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Detecting pediatric delirium in critically ill children is important. The Sophia Observation withdrawal Symptoms and Delirium scale (SOS-PD) is a tool for assessing both pediatric delirium and iatrogenic withdrawal symptoms and contains a question for parents to assist in detecting pediatric delirium. The aim was to translate the Japanese SOS-PD and to perform a cross-culture validation of the J-SOS-PD pediatric delirium dimension while confirming the accuracy of family assessments of pediatric delirium. The translation was undertaken with the internationally established forward- backward translation method. Pediatric delirium was simultaneously evaluated and compared between psychiatric diagnoses based on assessment by a pediatric intensivist and the Japanese version of the SOS-PD as evaluated by PICU researchers. We evaluated the criterion validity (sensitivity and specificity), cut-off point using a receiver operating characteristic (ROC) curve, and reliability with Cohen's κ coefficient and intraclass correlation coefficients (ICC). A total of 125 independent assessments were performed in 67 children with a median age of 15 (IQR 5, 54) months and with a pediatric delirium-positive rate of 30% based on psychiatric evaluation. Based on the ROC curve analysis, the cut-off point of 4 was the most appropriate within the original scale and the Japanese SOS-PD version showed high sensitivity (0.92, 95% CI 0.84-1.00) and specificity (0.97, 95% CI 0.94-1.00) at a cut-off point of 4 and high reliability within the researcher assessments (κ = 0.95). We also verified family assessments of pediatric delirium as showing high sensitivity (0.90) and specificity (0.89) over 36 assessments. The Japanese version of the SOS-PD shows a high accuracy similar to the original. Moreover, we revealed high accuracy in family perception of pediatric delirium that could promote family presence in PICU settings.

Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections. We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models. We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2–46·3; IQR 3·1–9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6–31·1; 4·8–9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6–24·1; 3·7–16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2–4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8–10·9) to 2·5 per 1000 catheter-days (1·4–4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39–0·50, p<0·0001; I2=89%). Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs. None.

ObjectivesThis study aimed to identify determinants that hinder or facilitate implementation of the Feverkidstool, a clinical decision support tool offering a quantitative, evidence-based approach, to manage children with fever in the emergency department (ED) setting.DesignQualitative study using semistructured interviews, analysed through directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR).SettingSecondary and tertiary paediatric emergency departments in three hospitals in the Netherlands.ParticipantsEighteen potential end users of the Feverkidstool, including paediatricians and paediatric residents working in the ED and involved in the care of febrile children, participated in the study.Primary outcome measureDeterminants of Feverkidstool implementation, categorised by CFIR domains: intervention characteristics, outer setting, inner setting, characteristics of individuals and implementation process.ResultsRespondents (n=18) perceived the evidence-based guidance by the Feverkidstool and its potential to reduce antibiotic use as valuable. However, concerns were raised about its applicability to critically ill children and those with comorbidities. User-friendliness was seen as a facilitator, whereas the need for C reactive protein testing and lack of integration with electronic health records were mentioned as barriers. The ability to standardise care for febrile children was considered an important benefit of using the Feverkidstool.ConclusionBarriers and facilitators across all CFIR domains are identified. Addressing these will facilitate implementation. When effectively implemented, the Feverkidstool has the potential to improve care for children presenting with fever in the ED. This may potentially lead to a more standardised approach and reduce unnecessary antibiotic prescriptions.

Purpose Sedatives administered to critically ill children should be titrated to effect, because both under- and oversedation may have negative effects. We conducted a systematic review to examine reported incidences of under-, optimal, and oversedation in critically ill children receiving intensive care. Methods A systematic literature search using predefined criteria was performed in PubMed and Embase to identify all articles evaluating level of sedation in PICU patients receiving continuous sedation. Two authors independently recorded: study objective, study design, sample size, age range, details of study intervention (if applicable), sedatives used, length of sedation, sedation scale used, and incidences of optimal, under-, and oversedation as defined in the studies. Results Twenty-five studies were included. Two studies evaluated sedation level as primary study outcome; the other 23 as secondary outcomes. Together, these studies investigated 1,163 children; age range, 0–18 years. Across studies, children received many different sedative agents and sedation level was assessed with 12 different sedation scales. Optimal sedation was ascertained in 57.6 % of the observations, under sedation in 10.6 %, and oversedation in 31.8 %. Conclusions This study suggests that sedation in the PICU is often suboptimal and seldom systematically evaluated. Oversedation is more common than undersedation. As oversedation may lead to longer hospitalization, tolerance, and withdrawal, preventing oversedation in pediatric intensive care deserves greater attention.

