The Swedish version of EMPATHIC-30 translation and initial psychometric evaluation

BACKGROUND

One way to measure quality of care is by measuring satisfaction of provided care among patients and their families. EMpowerment of PArents in THe Intensive Care 30 (EMPATHIC-30) is a self-reported questionnaire grounded on the principles of FCC aiming to measure parents' satisfaction with paediatric intensive care. There is lack of Swedish questionnaires measuring satisfaction with paediatric intensive care based on family-centered care principles.

AIM

The aim was to translate the instrument EMpowerment of PArents in THe Intensive Care 30 (EMPATHIC-30) into the Swedish language and evaluate psychometrically the Swedish version in a paediatric intensive care context.

METHODS

The instrument EMPATHIC-30 was translated and adapted to Swedish context, thereafter, assessed by expert panels consisting of nurses (panel one; n = 4; panel two; n = 24) and parents (n = 8) with experience in paediatric intensive care. Construct validity, item characteristics and reliability were tested in a cohort of 97 parents whose child had been treated for at least 48 h at two out of four Paediatric Intensive Care Unit (PICUs) in Sweden. Parents whose child died during hospitalisation were excluded.

RESULTS

The Swedish version of EMPATHIC-30 showed an acceptable internal consistency with Cronbach's alpha coefficient for the total scale 0.925. Cronbach's alpha on the domain level varied between 0.548-0.792 with the lowest coefficient in the domain Organisation. Inter-scale correlation revealed acceptable correlations for both subscales (0.440-0.743) and between total scale and subscales (0.623-0.805), which demonstrated good homogeneity for the instrument in its entirety. One problem regarding the domain Organisation and especially the item "It was easy to contact the pediatric intensive care unit by telephone" was revealed, which indicated that the item needs to be reformulated or that the factor structure needs to be further evaluated.

CONCLUSION

The findings from the current study indicated that the Swedish version of EMPATHIC-30 has acceptable psychometric properties and can be used in Swedish PICUs. Using EMPATHIC-30 in clinical practice can give an indication of the overall quality of family-centered care at the PICU.

Kangaroo position during neonatal ground ambulance transport: Parents' experiences

BACKGROUND

Kangaroo mother care including skin-to-skin care aims to overcome the negative effects of separating parents and infants and to increase the quality of care for infants and parents in need of neonatal care. In most cases where inter-hospital transport is needed, the infant is placed in a transport incubator, which increases the risk of separation due to ambulance service restrictions that imply that parents are not allowed to accompany these transport trips.

AIM

To illuminate parents' experiences of holding their infant in a kangaroo position during neonatal ground ambulance transport.

STUDY DESIGN

A qualitative design with an inductive approach.

METHODS

A total of 11 open interviews with Swedish parents were conducted two to seven days after their infant had been transferred in a kangaroo position between hospitals. The transcribed interviews were analysed using qualitative content analysis.

RESULTS

The emerged overarching category was "an uninterrupted closeness chain." The parents experienced that holding their infant during the transport extended the time they were close to their infant. Using the kangaroo position during ground ambulance transport also created a feeling of being important as a parent, as their participation during transport was appreciated. Parents' experiences were allocated into three categories: "Strengthen the feeling of being important as a parent," "promote security and create a positive environment for the baby" and "the professionals' attitude promotes security."

CONCLUSION AND RELEVANCE FOR CLINICAL PRACTICE

This knowledge about parents' experiences is important in the continued work to develop interventions that focus on promoting zero separation in neonatal care. Using kangaroo position in a safety harness during ambulance transport enhances zero separation and closeness. To encourage the implementation of kangaroo position during ambulance transport, further research is needed to address parents' experiences of zero separation during transport of infants to a higher level of care.

