The occurrence of adverse events is associated with increased morbidity and mortality in children admitted to a single pediatric intensive care unit

Effective Communication Supported by an App for Pregnant Women: Quantitative Longitudinal Study

BACKGROUND

In the medical field of obstetrics, communication plays a crucial role, and pregnant women, in particular, can benefit from interventions improving their self-reported communication behavior. Effective communication behavior can be understood as the correct transmission of information without misunderstanding, confusion, or losses. Although effective communication can be trained by patient education, there is limited research testing this systematically with an app-based digital intervention. Thus, little is known about the success of such a digital intervention in the form of a web-app, potential behavioral barriers for engagement, as well as the processes by which such a web-app might improve self-reported communication behavior.

OBJECTIVE

This study fills this research gap by applying a web-app aiming at improving pregnant women's communication behavior in clinical care. The goals of this study were to (1) uncover the potential risk factors for early dropout from the web-app and (2) investigate the social-cognitive factors that predict self-reported communication behavior after having used the web-app.

METHODS

In this study, 1187 pregnant women were recruited. They all started to use a theory-based web-app focusing on intention, planning, self-efficacy, and outcome expectancy to improve communication behavior. Mechanisms of behavior change as a result of exposure to the web-app were explored using stepwise regression and path analysis. Moreover, determinants of dropout were tested using logistic regression.

RESULTS

We found that dropout was associated with younger age (P=.014). Mechanisms of behavior change were consistent with the predictions of the health action process approach. The stepwise regression analysis revealed that action planning was the best predictor for successful behavioral change over the course of the app-based digital intervention (β=.331; P<.001). The path analyses proved that self-efficacy beliefs affected the intention to communicate effectively, which in turn, elicited action planning and thereby improved communication behavior (β=.017; comparative fit index=0.994; Tucker-Lewis index=0.971; root mean square error of approximation=0.055).

CONCLUSIONS

Our findings can guide the development and improvement of apps addressing communication behavior in the following ways in obstetric care. First, such tools would enable action planning to improve communication behavior, as action planning is the key predictor of behavior change. Second, younger women need more attention to keep them from dropping out. However, future research should build upon the gained insights by conducting similar internet interventions in related fields of clinical care. The focus should be on processes of behavior change and strategies to minimize dropout rates, as well as replicating the findings with patient safety measures.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03855735; https://classic.clinicaltrials.gov/ct2/show/NCT03855735.

Moderate and severe adverse events in pediatrics: characteristics of incidents reported during the COVID-19 pandemic

OBJECTIVE

To verify the characteristics of safety incident reports resulting in moderate and severe harm to pediatric patients in two hospitals during the COVID-19 pandemic.

METHOD

Cross-sectional study conducted in two hospitals in southern Brazil. The sample consisted of 137 notifications from March 2020 to August 2021. The data were collected through the electronic records of the institutions' notification systems and analyzed using descriptive and inferential statistics.

RESULTS

The most prevalent incidents were related to clinical processes or procedures (41.6%), affecting slightly more females (49.6%) and infants (39.4%). The majority of incidents (48.2%) occurred in inpatient units. The event sector (p=0.001) and the shift (p=0.011) showed statistically significant associations in both hospitals.

CONCLUSION

The characteristics of the notifications are similar between the institutions surveyed, with a low number of moderate and severe incidents.

Emergency room nurses' caring ability and its relationship with patient safety outcomes: A cross-sectional study

INTRODUCTION

Nurse caring ability plays a crucial role in providing quality care and ensuring patient safety. However, further research is warranted to understand the specific impact of caring ability on patient safety in the emergency department.

AIM

This study has two-fold purposes: (a) to examine the association between nurses' demographic characteristics and their perceptions of their caring ability, and (b) to explore the relationship between nurses' caring ability and nursing care quality, as well as its impact on adverse patient events and missed care.

METHODS

This cross-sectional study included a convenience sample of emergency room nurses working in select hospitals in the Philippines. Descriptive statistics and regression analyses were performed to analyze the data.

