An office or a bedroom? Challenges for family-centered care in the pediatric intensive care unit

Although the modern pediatric intensive care unit (PICU) has followed general pediatrics and adopted the family-centered care model, little is known about how families prospectively experience PICU care. The authors' goal was to better understand the experiences of families whose child was hospitalized in a PICU. They conducted a 12-month prospective ethnographic study in a PICU in a tertiary care hospital in a large North American urban center. Data were obtained via participant-observation and formal and informal interviews with 18 families and staff key informants. Findings revealed a disconnect between the espoused model of family-centered care and quotidian professional practices. This divergence emerged in the authors' analysis as a heuristic that contrasts a professional "office" to a sick child's "bedroom." PICU practices and protocols transformed the child into a patient and parents into visitors; issues such as noise, visitation, turf, and privacy could favor staff comfort and convenience over that of the child and family. The authors' discussion highlights suggestions to overcome this divergence in order to truly make the PICU family centered.     

What is the risk of nocturnal supine enteral nutrition?

One complication of enteral nutrition (EN) is gastro-esophageal reflux disease. Semi-recumbent position is advised because posture influence reflux in critically ill patients. No data is available in stable patients. AIM: To study influence of position on reflux during nocturnal nutrition by percutaneous endoscopic gastrostomy in stable patients. METHODS: Prospective cross-over study. Reflux was measured by 48 h-pH-metry, in supine and semi-recumbent position. The end point was % time spent under pH 4. For analysis, 2 subgroups were identified (refluxers and non-refluxers). A total of 16 patients (65 year+/-13) were included, most had neurological diseases. RESULTS: There was no increase of reflux probability in any position in all patients (% time spent under pH 4: supine vs. semi-recumbent: 4.4+/-7.7 vs. 3.5+/-7.0 NS). In non-refluxers, supine position did not increase % time under pH 4 (0.1+/-0.12 vs. 0.3+/-0.6, NS), and did not modify other parameters (number of reflux 0 +/-0.9 vs. 7 +/-19 NS, duration of the longest reflux (min) 1.1+/-1.7 vs. 1+/-1.7 NS). In refluxers, supine position did not worsen pre-existent reflux (% time under pH 4: 11.7+/-8.7 vs. 8.9+/-9.7 NS, number of reflux 119+/-88 vs. 91+/-89 NS, duration of the longest reflux (min) 19+/-19 vs. 24+/-21 NS). CONCLUSION: Our data suggest that position does not influence reflux in stable patients with EN.     

Enteral nutrition practice in a surgical intensive care unit: what proportion of energy expenditure is delivered enterally?

The object of this study was to document enteral feeding practice in critically ill patients in a surgical intensive care unit. We asked what proportion of measured energy expenditure is delivered enterally. Patient, material, and therapy-related factors should be assessed and related to enteral nutrition.Sixty patients receiving enteral nutrition for a period of at least 10 days were included in the study. Mean daily energy expenditure was 27.8+8.7 kcal/kg. Mean daily enteral delivered calories reached 19.7+/-10.3 kcal/kg (P<0.05). Twenty-one out of 60 (35%) patients were fed isocalorically; 46% of enteral nutrition days failed to reach 80% of energy expenditure. Ten out of 30 patients (33%) fed over a gastric tube were nourished isocalorically in comparison to 8 out of 20 patients (40%) fed over a duodenal tube. Factors associated with hypocaloric enteral feeding in multiple logistic regression were abdominal, pelvic and lumbal spine trauma, gastrointestinal intolerance, problems with the feeding tube, additional surgical interventions, airway management and use of fentanyl. In the course of the study, gastrointestinal complications were the cause for more than 50% of insufficient enteral delivery cases, while therapy and material related reasons contribute to only a minor part.Abdominal, pelvic and lumbal spine traumas are associated with a higher possibility towards developing problems with enteral delivery, as shown by odds-ratios greater than eight. These diagnoses amounted in our investigation to nearly 40% and make a great difference to medical patients. Therefore, recommendations for optimising enteral feeding must take the concerned patient collective into account.     

Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature

OBJECTIVE: Nutritional support is part of the standard of care for the critically ill adult patient. In the average patient in the intensive care unit who has no contraindications to enteral nutrition (EN) or parenteral nutrition (PN), the choice of route for nutritional support may be influenced by several factors. Because EN and PN are associated with risks and benefits, we systematically reviewed and critically appraised the literature to compare EN with PN the critically ill patient. METHODS: We searched computerized bibliographic databases, personal files, and relevant reference lists to identify potentially eligible studies. Only randomized clinical trials that compared EN with PN in critically ill patients with respect to clinically important outcomes were included in this review. In an independent fashion, relevant data on the methodology and outcomes of primary studies were abstracted in duplicate. The studies were subsequently aggregated statistically. RESULTS: There were 13 studies that met the inclusion criteria and, hence, were included in our meta-analysis. The use of EN as opposed to PN was associated with a significant decrease in infectious complications (relative risk = 0.64, 95% confidence interval = 0.47 to 0.87, P = 0.004) but not with any difference in mortality rate (relative risk = 1.08, 95% confidence interval = 0.70 to 1.65, P = 0.7). There was no difference in the number of days on a ventilator or length of stay in the hospital between groups receiving EN or PN (Standardized Mean Difference [SMD] = 0.07, 95% confidence interval = -0.2 to 0.33, P = 0.6). PN was associated with a higher incidence of hyperglycemia. Data that compared days on a ventilator and the development of diarrhea in patients who received EN versus PN were inconclusive. In the EN and PN groups, complications with enteral and parenteral access were seen. Four studies documented cost savings with EN as opposed to PN. CONCLUSION: The use of EN as opposed to PN results in an important decrease in the incidence of infectious complications in the critically ill and may be less costly. EN should be the first choice for nutritional support in the critically ill.     

