-Based Pharmacometric Model to Characterize Iatrogenic Withdrawal Syndrome in Critically Ill Children

For the management of iatrogenic withdrawal syndrome (IWS) in children, a quantitative understanding of the dynamics of IWS of commonly used opioids and sedatives is lacking. Here, we introduce a new mechanism-based pharmacokinetic-pharmacodynamic (PKPD) modeling approach for studying IWS in pediatric clinical datasets. One thousand seven hundred eighty-two NRS_withdrawal scores of IWS severity were analyzed, which were collected from 81 children (age range: 1 month–18 years) that received opioids or sedatives by continuous infusion for 5 days or more. These data were successfully fitted with a PKPD model consisting of a plasma and a dependence compartment that well characterized the dynamics of IWS from morphine, fentanyl, and ketamine. The results suggest that (1) instead of decreasing the infusion rate by a set percentage at set intervals, it would be better to lengthen the weaning period when higher infusion rates are administered prior to weaning; (2) for fentanyl specifically, the risk of IWS might be lower when weaning with smaller dose reductions every 12 h instead of weaning with greater dose reductions every 48 h. The developed PKPD model can be used to evaluate the risk of IWS over time and the extent to which it is affected by different weaning strategies. The results yield hypotheses that could guide future clinical research on optimal weaning strategies. The mechanism-based PKPD modeling approach can be applied in other datasets to characterize the IWS dynamics of other drugs used in pediatric intensive care.

[Communication about in hospital resuscitation orders]

BACKGROUND

The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives.

AIM

To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding.

METHODS

This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire.

RESULTS

A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically.

CONCLUSIONS

The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

Integrating Placebo Effects in General Practice: A Cross-Sectional Survey to Investigate Perspectives From Health Care Professionals in the Netherlands

Objectives: Placebo effects, beneficial treatment outcomes due to non-active treatment components, play an important role in the overall treatment response. To facilitate these beneficial effects it is important to explore the perspectives of health care professionals (HCPs) on the integration of placebo effects in clinical care. Three themes were investigated: knowledge about placebo effects and factors that contribute to these, frequency of placebo use, and attitudes toward acceptability and transparency of placebo use in treatment. Methods: A cross-sectional survey, according to the Checklist for Reporting Results of Internet E-Surveys guidelines and STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE), was conducted in the Netherlands in 2020. The survey was conducted in two samples: a (nested) short survey in 78 nurses during working shifts (sample 1) and an extended online survey in 47 general HCPs e.g., medical psychologists, oncologists, surgeons (sample 2). Results: Respondents from both samples reported to be somewhat or quite familiar with placebo effects (24.0 and 47.2%, respectively). From the six placebo mechanisms that were presented, mind-body interaction, positive expectations, and brain activity involved in placebo effects were rated as the most influential factors in placebo effects [F_(5,119) = 20.921, p < 0.001]. The use of placebo effects was reported in 53.8% (n = 42) of the nurses (e.g., by inducing positive expectations), and 17.4% of the HCPs (n = 8 reported to make use of pure placebos and 30.4% of impure placebos (n = 14). Attitudes toward placebo use in treatment were acceptant, and transparency was highly valued (both up to 51%). Conclusions: The findings from this study address knowledge gaps in placebo effects in practice and provide insights in attitudes toward the integration of placebo effects from HCPs. Altogether, integrating these findings may potentially optimize treatment outcomes.

Implementation strategies used to implement nursing guidelines in daily practice: A systematic review

OBJECTIVES

Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.

DESIGN

Systematic review. PROSPERO registration number: CRD42018104615.

DATA SOURCES

We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.

REVIEW METHODS

Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.

RESULTS

A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.

CONCLUSIONS

A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes.

Perspectives of patients, relatives and nurses on rooming-in for adult patients: A scoping review of the literature

AIM

To explore the perspectives of patients, their relatives and nurses on rooming-in for adult patients.

BACKGROUND

The practice of having family stay overnight with an adult patient in hospital is quite new. To support rooming-in programs, the perspectives from all stakeholders should be taken into account.