RESULTS

A total of 164 out of the 200 emergency nurses invited responded to the survey. The mean score for the caring ability inventory was 67.89 out of 80. Nurses' demographic characteristics, including job status (working part-time) and hospital size (working in small and medium-sized hospitals), were associated with higher levels of caring ability. Higher levels of nurses' caring ability were associated with better nursing care quality (β = 0.259, p <.001), a reduction in adverse events (β = -0.169, p <.05), and a decrease in instances of missed care (β = -0.158, p <.01).

CONCLUSION

This study emphasizes the significance of nurses' characteristics in influencing nurse caring abilities. Additionally, the results underscore the importance of nurse caring ability in the emergency department and its association with nursing care quality and patient safety outcomes. Organizational strategies directed toward promoting and enhancing nurse caring ability in the emergency department can have positive implications for nursing practice, including improved nursing care quality, reduced adverse events, and decreased instances of missed care.

Scoping Review of Fall Risk Assessment Tools for Women Who Receive Maternity Care

OBJECTIVE

To identify and describe fall risk assessment tools used for women who receive maternity care.

DATA SOURCES

PubMed, CINAHL Complete, MEDLINE Complete, Cochrane Library, Scopus, SciELO, and Repositórios Científicos de Acesso Aberto de Portugal (RCAAP).

STUDY SELECTION

We considered reports published until November 28, 2022, that included women during pregnancy, childbirth, or the postpartum period; involved the use of fall risk assessment tools, regardless of context; and were published in English, French, Portuguese, or Spanish.

DATA EXTRACTION

We extracted the following data from the included reports: author(s)/year/country, aim/sample, research design/type of report, tool (i.e., the fall risk assessment tool used), findings, reliability, and validity.

DATA SYNTHESIS

We found 13 reports in which the authors addressed nine fall risk assessment tools. Seven of these tools were applied during pregnancy (Kyle's tool, Pregnant Women Information Form and Assessment Scale for Risk of Falling in Pregnant Women, Obstetric Fall Risk Assessment System), labor (Obstetric Fall Risk Assessment System), the postpartum period (Cooksey-Post Obstetric Delivery Fall Risk Assessment, Kyle's tool, Risk of Falling in Post-partum Women (SLOPE), Obstetric Fall Risk Assessment System, Post-epidural Fall Risk Assessment Score, and Maternal Fall Risk Assessment Scale). The Dionne's Egress Test and the Motor Strength Scale do not address the characteristics of the women who receive maternity care. Psychometric characteristics were available for the Pregnant Women Information Form and Assessment Scale for Risk of Falling in Pregnant Women, Post-epidural Fall Risk Assessment Score, Maternal Fall Risk Assessment Scale, and Risk of Falling in Post-partum Women.

CONCLUSION

Some fall risk assessment tools are used to assess women who receive maternity care without proper validation in this specific population. The use of fall risk assessment tools that are validated for women who receive maternity care may help nurses make clinical judgments when assessing fall risk and implement measures for fall prevention.

Pediatric unplanned extubation risk score: A predictive model for risk assessment

BACKGROUND

Unplanned extubation is one of the most common preventable adverse events associated with invasive mechanical ventilation.

OBJECTIVE

This research study aimed to develop a predictive model to identify the risk of unplanned extubation in a pediatric intensive care unit (PICU).

METHODS

This single-center, observational study was conducted at the PICU of the Hospital de Clínicas. Patients were included based on the following criteria: aged between 28 days and 14 years, intubated, and using invasive mechanical ventilation.

RESULTS

Over 2 years, 2,153 observations were made using the Pediatric Unplanned Extubation Risk Score predictive model. Unplanned extubation occurred in 73 of 2,153 observations. A total of 286 children participated in the application of the Risk Score. This predictive model was created to categorize the following significant risk factors: 1) inadequate placement and fixation of the endotracheal tube (odds ratio 2.00 [95%CI,1.16-3.36]), 2) Insufficient level of sedation (odds ratio 3.00 [95%CI,1.57-4.37]), 3) age ≤ 12 months (odds ratio 1.27 [95%CI,1.14-1.41]), 4) presence of airway hypersecretion (odds ratio 11.00 [95%CI,2,58-45.26]) inadequate family orientation and/or nurse to patient ratio (odds ratio 5.00 [95%CI,2.64-7.99]), and 6) weaning period from mechanical ventilation (odds ratio 3.00 [95%CI,1.67-4.79]) and 5 risk enhancement factors.