Which nutritional measurements assess protein-energy nutritional status in patients receiving home parenteral nutrition?

Weight, midarm circumference, triceps skinfold thickness, arm muscle circumference, albumin, prealbumin, transferrin and total lymphocyte count were measured at each outpatient visit in patients reveiving home parenteral nutrition from September 1987 to November 1991. Each nutritional variable was analysed for individuals and for the whole group. Group data were expressed using the actual values obtained and successive differences (the change between clinic attendances). Nutritional variables were evaluated using a correlation matrix. Identical analysis of individual and group data demonstrates that laboratory investigations are of little value in the assessment of nutritional status in patients receiving home parenteral nutrition. Anthropometry detected changes in body weight secondary to changes in muscle and/or fat in 80% of patients. Pooling anthropometric data distors the relationship between variables owing to inter-individual variability when actual values are used. The method of successive differences is the preferred method of analysis for group anthropometric data.     

Is enteral nutrition optimally used in hospitalized patients? A study of the practice of nutrition in a Swedish hospital

Thirty patients with parenteral nutrition were studied in order to evaluate if they could be given enteral nutrition instead. Based upon absolute and relative contraindications for enteral nutrition, we calculated that 80% of the patients were possible candidates for enteral nutrition. Long-term use of parenteral nutrition may cause complications. Besides metabolic and other advantages when enteral nutrition is used, economical gains are also important. We have calculated an estimated annual net profit of US$ 357,000 in our hospital, if enteral instead of parenteral feeding is used in patients suitable for the former type of feeding. This implies that it is really cost-beneficial to consider enteral nutrition in hospitalized patients. Although parenteral nutrition will continue to have its place in the management of different occasions, increased use of enteral nutrition may result in improved patient outcomes and improved cost-effectiveness.     

What factors are associated with poor developmental attainment in young Canadian children?

BACKGROUND: This study was undertaken to determine the association between poor developmental attainment (PDA) and biological, home environment and socio-demographic factors in a population-based sample of Canadian children. METHODS: Cross-sectional data from two cycles (1994/95 and 1996/97) of the National Longitudinal Survey of Children and Youth were used. Children aged 1-5 years were included. PDA was defined as < or = 15th percentile for motor and social developmental skills (1-3 year olds) or Peabody Picture Vocabulary Test (4-5 year olds). Multiple logistic regression was used. RESULTS: The proportion of children with PDA varies across Canada, between males and females, and by age. Among 1 year olds in Cycle I, having a low birthweight (OR=3.3; 95% CI: 2.1-5.2), being male (OR=1.6; 95% CI: 1.2-2.2) and having a mother who is an immigrant (OR=1.6; 95% CI: 1.1-2.2) increased the odds of PDA. Similar results were observed in Cycle II. Among children aged 4-5 years in Cycle II, having a mother who is an immigrant (OR=5.3; 95% CI: 4.1-6.9) and a mother with low educational attainment (OR=2.8; 95% CI: 2.1-3.9) increased the odds of PDA. Low income was a significant predictor of PDA across all age groups. INTERPRETATION: The strong and consistent associations with living in a low-income household, having a mother with low educational attainment or a mother who is an immigrant highlight the need for targeting developmental assessments and services to this population.     

Microdialysis in the intensive care unit: a novel tool for clinical investigation or monitoring?

Microdialysis is a minimally invasive tool that allows us to gain insight into metabolism at the tissue level. In human investigations, it can be safely performed in the brain (neurosurgical patients), skeletal muscle and adipose tissue. Basically, the technique allows interstitial concentrations of small solutes to be evaluated. Several limitations of the method and possible ways to circumvent them are indicated. Recent technical developments are reviewed. At present, this method is rarely used in metabolic monitoring of critically ill patients, but its potential applications are highlighted.     

An outbreak of Legionella longbeachae infection in an intensive care unit?