METHODS

All types of studies on rooming-in in adult healthcare settings were included in this scoping review. Rooming-in has been defined as the practice where 'family members or trusted others are facilitated to continuously stay with the patient and are provided with facilities to sleep in the patient's room'.

RESULTS

Seven studies were included: one randomized controlled trial, three qualitative studies, and three correspondence articles. Generally, patients felt safe in the presence of a family member, but could also feel restricted in their freedom and privacy. Family members saw a benefit for the patient, considered rooming-in a moral duty, and were happy to help. Nonetheless, family members reported rooming-in as physically and emotionally stressful. Nurses described that patients were less anxious and more easily adjusted to the hospital environment.

CONCLUSIONS

The reviewed studies suggest that patients, family members, and nurses have both positive and negative experiences with rooming-in. The concept of rooming-in varies from continuous presence and involvement of relatives to one overnight stay in the patient's room. Each interpretation has its own implications for policy, design, guidelines and feasibility of rooming-in. Nursing staff should be included in decision-making processes for this practice.

Effects of de-implementation strategies aimed at reducing low-value nursing procedures: a systematic review and meta-analysis

Background

In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures.

Methods

PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the ‘Cochrane Effective Practice and Organisation of Care’ (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel–Haenszel risk ratios (95% CI) were calculated using a random effects model.

Results

Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20).

Conclusions

The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used.

Trial registration

The review is registered in Prospero (CRD42018105100).

The impact of introducing nurse-led analgesia and sedation guidelines in ventilated infants following cardiac surgery

INTRODUCTION

Enhanced clinical outcomes in the Paediatric Intensive Care Unit following standardisation of analgesia and sedation practice are reported. Little is known about the impact of standardisation of analgesia and sedation practice including incorporation of a validated distress assessment instrument on infants post cardiac surgery, a subset of whom have Trisomy 21. This study investigated whether the parallel introduction of nurse-led analgesia and sedation guidelines including regular distress assessment would impact on morphine administered to infants post cardiac surgery, and whether any differences observed would be amplified within the Trisomy 21 population.

METHODOLOGY

A retrospective single centre before/after study design was used. Patients aged between 44 weeks postconceptual age and one year old who had open cardiothoracic surgery were included.

RESULTS

61 patients before and 64 patients after the intervention were included. After the intervention, a reduction in the amount of morphine administered was not evident, while greater use of adjuvant sedatives and analgesics was observed. Patients with Trisomy 21 had a shorter duration of mechanical ventilation after the change in practice.

CONCLUSION

The findings from this study affirm the importance of the nurses' role in managing prescribed analgesia and sedation supported by best available evidence. A continued education and awareness focus on analgesia and sedation management in the pursuit of best patient care is imperative.

Exploring the Relationship Between Morphine Concentration and Oversedation in Children After Cardiac Surgery

Titrating analgesic and sedative drugs in pediatric intensive care remains a challenge for caregivers due to the lack of pharmacodynamic knowledge in this population. The aim of the current study is to explore the concentration‐effect relationship for morphine‐associated oversedation after cardiac surgery in children aged 3 months to 3 years. Data on morphine dosing, as well as morphine plasma concentrations, were available from a previous study on the pharmacokinetics of morphine after cardiac surgery in children. Oversedation was defined as scores below 11 on the validated COMFORT–behavioral scale. Population pharmacokinetic‐pharmacodynamic modeling was performed in NONMEM 7.3. The probability of oversedation as a function of morphine concentration was best described using a step function in which the EC₅₀ was 46.3 ng/mL. At morphine concentrations below the EC₅₀, the probability of oversedation was 2.9% (0.4& to 18%), whereas above the EC₅₀ percentages were 13% (1.9% to 52%) (median value [95% prediction interval from interindividual variability]). Additionally, the risk of oversedation was found to be increased during the first hours after surgery (P < .001) and was significantly lower during mechanical ventilation (P < .005). We conclude that morphine concentrations above approximately 45 ng/mL may increase the probability of oversedation in children after cardiac surgery. The clinician must evaluate, on a case‐by‐case basis, whether the analgesic benefits arising from dosing regimen associated with such concentrations outweigh the risks.