Parents' Views of Family-Centered Care at a Pediatric Intensive Care Unit-A Qualitative Study

Purpose: To describe parents' views of family-centered care at a pediatric intensive care unit. Design and Methods: A qualitative descriptive study with a deductive and inductive approach was conducted based on the principles of family-centered care. Inclusion criteria were parents of children cared for at a pediatric intensive care unit for at least 48 h. Parents of children who died during the hospital stay were excluded. The sample consisted of spontaneous responses from 70 parents to five open questions in the EMpowerment of PArents in THe Intensive Care questionnaire, which was completed at discharge. The spontaneous responses were analyzed using thematic analysis. Results: The analysis of the parents' statement illuminated that partnership, the essence of family-centered care, appeared incomplete. Partnership was particularly evident regarding parents' experiences of being treated with empathy and respect. It also seemed prominent in situations where the professional team provided support to the child, parents, and family. Based on the parents' statements there was potential for development of the family-centered care approach in aspects such as decision-making concerning care and treatment, as well as improving person-centered communication on order to capture parents' experiences and needs in the highly technological pediatric intensive care unit environment. Conclusions: Although in general parents were satisfied with the care, areas for improvement were identified such as participation in decision-making about care and treatment as well as person-centered communication. The results can contribute to future quality improvement interventions focusing family centered care at pediatric intensive care units.

Parents' Experiences of Having a Baby With a Congenital Heart Defect and the Child's Heart Surgery

The incidence of children born with congenital heart disease is 1%. Congenital heart disease is among the birth defects that lead to the longest hospital stays, and children with congenital heart disease often require frequent hospitalization and several heart operations, along with lifelong follow-up visits. This study aims to describe parents' experiences when their child has a heart defect and undergoes open heart surgery. A total of 10 parents were interviewed: 8 mothers and 2 fathers. The interviews took place 2 years after the heart surgery. The interviews were analyzed using a content analysis method, which resulted in 4 categories: maintaining belief, experiencing the surgery as a turning point, experiencing the pediatric intensive care unit with anxiety and fear, and perception of support. When parents face their child having a congenital heart defect and plan heart surgery, the whole family is living through a stressful time and has to handle many difficult situations. Parents need support from the health care team.

Functional remodelling and left ventricular dysfunction after repeated ischaemic episodes. A chronic experimental porcine model

This experimental study was set up to investigate left ventricular function and remodelling after repeated ischaemic episodes using magnetic resonance imaging (MRI). A significant reduction in mortality due to coronary heart disease (CHD) has been explained by both a decline in the incidence of acute myocardial infarction (AMI) and an improved post-AMI survival rate, suggesting a change in the natural history of CHD. Experimental intracoronary microembolization can induce different ischaemic patterns and the functional impact of repeated ischaemic episodes different from occlusion of central epicardial arteries can be studied. In this study repeated intracoronary microembolizations were performed in 20 domestic pigs. After 129 d, MRI was performed for assessment of left ventricular volume, mass and wall stress. Six pigs underwent serial MRI at baseline, immediately after embolization and at the end of the observation period. Microembolizations induced acute myocardial infarct expansion and increased left ventricular wall stress preceding chronic remodelling. End systolic and end diastolic volumes increased from 15.1 +/- 2.7 cm3 to 41.3 +/- 11.5 cm 3 (p < 0.002), and from 52.0 +/- 6.7 cm3 to 81.1 +/- 9.2 cm3 (p < 0.0007), respectively. End systolic wall stress increased from and 17.5 +/- 2.7 to 29.7 +/- 6.2 N/m2 (p < 0.001). Left ventricular filling pressures and cardiac index were unchanged. Histological examination revealed a diffuse pattern of perivascular fibrosis covering 12 +/- 3% of the left ventricular wall. This study demonstrates that repeated ischaemic episodes different from confined regional myocardial infarctions induce acute infarct expansion and chronic left ventricular remodelling in pigs. Serial assessment of absolute left ventricular volumes and mass is important during acute/chronic remodelling.

The hemodynamic impact of diffuse myocardial ischemic lesions: an animal experimental model based on intracoronary microembolization