CONCLUSIONS

The scoring system demonstrated effective sensitivity for estimating the risk of UE with the observation of six aspects, which overlap as an isolated risk factor or are associated with a risk enhancement factors.

Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews

BACKGROUND

Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.

OBJECTIVES

The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.

METHODS

A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study's quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.

RESULTS

Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.

CONCLUSIONS

Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.

Comparing the Effectiveness of a Web-Based Application With a Digital Live Seminar to Improve Safe Communication for Pregnant Women: 3-Group Partially Randomized Controlled Trial

BACKGROUND

Medical internet interventions such as asynchronous apps and synchronous digital live seminars can be effective behavior change interventions. The research question of this study was whether digital interventions based on the Health Action Process Approach can improve pregnant women's safe communication and patient safety in obstetric care.

OBJECTIVE

This study aims to compare a digital live seminar with a web-based application intervention and a passive control group and to identify which social cognitive variables determine safe communication behavior and patient safety.

METHODS

In total, 657 pregnant women were recruited, and hereof, 367 expectant mothers from 2 German university hospitals participated in the pre-post study (live seminar: n=142; web-based app: n=81; passive control group: n=144). All interventions targeted intention, planning, self-efficacy, and communication of personal preferences. The 2.5-hour midwife-assisted live seminar included exercises on empathy and clear communication. The fully automated web-based application consisted of 9 consecutive training lessons with the same content as that of the live seminar.

RESULTS

Controlled for sociodemographic characteristics, repeated measures analyses of covariance revealed that pregnant women significantly improved their self-reported communication behavior in all groups. The improvement was more pronounced after the digital live seminar than after the web-based application (P<.001; ηp2=0.043). Perceived patient safety improved more for pregnant women participating in the live seminar than for those participating in the web-based application group (P=.03 ηp2=0.015). A regression analysis revealed that social cognitive variables predicted safe communication behavior.

CONCLUSIONS

Overall, the web-based application intervention appeared to be less effective than the digital live training in terms of communication behavior. Application interventions addressing communication behaviors might require more face-to-face elements. Improving intention, coping planning, and coping self-efficacy appeared to be key drivers in developing safe communication behavior in pregnant women. Future research should include social learning aspects and focus on the practical application of medical internet interventions when aiming to improve pregnant women's communication and patient safety in obstetrics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03855735; https://clinicaltrials.gov/ct2/show/NCT03855735.

Long-term functional outcomes of children after critical illnesses: A cohort study

OBJECTIVE

To assess children's functional outcomes one year after critical illness and identify which factors influenced these functional outcomes.

DESIGN

Ambispective cohort study.

SETTING

Pediatric intensive care unit (PICU) in a tertiary academic center.

PARTICIPANTS

Children (1 month-17-year-old) and their caregivers.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Demographic, clinical, and functional status.

RESULTS

Of 242 patients screened, 128 completed the year follow-up. These children had significant changes in functional status over time (p<0.001). The functional decline occurred in 62% of children at discharge and, after one year, was persistent in 33%. Age>12 months was a protective factor against poor functional outcomes in two regression models (p<0.05). A moderately abnormal functional status and a severely/very severely abnormal functional status at discharge increased the risks of poor functional outcomes by 4.14 (95% CI 1.02-16.72; p=0.04), and 4.76 (CI 95% 1.19-19.0; p=0.02). A functional decline at discharge increased by 6.86 (95%CI: 2.16-21.79; p=0.001) the risks of children's long-term poor functional outcomes, regardless of the FSS scores.

CONCLUSION

This is the first study evaluating long-term functional outcomes after pediatric critical illnesses in Latin America. Our findings show baseline data and raise relevant questions for future multicentre studies in this field in Latin America, contributing to a better understanding of the effects of critical illnesses on long-term functional outcomes in children.

"Attempting to protect self and patient:" A grounded theory study of error recovery by intensive care nurses

AIM

The aim of this study was to explore the process of error recovery (ER) by nurses in intensive care unit (ICU).

