The pediatric intensive care unit (PICU) has been described as a stressful place for parents of critically ill children. Research to date has examined parents’ needs and stressors with a child in PICU. There is a paucity of research examining the experience for parents of a child who is transferred from the PICU to the hospital ward. Open-ended interviews were conducted with 10 parents within 24-48 hours after transfer from a PICU to a hospital ward at a children’s hospital in Canada to understand this experience. Parents revealed that the experience involved a search for comfort through transitions as expressed through the themes of: ‘being a parent with a critically ill child is exhausting’, ‘being kept in the know’, ‘feeling supported by others’, and ‘being transferred’. The findings from this study can help nurses and other health professionals working with parents to support them through the transition from PICU. Recommendations are made for the inclusion of family-centered care practices to assist parents through transitions.

The unexpected admission of a child to the pediatric intensive care unit (PICU) creates feelings of uncertainty, distress, and fear and is a devastating experience for primary caregivers. Health care providers must address primary caregivers` concerns to enhance primary caregivers’ coping abilities. While a family-centred approach to care can assist in diminishing uneasy feelings experienced by primary caregivers, this philosophy of care is not consistently used in everyday practice. The PICU is a unique area of care that focuses on restoring the health of critically ill children with the use of machines and equipment. However, the use of technology for life sustaining measures creates additional responsibilities for health care providers, potentially compromising the quality of patient care. There is evidence to support that the involvement of the primary caregiver in the care of the critically child can address the gap that commonly exists between technology and holistic patient care. Furthermore, involvement in care increases primary caregivers’ satisfaction with the care their child receives and may also improve patient outcomes. Most importantly, the involvement of primary caregivers in the care of the critically ill child encompasses a family-centred approach to care. By increasing health care provider’s awareness of family-centred care within the PICU, primary caregiver’s needs may be more effectively addressed during this devastating and vulnerable time. Health care providers are key players in the promotion of family-centred care in the PICU; however, they are often faced with multiple challenges and barriers. Increasing health care providers’ awareness around the components of family-centred care can facilitate its implementation into practice by understanding how primary care givers define and experience ii family-centred care. Accordingly, a qualitative study guided by the philosophy of hermeneutic phenomenology was conducted to elicit a detailed description of the lived experience of family-centred care from the perspective of the primary caregiver. Participants in this study consisted of those primary caregivers who had previously had a child admitted to the PICU. Participants were recruited from a large mid-western hospital. In total nine primary caregivers ranging in age from 33 to 44 years with the mean age being 37 years participated in the study. Nine of the participants were mothers and two were fathers. All participants took part in semi-structured, open-ended interviews. A total of nine interviews were conducted with two of the interviews involving both parents. Demographic data and field notes were recorded. All field notes and interview data were transcribed. The transcripts were reviewed repeatedly for significant statements in an attempt to find meaning and understanding through themes. The data analysis revealed the essence of the lived experience of family-centred care to be being present. Three themes communicated the essence and included: (a) physical presence, (b) participation in care and, (c) advocating. Three themes from the data emerged around how primary caregivers defined family-centred care and included: (a) collaboration, (b) being updated and, (c) continuity of care. Finally, primary caregivers identified four conditions that needed to be in place to experience family-centred in the PICU which included: (a) being present for rounds, (b) caring behaviours, (c) feeling welcomed and, (d) support. The findings from this study may be used to guide policy around family-centred care and improve on, or bring new insights around interventions related to family-centred care. Future recommendation for nursing practice, education and research are presented.

