Erwin Ista

Implementation of standard sedation management in paediatric intensive care: effective and feasible?

OBJECTIVEnTo study the effects of the introduction of a sedation treatment protocol for children in intensive care, including nurses compliance.nnnBACKGROUNDnWhile several sedation guidelines for adults and children have been developed and implemented, there is little evidence on use of sedation protocols in critically ill infants.nnnDESIGNnPretest-posttest intervention study.nnnMETHODSnAdministered sedatives and analgesics over the first seven days of admission were documented for convenience samples, before (n = 27) and after (n = 29) implementation of standard sedation assessments and a sedation protocol. Sedation was assessed with the COMFORT behaviour scale, Nurse Interpretation of Sedation Score and the Visual Analogue Scale for three-month periods, both pretest and posttest. Starting 21 months after the posttest, nurses compliance with the sedation protocol, as well as administered sedatives and analgesics were evaluated for 12 months.nnnRESULTSnInfants in the posttest period received significantly more midazolam and morphine. The proportion of patients adequately sedated on the grounds of COMFORT scores had increased from 63% pretest to 72% posttest and to 75% in the long run. Adequate sedation as judged from the sedation protocol cutoffs was found in 71% of the assessments. In 45% of assessments indicating undersedation, the infusion rate had been increased on the guidance of the protocol. A survey among staff revealed that most considered the sedation protocol comprehensible and useful.nnnCONCLUSIONnThis study showed that regular sedation assessment in critically ill children was feasible and had become standard practice two years after the first posttest. There is insufficient evidence to conclude whether implementation of a sedation treatment protocol indeed improves sedation treatment.nnnRELEVANCE TO CLINICAL PRACTICEnThis sedation protocol provides decision trees for increasing or weaning of sedatives in both haemodynamically stable and unstable patients. It standardizes sedation management and allows nurses to adapt medication themselves.

Delirium in Critically Ill Children: An International Point Prevalence Study*

Objectives: To determine prevalence of delirium in critically ill children and explore associated risk factors. Design: Multi-institutional point prevalence study. Setting: Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia. Patients: All children admitted to the pediatric critical care units on designated study days (n = 994). Intervention: Children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the bedside nurse. Demographic and treatment-related variables were collected. Measurements and Main Results: Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age less than 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and antiepileptics. Conclusions: Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

Nurses' views on patient self‐management: a qualitative study

AIMSnTo unravel outpatient nurses views on the role of people with chronic conditions in self-management, nurses own support role and to establish how these views relate to nurse-led self-management interventions.nnnBACKGROUNDnProviding self-management support is a core task of nurses in outpatient chronic care. However, the concept of self-management is interpreted in different ways and little is known about nurses views on patients role in self-management and nurses own support role.nnnDESIGNnQualitative design.nnnMETHODSnIndividual semi-structured interviews were held in 2012-2013 with outpatient nurses at a university medical hospital in the Netherlands. After transcription, data-driven codes were assigned and key elements of views and experiences were discussed in the research team. Finally, insights were merged to construct and characterize types.nnnRESULTSnTwenty-seven nurses were interviewed. The analysis identified three divergent views on self-management support: adhering to a medical regimen; monitoring symptoms; and integrating illness into daily life. These views differ with respect to the patients role in self-management, the support role of the nurse and the focus of activities, ranging from biomedical to biopsychosocial. The first two were mainly medically oriented. Nurses applied interventions consistent with their individual views on self-management.nnnCONCLUSIONnNurses had distinct perceptions about self-management and their own role in self-management support. Social and emotional tasks of living with a chronic condition were, however, overlooked. Nurses seem to lack sufficient training and practical interventions to provide self-management support that meets the integral needs of patients with a chronic condition.

A realist review: what do nurse-led self-management interventions achieve for outpatients with a chronic condition?

