1
|
Rørbech JT, Jensen CS, Dreyer P, Herholdt-Lomholdt SM. Beyond objective measurements: Danish nurses' identification of hospitalized pediatric patients at risk of clinical deterioration - A qualitative study. J Pediatr Nurs 2022; 66:e67-e73. [PMID: 35710888 DOI: 10.1016/j.pedn.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/15/2022] [Accepted: 05/22/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE While the use of Pediatric Track and Trigger Tools as a standard to discriminate high level of urgency in pediatric care has received considerable attention, less focus has been given to other important factors such as nurses' clinical observations and judgement. The purpose of this study was to explore nurses' observational practice and focus on which non-measurable signs and symptoms nurses find important when identifying inpatient pediatric patients at risk of clinical deterioration. DESIGN AND METHODS This was an inductive qualitative study based on an interpretive description methodology. Data were obtained through participant observation of experienced nurses working in a Danish pediatric unit and focus group interviews with pediatric nurses. Field notes were taken, and focus group interviews were audio taped and transcribed. A thematic text condensation method was used to analyse data. RESULTS Findings revealed the following four main themes of non-measurable signs and symptoms that nurses find important when identifying children at risk of clinical deterioration: Colour and skin tone; sounds; movement patterns; behavioural signs. CONCLUSIONS This study suggest that pediatric patients show signs and symptoms that go beyond the objective measurements integrated in Pediatric Track and Trigger Tools and they should not be ignored as they are highly valuable to nurses who are responsible for observing inpatient pediatric patients at risk of clinical deterioration. IMPLICATIONS More empirical research on nurses' observational practice is recommended, especially research to identify the signs and symptoms - both measurable and non-measurable - that are significant to nurses at the bedside.
Collapse
Affiliation(s)
- Josefine Tang Rørbech
- Department of Paediatrics and Adolescent Medicine, Unit for Research and Development in Nursing for Children and Young People, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Claus Sixtus Jensen
- Department of Paediatrics and Adolescent Medicine, Unit for Research and Development in Nursing for Children and Young People, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark.
| | - Pia Dreyer
- Professor in clinical nursing, Intensive care, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | | |
Collapse
|
2
|
Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study. Eur J Pediatr 2022; 181:4199-4209. [PMID: 36178539 PMCID: PMC9649464 DOI: 10.1007/s00431-022-04606-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. There is practice variation in management due to differences in guidelines and their usage and adherence. We aimed to assess whether management in febrile children below 3 months attending European Emergency Departments (EDs) was according to the guidelines for fever. This study is part of the MOFICHE study, which is an observational multicenter study including routine data of febrile children (0-18 years) attending twelve EDs in eight European countries. In febrile children below 3 months (excluding bronchiolitis), we analyzed actual management compared to the guidelines for fever. Ten EDs applied the (adapted) NICE guideline, and two EDs applied local guidelines. Management included diagnostic tests, antibiotic treatment, and admission. We included 913 children with a median age of 1.7 months (IQR 1.0-2.3). Management per ED varied as follows: use of diagnostic tests 14-83%, antibiotic treatment 23-54%, admission 34-86%. Adherence to the guideline was 43% (374/868) for blood cultures, 29% (144/491) for lumbar punctures, 55% (270/492) for antibiotic prescriptions, and 67% (573/859) for admission. Full adherence to these four management components occurred in 15% (132/868, range 0-38%), partial adherence occurred in 56% (484/868, range 35-77%). CONCLUSION There is large practice variation in management. The guideline adherence was limited, but highest for admission which implies a cautious approach. Future studies should focus on guideline revision including new biomarkers in order to optimize management in young febrile children. WHAT IS KNOWN • Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. • There is practice variation in management of young febrile children due to differences in guidelines and their usage and adherence. WHAT IS NEW • Full guideline adherence is limited, whereas partial guideline adherence is moderate in febrile children below 3 months across Europe. • Guideline revision including new biomarkers is needed to improve management in young febrile children.