In ischemic heart disease, left ventricular function is affected by a diffuse and segmental loss of myocardium. The decline in the incidence of myocardial infarction and improved early revascularization in acute transmural ischemia predict a change in the natural history of ischemic heart disease. It is now believed that, minor ischemic episodes, which are known to induce multifocal myocardial degeneration, will predominate in the near future. The objective of the present study was to develop a clinically relevant experimental model for investigation of the pathophysiological significance of diffuse ischemic myocardial lesions. Cardiac performance was gradually depressed by selective intracoronary microembolization in 13 pigs. Left ventricular function was quantitated by ejection fraction (EF), pulmonary pressure, cardiac output, and derivatives of left ventricular pressure. Left ventricular volume was estimated by epicardial echocardiography, using a new, unbiased stereological volume estimator. A chronic substudy was performed in order to characterize the histological changes and to evaluate the feasibility of establishing a chronic preparation of the model. Embolization induced acute left ventricular dysfunction; left ventricular pressure change decreased from 966+/-274 to 637+/-146 mmHg/s, and early diastolic relaxation from 1403+/-515 to 824+/-344 mmHg/s, respectively. Ejection fraction decreased by 45%+/-5% and cardiac output by 29%+/-11%. End-diastolic volume increased significantly, from 66.1+/-13.2 to 77.0+/-19.4 cm3, and end-systolic volume increased from 35.9+/-13.9 to 52.3+/-7.6 cm3. No change in heart rate or left ventricular filling pressure was observed. Diffuse ischemic myocardial injury was identified after a mean follow-up of 40 days. Intracoronary microembolization induces acute left ventricular dysfunction due to microinfarcts. Increased left ventricular end-diastolic volume is the initial compensatory response to the acute impairment of cardiac performance in nontransmural myocardial ischemia. This model is suitable for the evaluation of the hemodynamic changes secondary to acute and chronic diffuse loss of functional myocardium.

Pharmacological characterization of coronary small arteries from pigs with chronic ischaemic myocardial remodelling

1. The effect of chronic ischaemic myocardial remodelling on small coronary artery reactivity in vitro was studied in a newly developed pig model. 2. Pigs were subjected to selective intracoronary embolizations with microspheres in the left anterior descending artery and circumflex artery causing scattered myocardial fibrosis. After an observation period of 130 days, heart dimensions and ejection fraction were determined with magnetic resonance imaging. Small arteries were isolated from the left ventricle and mounted as ring preparations in a myograph. Control arteries were taken from matched non-embolized pigs. 3. Compared with control pigs, end-systolic and diastolic volumes increased and left ventricular mass nearly doubled in embolized pigs. This indicates substantial myocardial hypertrophy, as the fraction area of fibrosis was only 12%. 4. Coronary small arteries preconstricted with 30 mmol/l KCI showed a normal contractile response to acetylcholine and 5-hydroxytryptamine. Sensitivity of the relaxation to bradykinin was nearly 3-fold increased and also slightly enhanced to isoprenaline in arteries from embolized pigs compared with controls, whereas relaxation to 5-hydroxytryptamine in the presence of ketanserin was similar. After inhibition of nitric oxide synthase with NG-nitro-L-arginine the sensitivity to acetylcholine increased to a similar extent in arteries from embolized pigs and controls. NG-Nitro-L-arginine abolished the relaxing effects of bradykinin and of 5-hydroxytryptamine in the presence of ketanserin. 5. We conclude that both the contractile function of the smooth muscle cells and the endothelial production or action of nitric oxide is preserved or slightly enhanced in coronary small arteries from pigs with chronic myocardial remodelling.

New semiautomated Doppler method for quantification of volumetric flow: intraoperative validation with multiplane transesophageal color Doppler imaging

We have validated a new semiautomated method for quantification of volumetric flow applied to multiplane transesophageal color Doppler mapping. This Doppler technique assumes only the incompressibility of the fluid and includes variations of flow area. By computing velocity vectors across a surface normal to the point of scanning, volumetric flow can be measured independently of the angle of incidence between the ultrasonic beam and the direction of blood flow. Mitral valvular flow rate was measured during surgery by transesophageal color Doppler echocardiography in 27 patients undergoing coronary artery bypass grafting at 45 sets of observations. The results were compared with those obtained by the thermodilution technique. The mean of the differences between the thermodilution technique and color Doppler echocardiography was 0.06 +/- 0.866 L/min for the mitral valvular flows (mean of differences [thermodilution-color Doppler] &/- 2 SDs of differences). Thus mitral valvular volumetric flow measured by this color Doppler method showed a close agreement to the thermodilution technique during surgery.

Hemodynamic evaluation of a new bileaflet valve prosthesis: an acute animal experimental study

BACKGROUND AND AIMS OF THE STUDY

A newly developed heart valve (Medtronic Parallel) was tested in an acute animal experimental model.