Bakgrund Djup sedering är associerat med förlängd vårdtid och ett flertal komplikationer för intensivvårdspatienten. Även för ytlig sedering medför komplikationer, stress och lidande. Studier visar på vikten av adekvat sedering, samt att skalor och protokoll används. Syftet med denna studie var att beskriva sederingsnivå, andel optimalt, över- och undersederade patienter, vårdtid i ventilator och vårdtid inom intensivvården för patienter på en svensk intensivvårdsavdelning. Metod Studien, med deskriptiv design, inkluderade konsekutivt sederade, ventilatorbehandlade patienter, 18 år och äldre, på en svensk intensivvårdsavdelning under nio månader. Primära utfallsvariabler var sederingsnivå, utifrån Motor Activity Assessment Scale och andel optimalt, över- och undersederade patienter. Sekundära variabler var vårdtid i ventilator och vårdtid på intensivvårdsavdelningen. Resultat Studien omfattade 34 patienter. Under vårdtid i ventilator med endotrackealtub hade 28  patienterna optimal sedering mer än två tredjedelar av vårdtiden. Medianvärdet för sederingsnivå under vårdtid med endotrackealtub var MAAS 2 (kvartilavstånd 2-2,25) jämfört med medianvärdet för sederingsnivån med trackealkanyl som var MAAS 3 (kvartilavstånd 2-3) (P < 0,001). Trettio patienter (88,2 %) var optimalt sederade med ett MAAS-värde på 2-3 (md) sett till hela vårdtiden. Fyra patienter (11.8 %) var översederade med ett MAAS-värde på 0-1,5 (md). Ingen patient var undersederad sett till hela vårdtiden. Konklusion Studien visar att majoriteten av intensivvårdspatienterna var optimalt sederade under större delen av vårdtiden i ventilator. Endast ett fåtal patienter var översederade och ingen patient var undersederad större delen av vårdtiden. Patienter vårdade med trackealkanyl var ytligare sederade än de med endotrackealtub.

nÃo hà / InfecÃÃes relacionadas à assistÃncia à saÃde (IRAS), em neonatologia, contemplam as infecÃÃes relacionadas à assistÃncia, e as relacionadas à falha na assistÃncia, prevenÃÃo, diagnÃstico e tratamento, a exemplo das transplacentÃrias e precoce neonatal de origem materna. As IRAS afetam mais de 30% de neonatos e, comparados à populaÃÃo pediÃtrica, os Ãndices sÃo atà cinco vezes maiores. Estima-se que no Brasil, 60% da mortalidade infantil ocorram no perÃodo neonatal, sendo a sepse neonatal uma das principais causas. A pesquisa tem como objetivo caracterizar as infecÃÃes neonatais precoces relacionadas à assistÃncia à saÃde, de recÃm-nascidos em Unidades de Terapia Intensiva Neonatal da Maternidade Escola Assis Chateaubriand (MEAC). Trata-se de um estudo transversal, de natureza descritiva e exploratÃria com abordagem quantitativa. Os dados foram coletados no perÃodo de janeiro a marÃo de 2012, nos registros da ComissÃo de Controle de InfecÃÃo Hospitalar (CCIH). Participaram do estudo 545 recÃm-nascidos com infecÃÃo precoce admitidos no perÃodo de janeiro de 2010 a dezembro de 2011. Fez-se anÃlise bivariada e multivariada com desfechos: prematuridade, baixo peso ao nascer e Ãbito. Dos recÃm-nascidos pesquisados, a maioria à de baixo peso, e 81% prematuros. Na anÃlise com variÃvel dependente prematuridade, a variÃvel sexo mostra associaÃÃo estatÃstica significante com desfecho RC= 1,67. Ser do sexo feminino hà risco de quase duas vezes mais em nascer prematuro em comparaÃÃo ao sexo masculino. Utilizando como variÃvel dependente baixo peso < 2.500 g, a variÃvel sexo tem associaÃÃo estatÃstica significante com desfecho RC= 1,94. Ser do sexo feminino o risco à de quase duas vezes mais em nascidos com peso menor que 2.500 g. Outra associaÃÃo estatÃstica à a idade gestacional e baixo peso ao nascer com RC= 60,3. RecÃm-nascido prematuro apresenta quase 60 vezes mais chances de nascimento com baixo peso em comparaÃÃo aos nascidos a termo. Na anÃlise de regressÃo logÃstica bivariada, Ãbito e variÃveis independentes, para os nascidos com idade gestacional < 37 semanas mostra-se associaÃÃo estatÃstica significante com desfecho RC= 4,14 e baixo peso ao nascer RC= 3,94. Conclui-se que as infecÃÃes neonatais precoces tem alta incidÃncia em recÃm-nascidos. SÃo de difÃcil controle por estar na dependÃncia da qualidade dos cuidados durante a assistÃncia prÃ-natal, perinatal e neonatal. / Infections related to Health Care (IRAS), neonatology, include both the care-associated infections, and those related to failure to care, prevention, diagnosis and treatment, the example of transplacental and early neonatal of maternal origin. The IRAS affect more than 30% of neonates, and when compared to the pediatric population, their rates can be up to five times higher. It is estimated that in Brazil, 60% of infant mortality occur in the neonatal period, neonatal sepsis is a major cause. The research aimed to characterize the early neonatal infections related to health care occurred in newborns of Neonatal Intensive Care Units of Maternity School Assis Chateaubriand (MEAC). This is a cross-sectional study, descriptive and exploratory in nature with a quantitative approach. Data were collected in the period from January to March 2012, through the records of the Committee on Infection Control (HICC). The study identified 545 infants with early infection admitted to the units in the period January 2010 to December 2011. It was performed bivariate and multivariate outcomes (prematurity, low birth weight and death). Newborn surveyed, most were born underweight, and 81% were preterm. In the analysis using as dependent variable prematurity, the gender variable shows a statistically significant association with the outcome OR = 1.67. Being female is a risk almost twice as in preterm birth compared to males. Using as dependent variable low weight < 2.500 g, the gender variable was statistically significant association with outcome OR = 1.94. Being female is a risk almost twice as being born weighing less than 2.500 g. Another statistical association is low gestational age and low birth weight OR = 60.3 Premature infant has nearly 60 times more likely to be born underweight compared those born at term. In bivariate logistic regression analysis, death, and independent variables, for those born with a gestational age < 37 weeks showed statistically significant association with outcome OR = 4.14 and low birth weight OR = 3.94. We conclude that early neonatal infection has a high incidence in newborns. They are difficult to control because it is dependent on the quality of nursing during the prenatal, perinatal and neonatal care.

