The impact of the clinical environment on family centred care in the neonatal unit: A qualitative investigation

It has been suggested that the clinical environment has a significant impact on the wellbeing and recovery of patients. Furthermore, the design, physical environment and use of resources within the neonatal unit (NNU) is crucial to family centred care (FCC) and the provision of a supportive infrastructure for patients, families, staff and carers. It has also been claimed that poorly designed NNU can hinder the best intentioned efforts of NNU staff. This paper reports the findings of a qualitative investigation using non-participant observation and follow up interviews with key informants aimed at understanding ways in which the clinical environment might influence and impact upon the behaviour and practice of those employed within the NNU. Results indicate that topics such as noise, lighting, heating, ventilation and particularly space in which to care for patients and families are significant issues. It is concluded that poor clinical environments may impede staff in achieving improvements in care quality, and that an ergonomic, supportive environment is required within the NNU in order to enable quality care and increase efficiency. Further investigation into resource managed NNU, guided by lean thinking and the productive ward literature may provide a means of enabling improved FCC.     

Parent and nurse perceptions on the quality of family-centred care in 11 European NICUs

BackgroundFamily-centred care (FCC) is a state-of-the-art practice in neonatal intensive care units (NICU) based on its shown benefits on the well-being of both infants and parents. However, there is no systematic knowledge about how FCC is implemented in different European contexts.ObjectivesTo describe parents’ presence and the quality of FCC from the perspectives of mothers, fathers and nurses in 11 European NICUs.MethodsA prospective survey was conducted in Finland, Sweden, Norway, Estonia, Spain and Italy. The perceived quality of FCC was measured using 8 text-message questions sent to the parents’ mobile phones, one question each day, during the infant's hospital stay. Nurses answered corresponding questions through a Web questionnaire during a 3-month period. The responses were rated on a 7-point Likert scale. Parents who were not present in the unit during the day used a “0” response.ResultsA total of 262 families of preterm infants born before 35 gestational weeks participated in the study. Mothers gave 5045 responses, fathers gave 3971 responses and nurses gave 11,132 answers. The mothers were present during 92.7% and the fathers during 77.9% of the study days. The mothers rated the quality of FCC slightly higher than the fathers did (5.8 [95% CI 5.7–5.9] vs. 5.7 [95% CI 5.6–5.8], mean difference of 0.12 [95% CI 0.05–0.2], p < 0.001). There was wide variation in the parents’ presence and the quality of FCC between the units. The weakest aspects of FCC were emotional support, parents’ participation in decision-making and fathers’ participation in infant care. The perceived quality of FCC between the nurses and parents were comparable.ConclusionsThis study showed a high perceived quality of FCC in 11 European units, as indicated by both parents and nurses. The innovative data-collection method and instrument successfully quantified each unit's FCC profile for further quality improvement and should be trialled in other NICUs and countries.     

Observational study of children admitted to United Kingdom and Republic of Ireland Paediatric Intensive Care Units after out-of-hospital cardiac arrest

AimsTo estimate the prevalence of children admitted after out-of-hospital cardiac arrest (OHCA) to UK and Republic of Ireland (RoI) Paediatric Intensive Care Units (PICUs) and factors associated with mortality to inform future clinical trial feasibility.MethodObservational study using a prospectively collected dataset of the Paediatric Intensive Care Audit Network (PICANet) of 33 UK and RoI PICUs (January 2003 to June 2010). Cases (0 to <16 years), with documented OHCA surviving to PICU admission and requiring mechanical ventilation were included. Main outcomes were prevalence for admission and death within PICU. Factors associated with mortality were examined with multiple logistic regression analysis.Results827 of 111,170 admissions (0.73%; 95% CI [0.48 to 0.98%]) were identified as children admitted following OHCA. PICU mortality for OHCA was 50.5% (418/827). Recruitment into an adequately sized clinical trial would not be feasible with the current prevalence rate. Characteristics at PICU admission associated with increased risk of death included; bilateral unreactive pupils, genetically inherited condition, inter-hospital transfer to PICU, requirement for vasoactive drugs and greater base deficit. Factors associated with reduced risk of death were submersion or a respiratory aetiology and pre-existing respiratory or cardiac conditions.ConclusionsLess than 120 children a year are admitted to PICUs in the UK and RoI after OHCA, limiting options for conducting UK intervention trials. The risk factors associated with mortality identified in this study will allow risk stratification in future studies.     

The impact of family-centered care interventions on neonatal and parental outcomes in a Turkish hospital

AimThis study aimed to improve nurses’ attitudes towards parental engagement and to examine the impact of implementing nursing interventions related to family-centred care on neonatal and parental outcomes in a university hospital in Turkey.MethodsA quasi-experimental, nonequivalent, and post-test research design was used. Using convenience sampling, the study was completed with 128 preterm infants and their parents, including 64 in the experimental group and 64 in the control group at a neonatal intensive care unit of a university hospital. The control group data were collected from medical records and parents before practising family-centred nursing interventions developed for the experimental group. In addition, nurses were given a four hour training session aimed to improve their attitudes towards parental participation in care, with the nurses’ attitudes measured before, immediately after, and one month after the training. The experimental group data were collected from medical records and parents after 10 nursing interventions based on family-centred care supported by managers began to be implemented by trained nurses in the neonatal intensive care unit. The Parent-Preterm Infant Characteristics Form, Maternal Attachment Inventory, Empowerment of Parents in the Intensive Care-Neonatology (EMPATHIC-N), and Parental Engagement Attitude Scale were used for the data collection.FindingsWhile nurses’ scores of attitudes toward parental participation obtained immediately after and one month after the training were higher than those before the training, the scores one month after were lower compared to those immediately after. The results indicated that discharge weight gain of infants in the experimental group were significantly higher than those in the control group and that there was no significant difference between the groups in length of stay at neonatal intensive care unit. The maternal attachment and satisfaction scores of the parents in the experimental group were significantly higher than those in the control group.ConclusionImplementing family-centred nursing care interventions, developed based on unit needs and supported by managers, with trained neonatal intensive care nurses positively impacted parent-infant attachment, parent satisfaction, and infant weight gain.     

