Thesis (M.S.)--University of Michigan, 1996. / Includes bibliographical references.

Children admitted to the pediatric intensive care unit (PICU) are at high risk of malnutrition due to the stress of critical illness, and challenges with meeting nutrient needs. The objectives of this study were to describe the prevalence of malnutrition (undernutrition) at admission and discharge from the PICU and the adequacy of dietary intakes during PICU stay according to current practice guidelines. Sixty patients (median age 1.8y) were enrolled. Malnutrition (moderate-severe) was identified in 12% of patients at admission and 15% at discharge using weight-for-length and BMI-for-age z scores. Mid-upper arm circumference z score declined significantly (p=0.002) during PICU stay. Median (IQR) delivery of enteral energy and protein during the first 10 days was 64 (50-73)% and 62 (40-82)%, respectively, of prescribed goal. A total of 174 feeding interruptions were noted in 36 enterally fed patients. Malnutrition was present in the PICU and areas for improvement in nutrient delivery were identified.

Critical illness can lead to profound physical morbidity that persists for years post-intensive care unit (ICU) discharge. Rehabilitation started in ICU can mitigate morbidity and improve outcomes, however, there are gaps in existing research. This thesis includes manuscripts addressing three areas: primary research reporting, patient-reported outcome measures (PROM), and research intervention implementation. The first manuscript was a scoping review of ICU rehabilitation interventions. Previous systematic reviews assessed the effectiveness of ICU rehabilitation to improve functional outcomes, and identified conflicting results and deficiencies in study reporting. I conducted a scoping review to describe the types, amounts, and reporting of rehabilitation interventions in ICU studies. I identified 117 prospective ICU rehabilitation studies from database inception to 2016 and assessed the completeness of study and intervention reporting using standardized reporting guidelines. Results identified adequate overall study reporting, however important reporting deficiencies in intervention and control groups, limiting future trial development and clinical implementation. The second manuscript evaluated the psychometrics of the Patient-Reported Functional Scale-ICU (PRFS-ICU) – a new PROM for ICU survivors in acute care. I demonstrated the PRFS-ICU was feasible, reliable, responsive, and valid in medical-surgical ICU patients able to follow commands. Results suggest the PRFS-ICU warrants future research and may be useful to assess and monitor patient perceptions of their functioning over time. The final manuscript was a self-administered electronic survey of frontline therapists, assessing barriers and facilitators to implementing a novel rehabilitation intervention in the context of research. Respondents implementing CYCLE, a trial of in-bed cycling with mechanically ventilated patients, identified two primary barriers to implementing the protocol: time required to conduct the protocol and concerns for provision of equitable service to all patients on their caseload. Together these manuscripts provide an important foundation to guide development, implementation, and evaluation of future ICU rehabilitation trials. / Thesis / Doctor of Philosophy (PhD) / Critical illness requiring intensive care unit (ICU) admission can lead to physical disability lasting years post-ICU. Exercises started in ICU can reduce disability. However there are important gaps in the research addressed by my thesis: 1) Summaries of studies found different results on the effects of exercise on disability, and details of exercises were sparse. I reviewed over 3 decades of exercise research for ICU patients and determined reporting must improve; 2) ICU patients had no standard way to report their own level of movement in hospital. I evaluated a measure, which may be useful to assess how patients think they are functioning; 3) ICU therapists reported challenges delivering exercises to patients in research studies. I conducted a survey and learned therapists needed more time to provide these exercises. My findings can inform future ICU exercise studies, assess how patients feel they are functioning, and optimize exercise delivery.

Thesis (Ph. D.)--University of Washington, 2002. / Vita. Includes bibliographical references (leaves 111-120).

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 5 uppsatser.

Thesis (Ph. D.)--University of Washington, 1998. / Vita. Includes bibliographical references (leaves [195]-230).