Collapse
|
3
|
Urbane UN, Petrosina E, Zavadska D, Pavare J. Integrating Clinical Signs at Presentation and Clinician's Non-analytical Reasoning in Prediction Models for Serious Bacterial Infection in Febrile Children Presenting to Emergency Department. Front Pediatr 2022; 10:786795. [PMID: 35547543 PMCID: PMC9082163 DOI: 10.3389/fped.2022.786795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Development and validation of clinical prediction model (CPM) for serious bacterial infections (SBIs) in children presenting to the emergency department (ED) with febrile illness, based on clinical variables, clinician's "gut feeling," and "sense of reassurance. MATERIALS AND METHODS Febrile children presenting to the ED of Children's Clinical University Hospital (CCUH) between April 1, 2017 and December 31, 2018 were enrolled in a prospective observational study. Data on clinical signs and symptoms at presentation, together with clinician's "gut feeling" of something wrong and "sense of reassurance" were collected as candidate variables for CPM. Variable selection for the CPM was performed using stepwise logistic regression (forward, backward, and bidirectional); Akaike information criterion was used to limit the number of parameters and simplify the model. Bootstrapping was applied for internal validation. For external validation, the model was tested in a separate dataset of patients presenting to six regional hospitals between January 1 and March 31, 2019. RESULTS The derivation cohort consisted of 517; 54% (n = 279) were boys, and the median age was 58 months. SBI was diagnosed in 26.7% (n = 138). Validation cohort included 188 patients; the median age was 28 months, and 26.6% (n = 50) developed SBI. Two CPMs were created, namely, CPM1 consisting of six clinical variables and CPM2 with four clinical variables plus "gut feeling" and "sense of reassurance." The area under the curve (AUC) for receiver operating characteristics (ROC) curve of CPM1 was 0.744 (95% CI, 0.683-0.805) in the derivation cohort and 0.692 (95% CI, 0.604-0.780) in the validation cohort. AUC for CPM2 was 0.783 (0.727-0.839) and 0.752 (0.674-0.830) in derivation and validation cohorts, respectively. AUC of CPM2 in validation population was significantly higher than that of CPM1 [p = 0.037, 95% CI (-0.129; -0.004)]. A clinical evaluation score was derived from CPM2 to stratify patients in "low risk," "gray area," and "high risk" for SBI. CONCLUSION Both CPMs had moderate ability to predict SBI and acceptable performance in the validation cohort. Adding variables "gut feeling" and "sense of reassurance" in CPM2 improved its ability to predict SBI. More validation studies are needed for the assessment of applicability to all febrile patients presenting to ED.
Collapse
Affiliation(s)
- Urzula Nora Urbane
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Eva Petrosina
- Statistics Unit, Riga Stradins University, Riga, Latvia
| | - Dace Zavadska
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Jana Pavare
- Department of Pediatrics, Riga Stradins University, Riga, Latvia.,Department of Pediatrics, Children's Clinical University Hospital, Riga, Latvia
| |
Collapse
|
4
|
Jensen CS, Lisby M, Kirkegaard H, Loft MI. Signs and symptoms, apart from vital signs, that trigger nurses' concerns about deteriorating conditions in hospitalized paediatric patients: A scoping review. Nurs Open 2021; 9:57-65. [PMID: 34761544 PMCID: PMC8685853 DOI: 10.1002/nop2.1105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
Aim This scoping review aimed to identify and map the signs and symptoms—apart from vital signs—that trigger nurses’ concerns about the deteriorating conditions of hospitalized paediatric patients. Design A scoping review was conducted in accordance with the Joanna Briggs Institute methodology. Methods Six databases, including MEDLINE, CINAHL, Embase, Scopus, Swemed and ProQuest Dissertations and Theses databases, were searched systematically. Of 5795 citations, seven matched the inclusion criteria. Results Objective observations, such as the patient's colour, pain‐level changes, and behavioural observations, were identified as signs that would trigger nurses’ concerns. Nurse's intuitive feelings or gut feelings when seeing a patient was also identified as an important factor for identifying a deteriorating paediatric patient. A “gut feeling” was described as both a reaction to patient signs and a feeling based on the nurse's intuition gained through experience. The signs or symptoms that would trigger this “gut feeling” were not identified.