Influence of a dedicated paediatric cardiac intensive care unit on patient outcomes

Background: The impact of a designated intensive care unit (ICU) for postoperative cardiac care in children is not clear. In our hospital (in the USA), we started a new Paediatric Cardiac Surgery programme 5 years ago, in September 2004. During the first 2 years of the programme, postoperative care was accomplished within the general paediatric ICU (PICU or c‐ICU). Subsequently, in September 2006, a dedicated cardiac ICU (d‐ICU) was established. We looked at our experience during these two periods to determine whether the designation of a separate ICU affected outcomes for these children. Design and Methods: We obtained Institutional Review Board (IRB) approval to review the medical records for all postoperative cardiac admissions to the ICU during the first 4 years of the programme (September 2004–September 2008). Variables collected included age, gender, diagnosis, type of cardiac surgery, Risk Adjustment for Congenital Cardiac Surgery, version 1 (RACHS‐1) classification, ventilator use, hospital stay, invasive line infections, ventilator‐related infections, wound infections, need for cardiopulmonary support, return to the operating room, re‐exploration of the chest, delayed sternal closure, accidental extubations, re‐intubation and mortality rates. These variables were summed and compared for the combined PICU and the dedicated paediatric cardiac ICU. Results: There were 199 cases performed in the first 2 years compared with 244 in the following 2 years. We saw a statistically insignificant increase in the number and complexity of cases during the second period (p = 0·08). However, morbidity declined as evidenced by the decrease in wound infection (p < 0·001) and need for chest re‐exploration (p < 0·001). In addition, mortality declined from 7 of 199 (3·5%) to 2 of 244 (0·8%). p < 0·04 and less children required resuscitation (p < 0·01). Conclusions: We believe the designation of a specific area for postoperative cardiac care was instrumental in the growth and development of our cardiac programme. This rapid change accomplished several crucial elements that lead to accelerated improvement in patient care and a decline in morbidity and mortality.     

专科医院ICU重症监护信息系统护理文书的优化与效果评价

目前国内外医院信息系统建设重点已由医院管理信息系统（hospitalinformationmanagementsystern,HMIS）转向临床信息系统（clinicinformationsystem,CIS）。据统计,美国25％的1000张床位以上大型医院使用了CIS。国内的CIS处于理论探索和临床初步摸索阶段,与国际先进水平相比还有较大的差距。     

目标性镇静护理在儿科监护室中的应用

目的探讨目标性镇静护理在儿科监护室中的应用效果。方法便利抽样法选取2015年3-4月入住上海交通大学附属儿童医院儿科监护室的患儿35例,设为观察组,采用目标性镇静护理;同法选取2015年1-2月目标镇静法实施前同一儿科监护室患儿35例设为对照组,采用常规镇静护理。分析比较两组患儿镇静效果、镇静前后和苏醒后生命体征变化以及遵医依从性情况。结果观察组患儿镇静效果明显高于对照组,两组相比较差异有统计学意义(P0.05);观察组患儿入住监护室镇静护理过程中生命体征变化平稳,与对照组相比,差异无统计学意义(P0.05);观察组患儿在转出监护室时遵医依从性优于对照组,两组比较,差异有统计学意义(P0.05)。结论目标性镇静护理在儿科监护室中应用明显提高了患儿遵医依从性,确保医疗活动的有效性,值得临床推荐应用。     

综合ICU危重孕产妇现状的临床研究

目的：分析ICU收治的危重孕产妇的临床特点、治疗干预结果。方法：收集2010-01～2012—10湖南省常德市第一人民医院中心ICU收治的46例急危重症孕产妇的临床资料,进行回顾性分析。结果：46例危重孕产妇平均年龄（28．8±6．4）岁,孕龄（32．2±7．6）周。人住ICU的最常见原因为产后大出血（11例,23．9％）,其次为妊娠相关性高血压（8例,17．4％）,死亡4例（8．7％）。合并基础疾病组ICU治疗时间（5．3±5．1）d,并发重症产科疾病组ICU治疗时间（2．7±1．7）d。结论：危重孕产妇人住ICU的最常见原因为产后大出血、妊娠相关性高血压。应根据孕产妇人住ICU的病因及早干预。     

Altered pharmacology in the Intensive Care Unit patient

Critically ill patients, not infrequently present alterations of physiological parameters that determine the success/failure of therapeutic interventions as well as the final outcome. Sepsis and polytrauma are two of the most common and complex syndromes occurring in Intensive Care Unit (ICU) and affect drug absorption, disposition, metabolism and elimination. Pharmacological management of ICU patients requires consideration of the unique pharmacokinetics associated with these clinical conditions and the likely occurrence of drug interaction. Rational adjustment in drug choice and dosing contributes to the appropriateness of treatment of those patients.     

Clinical review: impact of emergency department care on intensive care unit costs

Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.