Class of 2014 Abstract / Specific Aims: To evaluate the association of weight-based insulin dose with hypoglycemia in critically ill patients receiving continuous intravenous insulin infuions. To determine whether higher weight-based doses of insulin were associated with a higher incidence of hypoglycemia Methods: This was a retrospective, case-control study conducted at a tertiary care, academic medical center. Adult (>18 years) patients admitted to the intensive care unit (ICU) receiving intravenous (IV) regular insulin infusions for the management of hyperglycemia between 1 January 2008 and 30 March 2013 were included. Medical records were retrospectively reviewed. Each patient with hypoglycemia was matched with a non-hypoglycemic control subject, based on age range and sex. Laboratory data, patient demographics, hypoglycemic events, insulin infusion data, SOFA scores, length of hospital and ICU stay, and patient outcomes were collected and evaluated. Main Results: Sixty-one patients experienced a hypoglycemic event and were matched with 61 non-hypoglycemic control subjects for statistical analysis. With the exception of ethnicity (p = 0.041) as a demographic predictor of hypoglycemia; age, sex, weight, height, and BMI were not significant. The starting insulin infusion rate and the total number of insulin units per day administered were not found to be associated with hypoglycemia, p=0.107 and p=0.357, respectively. Conclusion: This study failed to show significance in the total units per day of insulin and the incidence of hypoglycemia. There was no statistical significance in BMI between case and control groups, thus no clear conclusion can be made associating hypoglycemia with weight-based insulin dosing.