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.

BackgroundSeveral antibiotic stewardship interventions have been proven effective and safe for reducing the high number of antibiotic prescriptions in late preterm and term neonates at risk of early-onset sepsis (EOS). For successful translation of EOS interventions to clinical practice, implementation strategies should be employed targeting stakeholders. The primary aim of this study is to assess the impact of implementing an antibiotic stewardship bundle, including the EOS calculator, procalcitonin-guided therapy and intravenous-to-oral switch therapy on antibiotic exposure for EOS in Dutch secondary hospitals. Secondary aims are to examine additional clinical outcomes and implementation outcomes.Methods and analysisWe will conduct a multicentre, prospective implementation study with interrupted time series and before-after analyses at the paediatric or specialised neonatal departments of 11 Dutch secondary hospitals and their surrounding neonatal care networks. A multimodal implementation strategy, designed using Implementation Mapping, is employed to facilitate implementation. The study population is twofold: (1) neonates born at 34 weeks of gestation or later with suspected EOS that will receive intervention-related care and (2) paediatricians, paediatric residents, neonatal nurses, maternity nurses and parents who are the focus of the implementation strategies. The primary outcome is days of antibiotic therapy per 1000 live-born neonates, which will be evaluated using interrupted time series analysis as well as before-after comparison. Secondary clinical outcomes will be assessed by comparing clinical data from the 12 months pre-implementation and post implementation. Implementation outcomes are adoption, fidelity, feasibility and acceptability of the interventions and fidelity and appropriateness of the implementation strategies. Implementation outcomes will be assessed using both qualitative and quantitative methods, including surveys, individual interviews and focus group interviews. A mixed-methods approach will be used to integrate clinical and implementation outcomes.Ethics and disseminationThe Medical Ethics Committee United (MEC-U) declared (reference: W24.132) that this study does not fall under the Dutch Medical Research Involving Human Subjects Act (WMO). Subsequently, ethical approval was granted by the Scientific Committee of the Franciscus Hospital (T110). The scientific committees of all participating sites adopted this decision and granted permission for local conduct of the study. As electronic health record data are sampled retrospectively and anonymously, a waiver of consent was given to collect these data. Informed consent will be obtained from participants completing surveys or taking part in interviews and focus group discussions. The findings will be disseminated through journal publications and conference presentations. Furthermore, practice and policy recommendations will be collaboratively developed with partner organisations.Trial registration numberNCT06845332.

ObjectiveFinancial incentives, provided following validated smoking cessation, hold substantial potential to cost-effectively promote cessation. To facilitate wider adoption, we systematically reviewed evidence addressing the barriers and facilitators to successful implementation of incentive-based smoking cessation interventions among (expectant) parents.Data sourcesWe conducted a systematic search to identify scientific and grey literature across nine electronic databases, from inception to 15 August 2024. Search terms included combinations of “smoking cessation”, “incentive”, “pregnancy”, “preconception” and “parent”.Study selectionEligible records reported and reflected on the implementation of smoking cessation programmes with incentives for (expectant) parents. Inclusion criteria were applied by two reviewers independently, with discrepancies resolved through consensus. Of 1100 unique records identified, 37 met inclusion criteria.Data extractionCharacteristics of the studies, interventions, incentives and implementation, along with barriers and facilitators, were independently extracted by two reviewers. Thematic analysis identified barriers and facilitators. Subgroup analysis explored patterns specific to lower socioeconomic populations.Data synthesisStudies reported on implementation in the USA (n=18), UK (n=10), Australia (n=4), the Netherlands (n=2), New Zealand (n=1), France (n=1) and international contexts (n=1). Barriers included misalignment with participants’ context and resources, recruitment and retention challenges, limited reliability of abstinence verification and high resource demands. Facilitators included ensuring acceptability, accessibility, feasibility, funding and integration into health services.ConclusionsWith the cost-effectiveness of financial incentives for smoking cessation among (expectant) parents already well-documented, this first systematic synthesis of the barriers and facilitators to implementing them in daily practice offers valuable guidance for advancing implementation efforts.PROSPERO registration number2023:CRD42023407648.