DESIGN

This qualitative study was conducted in 2018-2020 using the grounded theory methodology.

METHODS

Participants were 20 staff nurses, head nurses and nursing managers recruited from the ICUs. Sampling was started purposively and continued theoretically. Data were collected using semi-structured interviews and were analysed using the approach proposed by Corbin and Strauss.

RESULTS

The findings indicated that nurses' primary concern was for the patient and their own personal/professional identity. Five strategies were found including evaluating situation, identifying error, analysing error and situation, determining the agent for error correction, and reducing error effects. Contextual factors were also highlighted as being important in the error recovery. Attempting to protect self and patient" was the core category of the study. Nurses' concern about protecting patient life and their own personal/professional identity make them use unprofessional approaches for ER.

Patient safety culture in a COVID-19 ICU compared to a clinical-surgical ICU in the Brazilian Eastern Amazon: A cross-sectional study

BACKGROUND

The COVID-19 pandemic highlighted the need for a new dynamic in the organization and practices of health services, as it required rapid restructuring to promote safe and harm-free assistance.

OBJECTIVE

To assess the dimensions of the patient safety culture (PSC) from the perspective of the health team professionals in clinical-surgical ICU (G1) compared to a COVID-19 ICU (G2).

METHODS

Cross-sectional, analytical, descriptive and inferential study, using the "Hospital Survey on Patient Safety Culture" questionnaire.

RESULTS

The domain "Supervisor/Manager Expectations and Actions Promoting Patient Safety (PS)" was a potential weakness for G1 (p = 0.003). G2 was most positive on improving PS, being informed about errors, considering PS as a top priority to management, and that the units work together to provide the best care (p > 0.05). G1 was most negative about the work culture with staff from other units, exchange of information across units, and shift changes (p > 0.05). The highest PS grade was related to greater communication, and a smaller frequency of events was reported only for G2 (p > 0.05).

CONCLUSION

There must be a balance in terms of attention focused on PS between different ICUs in times of crisis, especially regarding the supervisors/managers actions.

Psychological Intervention to Improve Communication and Patient Safety in Obstetrics: Examination of the Health Action Process Approach

Background

Human failure and a lack of effective communication are the main reasons for preventable adverse events, compromising patient safety in obstetrics. In order to improve safety, team and communication interventions have been implemented but lack feasibility in obstetric care. Psychological models such as the health action process approach might help to improve interventions.

Methods

In a cross-sectional online survey with N = 129 healthcare workers (Study 1) and a paper-pencil survey with N = 137 obstetric healthcare workers at two obstetric university hospitals (Study 2), associations of social-cognitive variables were tested in a path analysis and a multiple regression. Preliminary results informed a communication training for all obstetric healthcare workers. A repeated-measures MANOVA was used to compare pre- and post-intervention data.

Results

Social-cognitive variables were associated according to model suggestions (β = –0.26 to 0.45, p < 0.05) except for planning in the first study. Triggers of adverse events were associated (β = –0.41 to 0.24, p < 0.05) with communication behavior (Study 2), action self-efficacy and planning (Study 1), as well as barriers to effective communication (both studies). The intervention was rated positively (M = 3.3/4). Afterward, fewer triggers were reported and coping self-efficacy increased. There were group differences regarding hospital, experience, and time.

Discussion

The health action process approach was examined in the context of safe communication in obstetrics and can be used to inform interventions. A theory-based, short training was feasible and acceptable. Perceived patient safety improved but communication behavior did not. Future research should aim to test a more comprehensive psychological communication intervention in a thorough RCT design.

Comparing the dangers of a stay in English and German hospitals for high-need patients

OBJECTIVE

To estimate the risk of an avoidable adverse event for high-need patients in England and Germany and the causal impact that has on outcomes.

DATA SOURCES

We use administrative, secondary data for all hospital inpatients in 2018. Patient records for the English National Health Service are provided by the Hospital Episode Statistics database and for the German health care system accessed through the Research Data Center of the Federal Statistical Office.