Collapse
Affiliation(s)
- Claus Sixtus Jensen
- Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Lisby
- Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | | |
Collapse
|
5
|
Jensen CS, Lisby M, Kirkegaard H, Loft MI. Signs and symptoms that trigger nurses' concerns about deteriorating conditions in hospitalized pediatric patients: a scoping review protocol. JBI Evid Synth 2020; 18:1594-1601. [PMID: 32813400 DOI: 10.11124/jbisrir-d-19-00220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this scoping review is to identify and map the signs and symptoms that trigger nurses' concerns about the deteriorating conditions of hospitalized pediatric patients. INTRODUCTION Standardized observations and risk assessments of hospitalized pediatric patients are important in modern health systems. The Pediatric Early Warning Score (PEWS) is based on objective criteria, such as vital parameters, but does not include subjective criteria, such as nurses' worry. A Dutch study has shown that adding indicators for "worry" or "concern" to an early warning system based on vital signs improves the prediction of unplanned adult admissions to intensive care units. However, this has not been studied in a pediatric population. Clarifying the signs and symptoms that trigger nurses' concerns about pediatric patients' conditions could possibly help them take actions based on their intuitive feelings and obtain medical support for pediatric patients in the early stages of deterioration. INCLUSION CRITERIA This review will consider studies that include nurses working in hospital settings who care for pediatric patients (up to 18 years of age). Specifically, this scoping review will explore the signs and symptoms that underlie nurses' concerns about a pediatric patient's condition when the patient's vital signs are not a cause of worry. METHODS This scoping review will be conducted in accordance with the JBI methodology for scoping reviews. The review will search MEDLINE (via PubMed), CINAHL, Embase, Scopus and Swemed databases. The review will also search for unpublished PhD dissertations using the ProQuest Dissertations and Theses.
Collapse
Affiliation(s)
- Claus Sixtus Jensen
- 1Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark 2Department of Clinical Medicine, Aarhus University, Aarhus, Denmark 3Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark 4Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | | | | | | |
Collapse
|
6
|
Geisler A, Zachodnik J, Laigaard J, Kruuse LS, Sørensen CV, Sandberg M, Persson EI, Mathiesen O. Using four different clinical tools as predictors for pain after total hip arthroplasty: a prospective cohort study. BMC Anesthesiol 2020; 20:57. [PMID: 32126971 PMCID: PMC7055106 DOI: 10.1186/s12871-020-00959-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background Treatment of postoperative pain remains a significant clinical problem, and prediction of patients with a risk of higher postoperative pain levels is an important focus. We aimed to identify patients undergoing total hip arthroplasty (THA) with risk of higher pain levels at 24 h postoperatively by using four simple and easily available clinical tools. Methods This prospective observational cohort study included 102 patients having THA at Zealand University Hospital in Denmark. The following predictive tools were investigated for identifying patients with higher postoperative pain levels at 24 h postoperatively, both at rest and during mobilization: preoperative pain by peripheral venous cannulation (PVC) (dichotomized according to numerical rating scale pain ≤ 2/> 2 (PVC-Low/PVC-High) (primary outcome); the post anesthesia care unit (PACU) nurses’ expectations of patients pain levels; patients early pain levels at the PACU; and patients own forecast of postoperative pain levels. The Mann-Whitney U test was used to analyze comparisons between prediction groups. For the primary outcome we considered a p-value < 0.01 as statistically significant and for other outcomes a p-value of 0.05. Results We found no significant differences between the PVC groups for pain during mobilization at 24-h postoperatively: PVC-Low: 6 (4–8) (median, (IQR)) versus PVC-High: 7 (5–8) (median, (IQR)), p = 0.10; and for pain at rest: PVC-Low 2 (0–3) (median, (IQR)) versus PVC-High 3 (2–5) (median, (IQR)), p = 0.12. Other comparisons performed between predictive groups did not differ significantly. Conclusions In this prospective cohort study of 102 THA patients, we did not find that preoperative pain by PVC, when using a cut-off point of NRS ≤ 2, were able to predict postoperative pain at 24 h postoperatively. Neither did PACU nurses’ prediction of pain, patients forecast of pain, nor did maximum pain levels at the PACU. Trial registration Retrospectively registered 20th February 2018 at ClinicalTrials.gov (NCT03439566).