Measuring process indicators and adverse events to assess the quality of care for inpatients with psychosis

BACKGROUND

Research into the quality of care in psychiatry is scarce. Data collection is falling behind that for other fields of medicine and therefore the opportunity to improve care is missed.

AIMS

In this medical record study we aim to determine: (i) whether or not patients' physical health indicators are assessed and pharmacological and behavioural treatment interventions applied; (ii) the incidence and nature of adverse events in psychotic inpatients.

METHODS

Medical records of inpatients with psychosis admitted to psychiatric wards at Amsterdam UMC, location AMC, Department of psychiatry, were screened with a previously developed and tested two-step patient safety tool.

RESULTS

Data of 299 admissions were included. Physical health indicators were not assessed in one-third of cases. Fifty-five percent of the patients were smokers but only 1% received an intervention. The family was actively involved in 43% of the cases. During 11,403 admission days, 235 adverse events had been recorded. The most frequent adverse event was adverse drug reactions (40%), which were mostly related to antipsychotic medication.

CONCLUSIONS

In conclusion, quality of care auditing is useful to prioritize areas that need improvement. Future research should focus on interventions to improve the quality of psychiatric care.

Children Listening to Music or Watching Cartoons During ER Procedures: A RCT

OBJECTIVE

This study aims to determine if listening to music and watching cartoons are effective to distract children from pain and distress during procedures in the emergency room (ER).

METHODS

This study is a single-center, 3-armed, superiority randomized controlled trial comparing listening to music, watching cartoons, and standard care during ER procedures in children aged 3-13 years. The primary outcome was pain measured from video footage with the Alder Hey Triage Pain Score (AHTPS). Children older than 4 years self-reported pain with the Faces Pain Scale-Revised (FPS-R). The secondary outcome was distress measured with the Observational Scale of Behavioral Distress-revised (OSBD-r). Another indicator of distress was heart rate.

RESULTS

Data of 191 participants were analyzed for the 3 groups: music (n = 75), cartoon (n = 62), and control (n = 54). The median age was 7.3 years (4.9-9.7). In multivariable analysis, pain assessed with the AHTPS was significantly lower (B = -1.173, 95% confidence interval -1.953, -0.394, p = .003) in the music group than in the control groups. Across the 3 groups, 108 children self-reported pain with the FPS-R after the procedure. The scores were lowest in the music group, but the differences between groups were not significant (p = .077). OSBD-r distress scores assigned during the procedures were not significantly different between the 3 groups (p = .55). Heart rate directly after the procedure was not statistically significantly different between the 3 groups (p = .83).

CONCLUSIONS

Listening to recorded music is a beneficial distraction for children experiencing pain during ER procedures, whereas watching cartoons did not seem to reduce pain or distress.

Supervised Multidimensional Item Response Theory Modeling of Pediatric Iatrogenic Withdrawal Symptoms

Item‐level data from composite scales can be analyzed with pharmacometric item response theory (IRT) models to improve the quantification of disease severity compared with the use of total composite scores. However, regular IRT models assume unidimensionality, which is violated in the scale measuring iatrogenic withdrawal in children because some items are also affected by pain, undersedation, or delirium. Here, we compare regular IRT modelling of pediatric iatrogenic withdrawal symptom data with two new analysis approaches in which the latent variable is guided towards the condition of interest using numerical withdrawal severity scored by nurses as a “supervising variable:” supervised IRT (sIRT) and supervised multi‐dimensional (smIRT) modelling. In this example, in which the items scores are affected by multiple conditions, regular IRT modeling is worse to quantify disease severity than the total composite score, whereas improved performance compared with the composite score is observed for the sIRT and smIRT models.

The fragile spirituality of parents whose children died in the pediatric intensive care unit

Spiritual care is recognized as a relevant dimension of health care. In the context of pediatric palliative end-of-life care, spirituality entails more than adhering to a spiritual worldview or religion. Interviews with parents whose critically ill child died in the pediatric intensive care unit revealed features of a spirituality that is fragmentary and full of contradictions. This type of spirituality, which we refer to as fragile, speaks of parents' connectedness with the deceased child and the hope of some kind of reuniting after one's own death. Acknowledging that fragments of spirituality can be part of parents' experiences in their child's end-of-life stage can be a meaningful contribution to compassionate care.