STUDY DESIGN

We calculated rates of three hospital-acquired adverse events and their causal impact on mortality and length of stay through propensity score matching and estimation of average treatment effects.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified based on diagnoses codes and translated Patient Safety Indicators developed by the Agency for Healthcare Research and Quality.

PRINCIPAL FINDINGS

For the average hospital stay, the risk of an adverse event was 5.37% in the English National Health Service and 3.26% in the German health care system. High-need patients are more likely to experience an adverse event, driven by hospital-acquired infections (2.06%-4.45%), adverse drug reactions (2.37%-2.49%), and pressure ulcers (2.25%-0.45%). Adverse event risk is particularly high for patients with advancing illnesses (10.50%-27.11%) and the frail elderly (17.75%-28.19%). Compared to the counterfactual, high-need patients with an adverse event are more likely to die during their hospital stay and experience a longer length of stay.

CONCLUSIONS

High-need patients are particularly vulnerable with an adverse event risking further deterioration of health status and adding resource use. Our results indicate the need to assess the costs and benefits of a hospital stay, particularly when care could be provided in settings considered less hazardous.

Poor Functional Outcomes in Pediatric Intensive Care Survivors in Brazil: Prevalence and Associated Factors

Survivors of pediatric critical illnesses develop temporary or permanent functional impairments. We do not have enough data on Brazilian children, however, and the available evidence mainly shows results from high-income countries. Our objective was to assess changes in children and adolescents' functional status surviving critical illnesses in Brazil, and to identify which factors contribute to these functional changes at pediatric intensive care unit (PICU) discharge. To develop this cross-sectional study, two researchers blinded to previous patient information applied the Functional Status Scale (FSS) with patients and caregivers at two different times in a tertiary PICU. The FSS examines six function domains as follows: (1) mental status, (2) sensory functioning, (3) communication, (4) motor functioning, (5) feeding, and (6) respiratory status. The functional decline/poor outcome was defined as an increase in points sufficient to alter the FSS total scores at discharge when comparing to the total baseline score. A total of 303 patients completed the study. Of these, 199 (66%) were with previous chronic conditions. The prevalence of functional decrease was 68% at PICU discharge. Young age (<12 months) and mechanical ventilation time ≥11 days increased by 1.44 (95% confidence interval [CI]: 1.20–1.74, p < 0.001) and 1.74 (95% CI: 1.49–2.03, p < 0.001), respectively, the chances of poor functional results at PICU discharge. This study is the first in Brazil to show that during the episode of critical illness, young age (≤12 months) and duration of invasive mechanical ventilation independently increased the chances of functional impairment in children.

Use of Electronic Health Records to Identify Exposure-Response Relationships in Critically Ill Children: An Example of Midazolam and Delirium

Adverse drug events are common in critically ill children and often result from systemic or target organ drug exposure. Methods of drug dosing and titration that consider pharmacokinetic alterations may improve our ability to optimally dose critically ill patients and reduce the risk for drug-related adverse events. To demonstrate this possibility, we explored the exposure-response relationship between midazolam and delirium in critically ill children. We retrospectively examined electronic health records (EHRs) of critically ill children <18 years of age hospitalized in the pediatric intensive care unit at Duke University; these children were administered midazolam during mechanical ventilation and had ≥1 Cornell Assessment of Pediatric Delirium (CAPD) score. We used individual-level data extracted from the EHR and a previously published population pharmacokinetic (PK) model developed in critically ill children to simulate plasma concentrations at the time of CAPD scores in 1,000 representative datasets. We used multilevel repeated measures models, with clustering at patient and simulation levels, to evaluate the associations between measures of drug exposure (e.g., concentration and area under concentration time curve) and delirium scores. We included 61 children, median age 1.5 years (range = 0.1–16.3), with 181 CAPD assessments. We identified similarities between simulated Empirical Bayesian parameter estimates from the EHR cohort and those from the PK model population. We identified a stronger association between drug concentration at the time of score and CAPD scores (coefficient 1.78; 95% confidence interval: 1.66–1.90) compared with cumulative dose per kilogram and CAPD scores (coefficient −0.01; 95% confidence interval: −0.01 to −0.01). EHR and PK models can be leveraged to investigate exposure-response relationships in critically ill children.

Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions

Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.