Collapse
Affiliation(s)
- Anja Geisler
- Department of Anesthesiology, Zealand University Hospital, Lykkebækvej 1, 4600, Koege, Denmark. .,Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Josephine Zachodnik
- Department of Anesthesiology, Zealand University Hospital, Lykkebækvej 1, 4600, Koege, Denmark
| | - Jens Laigaard
- Department of Anesthesiology, Zealand University Hospital, Lykkebækvej 1, 4600, Koege, Denmark
| | - Laura S Kruuse
- Department of Anesthesiology, Zealand University Hospital, Lykkebækvej 1, 4600, Koege, Denmark
| | | | - Magnus Sandberg
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Eva I Persson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Ole Mathiesen
- Department of Anesthesiology, Zealand University Hospital, Lykkebækvej 1, 4600, Koege, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| |
Collapse
|
7
|
Kawai R, Nomura O, Tomobe Y, Morikawa Y, Miyata K, Sakakibara H, Miura M. Retrospective observational study indicates that the paediatric assessment triangle may suggest the severity of Kawasaki disease. Acta Paediatr 2018; 107:1049-1054. [PMID: 29385646 DOI: 10.1111/apa.14249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/23/2017] [Accepted: 01/25/2018] [Indexed: 02/06/2023]
Abstract
AIM We examined whether the paediatric assessment triangle (PAT) could predict the severity of Kawasaki disease. METHODS We enroled patients diagnosed with Kawasaki disease between July 2012 and June 2016 at the emergency department of Tokyo Metropolitan Children's Medical Center in Tokyo, Japan. Triage nurses assigned participants to unstable or stable PAT groups. We compared the incidence of coronary artery aneurysms (CAA), the Kobayashi score, which measures resistance to intravenous immunoglobulin treatment, and the incidence of initial treatment resistance. RESULTS Of the 420 participants, who were aged 0-145 months with a mean age of 31.2 ± 23.9 months, 66 (16%) were assigned to the unstable PAT group. The incidence of CAA was similar between the two groups. The percentage of unstable PAT group participants with a Kobayashi score of at least five points (39 versus 18%, p < 0.001) and initial treatment resistance (25 versus 15%, p = 0.047) were significantly higher than in the stable PAT group. Unstable PAT was an independent risk factor for initial treatment resistance (odds ratio 2.02, 95% confidence interval 1.05-3.90, p = 0.035). CONCLUSION An unstable PAT was able to predict the severity of Kawasaki disease when measured by a higher rate of initial treatment resistance.
Collapse
Affiliation(s)
- Reiko Kawai
- Department of General Pediatrics; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Osamu Nomura
- Department of Pediatric Emergency Medicine; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Yutaro Tomobe
- Department of Neonatology; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Yoshihiko Morikawa
- Clinical Research Support Center; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Koichi Miyata
- Department of Cardiology; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Hiroshi Sakakibara
- Department of General Pediatrics; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Masaru Miura
- Clinical Research Support Center; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
- Department of Cardiology; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| |
Collapse
|