AIMnThe aim of this study was to examine how nurse-led interventions that support self-management of outpatients with chronic conditions work and in what contexts they work successfully.nnnBACKGROUNDnSelf-management could be directed at goals such as quality of life, adherence or patients empowerment. Self-management support is an increasingly important task of nurses. Many nurse-led interventions have been developed but it is not clear how these actually help improve patients self-management capabilities.nnnDESIGNnRealist review.nnnDATA SOURCESnPrimary research studies on self-management support interventions conducted by nurses from January 2000 until March 2015 were retrieved from all relevant databases. The studies had a before-after design and used qualitative and quantitative methods.nnnREVIEW METHODSnFor each study, we described how the intervention was supposed to improve self-management and compared this with the empirical evidence. Next, we described the context-mechanism-outcome strings for each separate study, explored patterns and integrated the findings.nnnRESULTSnThirty-eight papers were included, evaluating 35 interventions concerning a diversity of conditions. Seven different context-mechanism-outcome strings were identified. Interventions focusing on patients intrinsic processes were most successful. Least successful were interventions only providing education aimed at patient behaviour change. Various contexts can influence the success of the interventions: involvement of relatives, target group (i.e. chronic condition, motivation, being recently diagnosed or not), involvement of fellow patients and intervention group homogeneity or heterogeneity.nnnCONCLUSIONnSuccessful interventions focus on patients intrinsic processes (i.e. motivation or self-efficacy). This would guide nurses to decide what self-management support intervention they can best use in their specific setting and patient group.

Untangling ICU delirium: is establishing its prevention in high-risk patients the final frontier?

Dear Editor, Van den Boogaard et al. [1] recently reported the recalibration of a previously developed prediction model (PRE-DELIRIC) for delirium in critically ill patients. Selecting patients for preventive measures on the basis of PRE-DELIRIC may facilitate implementation of preventive (non-) pharmacologic measures. However, being able to identify patients at high risk for delirium may not be sufficient to facilitate implementation of preventive measures. Although health care workers in the ICU will acknowledge that delirium is important, stimulating them to ‘‘get with the guidelines’’ is more cumbersome. There often is a lack of belief that efforts to diagnose and manage delirium will translate into improved outcomes, although the contents of the Awakening and Breathing Coordination, Delirium monitoring and Early exercise (ABCDE) bundle are supported by clinical trials [2]. A second problem is that probably no one has ever seen a patient die as a direct consequence of delirium. The same cannot be said about circulatory or respiratory failure, which may explain why care bundles targeted at these organ systems may seem easier to implement. Further, delirium is still regarded by many as ‘‘an often present but inevitable problem of intensive care’’. However, recently such a perception was also common regarding central venous catheter related bloodstream infections. However, we now know that prevention is possible, saving many lives [3]. To get care bundles aimed at ICU delirium implemented the two barriers mentioned above should be addressed. First, false perceptions about prognostic implications and preventability of delirium should be addressed when present. To this end, implementation efforts led by local champions are critical, and include

What support is needed to self-manage a rheumatic disorder: a qualitative study

BackgroundToday, patients are expected to take an active role in the form of self-management. Given the burden of a rheumatic disorder, the patients cannot be expected to self-manage on their own. In order to develop self-management interventions that fit patients’ needs and preferences, it is essential to examine patients’ perspective on how support can be optimized. This study aimed to identify support needs of outpatients with rheumatic disorders and preferences for who should provide self-management support.MethodsA qualitative study was conducted using focus groups and individual interviews with outpatients with rheumatic disorders treated in a Dutch university hospital. Interview data was analysed with Directed Content Analysis and coded with predetermined codes derived from our model about support needs of chronically ill patients. This model distinguished three types of support: instrumental, psychosocial and relational support.ResultsFourteen patients participated in two focus group interviews and six were interviewed individually. Most patients preferred an active role in self-management. Nonetheless, they notably needed support in developing skills for self-managing their rheumatic disorder in daily life. The extent of support needs was influenced by disease stage, presence of symptoms and changes in one’s situation. A trusted relationship and partnership were conditional for receiving any kind of professional support. Patients wanted to be seen as experienced experts of living with a rheumatic disorder. Acquiring specific disease-related knowledge, learning how to deal with symptoms and fluctuations, talking about emotional aspects, and discussing daily life issues and disease-related information were identified as important elements of self-management support. It was considered crucial that support be tailored to individual needs and expertise. Professionals and relatives were preferred as support givers. Few patients desired support from fellow patients.ConclusionSelf-management was primarily seen as patient’s own task. Above all, patients wanted to be seen as the experienced experts. Professionals’ self-management support should be focused on coaching patients in developing problem-solving skills, for which practical tools and training are needed.