Critical illness is typically associated with a catabolic stress state in which patients commonly demonstrate a systemic inflammatory response that brings about changes in their body systems. Changes in the body systems make the critically ill dependent on mechanical ventilation and inotropic support for longer periods in order to survive. However, this inflammatory response can be attenuated by the timely introduction of nutritional support to provide energy and nutrients to diminish catabolism and promote anabolism. The result could be a decrease in the morbidity and mortality rates, as well as the financial burden on the patients, institutions and the state. Since registered nurses initiate and utilise feeding protocols to achieve target goals, there is a strong need for nurse-initiated feeding protocols. These protocols should be coupled with a comprehensive nurse-directed nutritional educational intervention that will focus on their safe and effective implementation. This focus on nursing nutrition education represents a major shift away from traditional education which has focused on dietitians and physicians. Evidence suggests that incorporating guideline recommendations into nurse-initiated protocols for starting and advancing enteral feedings is an effective strategy to improve the delivery of nutritional support. The study was aimed at exploring the provision of nutritional support to critically ill hospitalised patients by registered nurses to identify and describe possible gaps in the practice, through determining the potential relationship between the provision of nutritional support and characteristics of its providers. A quantitative, descriptive correlational study was undertaken. Seventy registered nurses working in neonatal/paediatric and adult critical care units in two public and three private hospitals in East London in the Eastern Cape participated in the study. The sample also included public critical care students. The results showed that registered nurses in private hospitals have more knowledge about the importance of nutritional support than their public hospital counterparts and students. The mean score was on the question was 80.3% with the highest score of 91% which was for the private hospital nurses, followed by 77.2% for public and 71.4% for students. Again, the mean score for knowledge on timing of initiating nutritional support was 48%, the highest score being 69.4% for students followed by private hospital nurses with 49.6%. Close to 63% (n = 44) of these nurses were either unsure about the availability of nutritional protocols or clearly attested to their non-availability. This is seen as an issue of concern because a protocol is meant to be a standard document with which all members of the ICU should be familiar. It is meant to guide and facilitate the manner of working in the unit. While facilitation of maintenance of nutritional support to patients is the responsibility of registered nurses, according to Regulation 2598(1984) section 45 (1) (q) of the South African Nursing Council, 68% (n = 48) of the respondents felt that this was in the practising scope of doctors and dietitians. The study concluded that the nurses are knowledgeable about the importance of nutritional support but knowledge gaps have been identified as far as the timing of initiating nutritional support is concerned. Some attested to unavailability of standard guidelines that are tailored into protocols guiding the provision of nutritional support by registered nurses in the critical care units. Nutrition should be prioritised as an important therapy for improving the outcomes of critically ill patients. Nurses need to analyse its provision, identify barriers to nutritional strategies and engage in nutritional education to empower themselves regarding the practice. Most importantly, there is a need for nurse-initiated nutritional protocols that are tailored from the broad nutritional guidelines and aligned with the local context and ways of practising. Nutritional support should be included as a key component of the curriculum in academic programmes that specialise in critical care nursing.

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.

Introduction: Improvements in the delivery of intensive care have led to a growing number of children with chronic medical conditions at significant risk of recurrent and prolonged critical illness. These patients are increasingly described as having pediatric chronic critical illness (CCI). To date, pediatric CCI is without an accepted consensus case definition. Objective: To evaluate how pediatric CCI has been defined in the current literature, including the concept of prolonged PICU admission, and describe the methodologies used to develop any existing definitions. Secondary aims included describing patient characteristics and outcomes evaluated in included studies. Methods: We searched four electronic databases for studies evaluating children identified with “CCI.” We also searched for studies describing prolonged PICU admission, as this concept is related to pediatric CCI. We developed a hybrid crowdsourcing and machine-learning (ML) methodology to complete citation screening. Screening and data abstraction were performed by two reviewers, independently and in duplicate. We completed data abstraction including details of population definitions, demographic and clinical characteristics of children with CCI, and outcomes evaluated. Results: Twenty-eight reviewers from 11 countries performed citation screening, with a mean sensitivity of 92%. Of 24,729 unique citations assessed for eligibility, 453 full-texts were reviewed and 67 studies were included. Of these, 12 studies (18%) defined CCI, most commonly by a prolonged PICU length of stay (LOS), either in isolation or in addition related to medical complexity patient characteristics and/or readmissions rate. The concept of prolonged PICU admission was defined in an additional 55 (82%) studies by a median of 14 days (range, 1 day-6 weeks). Conclusion: To our knowledge, this scoping review provides the most comprehensive epidemiologic evidence addressing pediatric CCI. Our results suggest a uniform consensus definition is needed in order to advance this emerging and important area of pediatric critical care research. / Thesis / Master of Science (MSc)

Diarrhea is common during critical illness; however, the etiology, definitions, incidence and risk factors for diarrhea and its impact on patient important outcomes require further investigation. There are many possible etiologies of diarrhea, including iatrogenic causes such as laxative medications, often administered as part of bowel protocols, as well as Clostriodiodes difficile associated diarrhea (CDAD). This thesis includes 6 chapters that address the knowledge gaps in the literature regarding the epidemiology of diarrhea in the intensive care unit (ICU), the impact of bowel protocols on diarrhea, and CDAD in critically ill adults. Chapter 1 provides an introduction to gaps in the literature that are addressed by the studies included in this thesis. Chapter 2 outlines the methodology used to inform the protocol for the Diarrhea, Incidence, Consequences and Epidemiology in the Intensive Care Unit (DICE-ICU) Study. Chapter 3 reports on the findings of DICE-ICU including the incidence, risk factors, definitions, and outcomes of patients who develop diarrhea in the ICU. Chapter 4 provides a content analysis of bowel protocols used in multiple ICUs. Chapter 5 summarizes a nested cohort study addressing the incidence, prevalence, timing, treatments, and outcomes of CDAD in critically ill patients enrolled in the PROSPECT Trial. Chapter 6 summarizes the work and discusses the strengths and limitations, implications and conclusions presented in this PhD thesis. / Thesis / Doctor of Philosophy (PhD)