Patienterna på en intensivvårdsavdelning ligger i riskzonen för oavsiktlig hypotermi. De tidigare identifierade riskgrupperna är bland annat förekomst av kontinuerlig hemodialys, vissa sederande läkemedel, stor mängd intravenös vätska samt kirurgiska ingrepp i generell anestesi. Hypotermi har negativa konsekvenser för patienterna som ökad blödningsrisk, försämrad sårläkning samt kardiologisk påverkan. Syftet med studien var att undersöka förekomsten av hypotermi hos intensivvårdade patienter. En retrospektiv deskriptiv studie på 583 vuxna patienter som vårdades på en intensivvårdsavdelning någon gång under 2009 genomfördes. Resultatet visade att 17 procent av patienterna hade drabbats av oavsiktlig hypotermi. Patienterna med intagningsorsakerna blödning och sepsis hade en ökad förekomst av hypotermi. Patienter med låg kroppsvikt samt äldre patienter hade en ökad förekomst av hypotermi vilket stämmer väl överens med tidigare studier. Däremot att yngre patienter samt kvinnliga patienter hade en högre förekomst av hypotermi är nya fynd. Det förefaller viktigt för intensivvårdssjuksköterskan att tidigt identifiera patienter i riskgrupper för oavsiktlig hypotermi och aktivt förhindra dess uppkomst. / The patients on an intensive care unit are often at risk for inadvertent hypothermia. Previously identified groups at risk include patients receiving continuous renal replacement therapy, some sedative drugs, large amounts of intravenous fluids and surgical procedures during general anesthesia. Hypothermia has negative consequences for patients such as increased risk for hemorrhaging, impaired wound healing and cardiological effects. The purpose of the study was to determine the prevalence of inadvertent hypothermia in patients receiving intensive care. We performed a retrospective descriptive study on 583 adult patients who had been admitted to an intensive care unit. The results showed that 17 percent of the patients had inadvertent hypothermia. The patients admitted under the categories bleeding or septicemia had an increased occurrence of hypothermia. Patients with lower bodyweight and elderly patients had a higher occurrence which concurs with previous research. We also found that younger patients and female patients had a higher occurrence of hypothermia which is new findings. It appears that it is important for the intensive care unit nurse to early identify those patients at risk and to actively prevent its occurrence.

The pediatric intensive care unit (PICU) has been described as a stressful place for parents of critically ill children. Research to date has examined parents’ needs and stressors with a child in PICU. There is a paucity of research examining the experience for parents of a child who is transferred from the PICU to the hospital ward. Open-ended interviews were conducted with 10 parents within 24-48 hours after transfer from a PICU to a hospital ward at a children’s hospital in Canada to understand this experience. Parents revealed that the experience involved a search for comfort through transitions as expressed through the themes of: ‘being a parent with a critically ill child is exhausting’, ‘being kept in the know’, ‘feeling supported by others’, and ‘being transferred’. The findings from this study can help nurses and other health professionals working with parents to support them through the transition from PICU. Recommendations are made for the inclusion of family-centered care practices to assist parents through transitions.