Background Management and monitoring of pain and sedation to reduce discomfort as well as side effects, such as over- and under-sedation, withdrawal syndrome and delirium, is an integral part of pediatric intensive care practice. However, the current state of management and monitoring of analgosedation across European pediatric intensive care units (PICUs) remains unknown. The aim of this survey was to describe current practices across European PICUs regarding the management and monitoring of pain and sedation. Methods An online survey was distributed among 357 European PICUs assessing demographic features, drug choices and dosing, as well as usage of instruments for monitoring pain and sedation. We also compared low- and high-volume PICUs practices. Responses were collected from January to April 2021. Results A total of 215 (60% response rate) PICUs from 27 European countries responded. Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in low-volume PICUs (77% vs 63%, p  = 0.028). First-choice drug combination was an opioid with a benzodiazepine, namely fentanyl (51%) and midazolam (71%) being the preferred drugs. The starting doses differed between PICUs from 0.1 to 5 mcg/kg/h for fentanyl, and 0.01 to 0.5 mg/kg/h for midazolam. Daily assessment and documentation for pain (81%) and sedation (87%) was reported by most of the PICUs, using the preferred validated FLACC scale (54%) and the COMFORT Behavioural scale (48%), respectively. Both analgesia and sedation were mainly monitored by nurses (92% and 84%, respectively). Eighty-six percent of the responding PICUs stated to use neuromuscular blocking agents in some scenarios. Monitoring of paralysed patients was preferably done by observation of vital signs with electronic devices support. Conclusions This survey provides an overview of current analgosedation practices among European PICUs. Drugs of choice, dosing and assessment strategies were shown to differ widely. Further research and development of evidence-based guidelines for optimal drug dosing and analgosedation assessment are needed.

Backgrounds Reports of increasing incidence rates of delirium in critically ill children are reason for concern. We evaluated the measurement properties of the pediatric delirium component (PD-scale) of the Sophia Observation Withdrawal Symptoms scale Pediatric Delirium scale (SOS-PD scale). Methods In a multicenter prospective observational study in four Dutch pediatric ICUs (PICUs), patients aged ≥ 3 months and admitted for ≥ 48 h were assessed with the PD-scale thrice daily. Criterion validity was assessed: if the PD-scale score was ≥ 4, a child psychiatrist clinically assessed the presence or absence of PD according to the Diagnostic and statistical manual of mental disorders (DSM)-IV. In addition, the child psychiatrist assessed a randomly selected group to establish the false-negative rate. The construct validity was assessed by calculating the Pearson coefficient (r p ) for correlation between the PD-scale and Cornell Assessment Pediatric Delirium (CAP-D) scores. Interrater reliability was determined by comparing paired nurse-researcher PD-scale assessments and calculating the intraclass correlation coefficient (ICC). Results Four hundred eighty-five patients with a median age of 27.0 months (IQR 8–102) were included, of whom 48 patients were diagnosed with delirium by the child psychiatrist. The PD-scale had overall sensitivity of 92.3% and specificity of 96.5% compared to the psychiatrist diagnosis for a cutoff score ≥4 points. The r p between the PD-scale and the CAP-D was 0.89 (CI 95%, 0.82–0.93; p  < 0.001). The ICC of 75 paired nurse-researcher observations was 0.99 (95% CI, 0.98–0.99). Conclusions The PD-scale has good reliability and validity for early screening of PD in critically ill children. It can be validly and reliably used by nurses to this aim.

IntroductionPerioperative music intervention has been proven effective in reducing anxiety, pain, neurohormonal stress response and medication requirement. Unfortunately, there is a gap between new effective interventions and their (interventions) integration in standard care protocols. The aim of this preimplementation and postimplementation study is to investigate the adherence to a music intervention in a tailored, multilevel, systematic implementation strategy and the initial impact of the implementation on postoperative pain in patients undergoing colorectal surgery.Methods and designA monocentre prospective preimplementation and postimplementation study was set up using The Consolidated Framework for Implementation Research to conduct a systematic implementation of music intervention in three phases. Primary outcomes are adherence to the music intervention and the initial impact of the music intervention implementation on postoperative pain scores on the first postoperative day. At least 100 patients will be included in the study. Secondary outcomes include adherence to the implementation strategy, penetration of music intervention in the standard care, assessment of the determinants for implementation, impact of the implemented music intervention on pain during the entire admission, anxiety, medication usage, complications, hospital and intensive care unit (ICU) length of stay.Ethics and disseminationThe Medical Ethics Review Board of Erasmus MC University Medical Centre Rotterdam, The Netherlands, has approved this protocol. The study is being conducted in accordance with the Declaration of Helsinki. Results of this trial will be published in peer-reviewed scientific journals and conference presentations.Trial registrationDutch Trial Register NL8071.