Using an intervention mapping approach to develop a discharge protocol for intensive care patients

BackgroundAdmission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need.MethodsIntervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study.ResultsFour former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice.ConclusionIntervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.

Self-management challenges and support needs among kidney transplantation recipients : A qualitative study

AIMSnThis study investigated self-management challenges and support needs experienced by kidney transplant recipients.nnnBACKGROUNDnAfter kidney transplantation, recipients are expected to take an active role in self-management. However, evidence suggests that nurses experience difficulties operationalizing self-management support. Greater insight into the recipients perspective could help to improve the adequacy and efficacy of nurse-led self-management support.nnnDESIGNnA cross-sectional qualitative study.nnnMETHODSnFocus groups and individual interviews were carried out with kidney transplant recipients treated in a Dutch university hospital. Directed content analysis (DCA) was used.nnnRESULTSnForty-one kidney transplant recipients participated. Challenges after transplantation included becoming an expert patient, adjusting daily life activities, dealing with medical regimen, forming relationships with nurses, dealing with social consequences, dealing with emotions related to transplantation and the donor and improving self-image. To be able to deal with these challenges, participants wished to receive disease specific knowledge and instruction, share personal experiences with fellow patients, share and discuss not only medical but also emotional and social issues with nurses and wanted to be encouraged through positive feedback. One-size fits all education was considered insufficient in meeting their needs.nnnCONCLUSIONSnAfter kidney transplantation, recipients experienced various challenges in dealing with the medical, emotional and social tasks. Current support from nurses overlooked recipients emotional and social support needs. Nurses need adequate tools and training to be able to meet recipients self-management support needs.

Implementation and evaluation of a follow-up programme after intensive care treatment: A practice development project

OBJECTIVESnThis study aimed to measure the effects of a newly developed follow-up programme on intensive care unit patient quality of care, as perceived by their relatives, and the appropriateness of the programme according to nurses.nnnMETHODS AND SETTINGnThis before and after implementation study was conducted in a level III intensive care unit for adult patients and related follow-up wards and included 135 intensive care nurses and 105 general ward nurses. The implemented programme included a personalised poster, a revised discharge protocol and follow-up visits on the ward. Eligible relatives of patients who had remained in the intensive care for a minimum of 48u202fhours were included.nnnMAIN OUTCOME MEASURES AND RESULTSnTotal quality of care and communication were assessed by relatives as high according to the Quality Monitor. Most intensive care nurses evaluated the usefulness of the discharge protocol as positive (71.8% partly/totally agreed) and in accordance with the patients needs (82.1% partly/totally agreed).nnnCONCLUSIONnCommunication and general support as perceived by patients relatives improved; however, no influence on the total quality of care of the revised discharge protocol was shown. Nurses considered the programme as useful. The intervention might enable nurses to better respond to the instrumental and affective needs of patients and their relatives.

Clinically effective implementation of intravenous paracetamol as primary analgesia after major surgery in neonates and young infants

We previously showed that intravenous paracetamol as primary analgesic after major non-cardiac (laparotomy or thoracotomy) surgery in infantsxa0<1u2009year of age reduces postoperative morphine consumption by 66% when compared with continuous intravenous morphine.1 Implementation of trial results is often challenging due to barriers such as low acceptance by healthcare professionals, lack of motivation and lack of awareness.2 Given the morphine-sparing effects of intravenous paracetamol we implemented intravenous paracetamol into our hospital’s clinical practice. We now present the real-life efficacy of intravenous paracetamol for this indication and adherence to the new postoperative pain protocol.nnThe setting for this observational study was a tertiary care paediatric intensive care unitxa0(PICU). In our new postoperative pain protocol, starting from January 2014, intravenousxa0paracetamol is the primary analgesic (figure …