Background: Based on survey data from both Canada and abroad, most people would prefer to be cared for and to die in their own homes. Although 70% of elderly patients state a preference for comfort care over high technology life prolonging treatment in an inpatient setting, 54% are still admitted to intensive care units (ICUs). Understanding their wishes regarding end-of-life care, and being able to engage in evidence informed end-of-life discussions has never been so important, in order to empower patients, and to optimize scarce resource management. For the purpose of this thesis, “very old” patients will be defined as those eighty years of age and older. All three manuscripts will be based on data from the Realistic 80 study, a prospective cohort trial of 1671 critically ill very old patients admitted to 22 Canadian ICUs. Objectives: Manuscript 1: To describe the hospital outcomes of the entire cohort of Realistic 80 patients, including their ICU mortality and length of stay, their hospital mortality and length of stay, and their ultimate dispositions. Manuscript 2: To derive a clinical prediction rule for hospital mortality in the medical patient cohort. Manuscript 3: To derive a clinical prediction rule for hospital mortality in the emergency surgical patient cohort. Data Source: A prospective, multicenter cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Methods: Clinical decision rule methodology was used to analyze the data set and to create two separate clinical prediction tools, one for critically ill elderly medical patients, and one for critically ill surgical emergency patients. A third manuscript describing general clinical outcomes was also produced. Results of Manuscript 1: A total of 1671 patients were included in this section of the “Realities, Expectations and Attitudes to Life Support Technologies in Intensive Care for Octogenarians: The Realistic 80 Study (a prospective cohort of nearly 2000 critically ill Canadian patients over eighty years old enrolled from 22 ICUs across Canada) that will provide the data for this thesis. The Realistic 80 cohort had a mean age of 84.5, a baseline Apache II score of 22.4, a baseline SOFA score of 5.3, an overall ICU mortality of 21.8%, and an overall hospital mortality of 35%. The cohort had a median ICU length of stay of 3.7 days, and an overall median hospital length of stay of 16.6 days. Only 46.4% of the survivors were able to return home to live. Results of Manuscript 2: Age, renal function, level of consciousness, and serum pH were the important predictors of hospital mortality in critically ill elderly medical patients. Our clinical prediction tool is very good, particularly at the all-important extremes of prognosis, and ready for external validation. Results of Manuscript 3: Renal function and serum pH were the important predictors of hospital mortality in critically ill elderly surgical patients. Our model’s performance is very good, and will serve to inform clinical practice once validated. Conclusions: Very old medical patients have longer ICU stays and higher mortality than their surgical counterparts. Premorbid health status and severity of illness are associated with mortality. Our medical patient clinical prediction tool is very good and ready for external validation. Our surgical emergency clinical prediction tool shows promise, but will require the incorporation of more patients and a repeat derivation phase prior to external validation or clinical implementation.

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / Nurses are subjected to occupational stress factors that can result in the syndrome of burnout. This study compared levels of burnout in nurses in a medical-surgical ICU setting to those in non-ICU medical-surgical settings. A randomized sample of 40 nurses of an urban hospital in Taiwan, twenty nurses in an ICU and 20 in five non-ICU settings (general medical-surgical wards), who returned the questionnaire used to measure burnout, were included in the study. The instrument utilized was the Staff Burnout Scale for Health Professionals. The study found no significant difference in levels of burnout in the two groups. Both groups in this study experienced a higher level of burnout than was reported in other studies in United States literature. In particular, two general medical-surgical wards which had high patient/nurse ratios, had very high levels of burnout. The study also found that all nurses with lower educational levels and ICU nurses with more years of work experience had more burnout. / 2031-01-01

The overuse of antibiotics is a large problem in healthcare today, accelerating the development of microbial resistance to antibiotics. Antibiotic stewardship campaigns have been implemented to help clinicians curb their use. Procalcitonin is a serum peptide and marker of inflammation secreted in response to microbial toxins. For this reason it is more specific to bacterial infections than other markers of general inflammation , like Creactive protein. The population of patients with sepsis in the Intensive Care Unit is one in which extended durations of antibiotics are used. The FDA has approved use of procalcitonin to guide de-escalation of antibiotic therapy in critically ill patients with sepsis to avoid both antibiotic overuse and antibiotic related side effects. Review of current literature shows that procalcitonin is efficacious in reducing duration of antibiotic therapy in patients with sepsis in the ICU setting. This result, however, is not being observed in clinical practice. This discrepancy is due to the inappropriate use of procalcitonin that does not align with use outlined in randomized control trials. We propose a study to determine how procalcitonin is being used in clinical practice in four Boston area hospital Intensive Care Units. Through chart review, we will identify patients in the Intensive Care Unit with sepsis from 2013-2018 recording patient demographic information and patient characteristics. We will determine whether they had PCT measured during their stay, and if they did, whether or not discontinuation of antibiotics was in accordance with FDA’s proposed algorithm. We will aim to compare whether discontinuing antibiotic therapy in accordance with the FDA’s procalcitonin deescalation algorithm is associated with reduced duration of antibiotic therapy or incidence of Clostridium Difficile infection. In conducting this study, we hope to identify patterns of procalcitonin use in clinical practice and provide further evidence that using the algorithm to guide therapy can serve as an effective tool in reducing exposure to unnecessary antibiotics and the complications from their use.