During a nine-day period, five patients in a 14-bed intensive care unit (ICU) were shown to have seroconverted with a four-fold or greater rise in serum antibody titre to Legionella longbeachae serogroup 1. A further two patients were observed to have high titres consistent with previous exposure but earlier serum samples were not available for comparison. No patients had antibody responses to Legionella pneumophila serogroups 1 and 2. L. longbeachae was not cultured from respiratory secretions from patients or from the environment within the unit. Legionella anisa was recovered from one cooling tower on the ninth floor of the tower block. The ICU is located on the first floor of the same tower and receives external air from two vents, one on the eastern and the other on the western aspect. All patients with serological evidence of L. longbeachae infection were concomitantly infected with multiresistant Staphylococcus aureus, and were located in bays on the eastern side of the unit. A large pigeon nest was discovered within 1-2 m of the eastern vent. Following removal of the birds' nest, no further cases were seen on routine screening of all patients within the unit over the next eight weeks. Alternatively, seroconversion may have been related to demolition of the adjacent nine-storey nurses home. This was begun one month before the first case was diagnosed and was completed four months later. The periodic northerly winds could have carried legionellae from the demolition site directly over the block housing the ICU and may have concentrated them near the eastern air vent. All patients had pneumonia, which was probably multifactorial in origin. There is some uncertainty whether the serological responses seen were an epiphenomenon or were truly indicative of infection with L. longbeachae.     

Does nutrition information about the energy density of meals affect food intake in normal-weight women?

This study investigated whether the energy density of foods affected energy intake when subjects were informed about the energy density of their meals. Forty normal-weight women ate breakfast, lunch, and dinner in the laboratory on three separate days. The entrée at each meal was varied in energy density to be either 1.25, 1.50, or 1.75 kcal/g (5.23, 6.28, or 7.32 kJ/g), but was held similar in macronutrient composition and palatability. On each day, the entrées at all three meals had the same energy density. All entrées were consumed ad libitum. Subjects were assigned to one of two groups. Subjects in the information group received a nutrition label with each meal, which showed the energy density of the entrée. Subjects in the no-information group did not receive any nutrition information. The results revealed that subjects in both groups had the same pattern of food intake across the three levels of energy density. Energy density significantly affected energy intake; subjects in both groups combined consumed 22% less energy in the condition of low energy density than in the condition of high energy density (p < 0.0001). These findings show that energy density can have a significant influence on energy intake, even when individuals are informed about the energy density of their meals.     

The BRIGHT Trial: What are the factors associated with nutrition risk?

Objectives

To determine the nutrition risk status and factors associated with nutrition risk among older adults enrolled in the Brief Risk Identification Geriatric Health Tool (BRIGHT Trial).

Design

A cluster randomised controlled trial.

Setting

Three main centres in New Zealand.

Participants

A total of 3,893 older adults were recruited from 60 general practices in three of the District Health Board (DHB) regions aged 75 years and older (or 65 years and older if Māori).

Measurements

Nutrition risk was assessed using the Australian Nutrition Screening Initiative (ANSI). Validated questionnaires were used to establish quality of life (WHOQOL-BREF), physical function (the Nottingham Extended Activities of Daily Living) and depressive symptoms (15 item Geriatric Depression Scale). Demographic, standard of living and health data were established.

Results

Sixty two percent of participants were identified to be at moderate or high nutrition risk. The mean ANSI score was 4.9 (range 0–21, maximum 29). Factors which independently predicted moderate or high nutrition risk were female gender, being Māori and other ethnicities versus European, not being married, taking multiple medications, having more depressive symptoms, cardiovascular disease and diabetes. Protective factors independently related to low nutrition risk were living with others, higher physical and social health related QOL and higher functional status. WHOQOL environmental and psychological factors were not associated with nutrition risk when other predictive factors were taken into account.

Conclusion

Nearly two thirds of participants were identified to be at higher nutrition risk. Women, living alone, taking multiple medications, with depressive symptoms, cardiovascular disease and ndiabetes were factors associated with higher nutrition risk. Those at low nutrition risk had a better functional status and physical and social health related QOL.     

Choosing to practice in rural dietetics: What factors influence that decision?

OBJECTIVE: The present study aimed to identify those factors that influence the decision of a dietitian to consider working in a rural area. DESIGN: A qualitative design using focus groups was chosen for this study to allow for in-depth data to be obtained. SETTING: University of Newcastle, Callaghan Campus. SUBJECTS: Twenty-three students/new graduates from the Bachelor of Health Science (Nutrition and Dietetics) degree at the University of Newcastle. MAIN OUTCOME MEASURES: Not applicable, this project was an exploratory study. RESULTS: A number of factors that influence the decision of dietetic students and newly graduated dietitians to consider working in a rural area were identified. These fell into the following main thematic areas: job prospects; rural lifestyle; comfort zones; support networks; promotion opportunities/professional development; type of work/work role; rural needs; and time frame. CONCLUSIONS: The present study found that choosing a location to work (whether it be a rural one or not) is a complex process and involves a number of interacting factors. Also those factors that may influence one dietitian to choose a career in a rural area may also be the factors that influence another dietitian not to choose a career in a rural area.