METHODS

Five prototype valves were implanted in the aortic position in seven 90 kg pigs to enable acute evaluation of the hemodynamic performance in terms of turbulent stresses and transvalvular pressure drop. Turbulent stresses in the ascending aorta were measured using a 10 MHz perivascular Doppler echocardiographic transducer designed to measure the radical velocity component at 17 different points covering the aortic cross-sectional area.

RESULTS

The drop in transvalvular peak pressure measured with fluid-filled catheters showed a non-linear relationship with cardiac output and was always < 12 mmHg. The Reynolds normal stresses were < 60 N/m2 in systole within 50 ms time windows, which is insufficient to cause mechanical damage of the formed elements of the blood.

CONCLUSIONS

From a hemodynamic point of view the performance of the Medtronic Parallel aortic valve is fully acceptable and within the range of other similar, currently available mechanical valves.

Validation of a new transit time ultrasound flowmeter in man

OBJECTIVES

To validate the new CardioMed CM 4000 transit time ultrasound apparatus for intraoperative measurement of volume blood flow in vivo in man.

DESIGN

Open, prospective series.

MATERIALS

Thirteen patients undergoing in situ saphenous vein grafting for chronic critical leg ischaemia and 12 patients subjected to myocardial revascularisation with the internal thoracic artery as coronary bypass.

METHODS

During operations, volume blood flows were measured simultaneously by exsanguination from the cut distal end of the in situ saphenous vein graft or the internal thoracic artery and by the transit time flowmeter equipment. In addition, the feasibility to detect arteriovenous fistula during in situ saphenous vein grafting was examined.

RESULTS

Within the examined blood flow range, the volume blood flow determined by the transit time method corresponded to the directly measured blood flow. For in situ saphenous vein grafts: y = -2.4 + 0.95.x (r = 0.99; 35 measurements in 13 patients), and for internal thoracic artery grafts: y = -9.6 + 1.1.x (r = 0.99; 21 measurements in 12 patients), where y is blood flow determined by transit time, and x is directly measured blood flow by exsanguination (r = correlation coefficient) as calculated by the least squares regression method. Fistula detection was easy and swift.

CONCLUSIONS

The transit time apparatus was simple to use during intraoperative settings and gave fast, precise measurements of volume blood flow.

A new Doppler method for quantification of volumetric flow: in vivo validation using color Doppler

OBJECTIVES

This study was designed to assess the accuracy of a new Doppler method for quantification of volumetric flow in vivo.

BACKGROUND

Noninvasive assessment of volumetric flow through heart valves and the great vessels remains a clinical goal. We present a new method for quantification of volumetric flow based on color Doppler mapping that computes velocity vectors over a surface normal to the point of scanning. This Doppler technique assumes only the incompressibility of the fluid. The method is basically independent of the angle of incidence between the ultrasound beam and the direction of blood flow and includes variations of flow area.

METHODS

The color Doppler method was tested in seven anesthetized pigs by measuring pulmonary volumetric flows using multiplane Doppler echocardiography. The results were compared with those obtained by the thermodilution technique. In addition, volumetric flows across the mitral valve were determined in 10 normal volunteers by transthoracic Doppler echocardiography and compared with flows obtained with velocity-encoded magnetic resonance imaging (MRI).

RESULTS

The mean value of the differences between the thermodilution technique and color Doppler were -0.16 +/- 0.94 liter/min for pulmonary volumetric flows (mean value of differences for [Thermodilution-Color Doppler] +/- 2 SD of differences). The mean value of the differences between MRI and color Doppler were 0.21 +/- 0.83 liter/min for mitral valvular volumetric flows (mean value of differences for [MRI-Color Doppler] +/- 2 SD of differences).

CONCLUSIONS

The method showed close agreement with thermodilution and MRI for assessment of volumetric flow in vivo. It is therefore a noninvasive method with potential applications for cardiac output measurement and for quantification of volumetric flow of valvular insufficiency and restrictive lesions.

Assessing the severity of aortic valve stenosis by spectral analysis of cardiac murmurs (spectral vibrocardiography). Part II: Clinical aspects

Assessing the severity of aortic stenosis remains an important clinical problem. The turbulent pressure fluctuations generated by the jet downstream of the stenotic valve produce vibrations in the aortic wall. These vibrations are transmitted through the chest to the skin surface, where they can be recorded as systolic ejection murmurs. The purpose of the present study was to estimate the transvalvular aortic pressure difference by spectral analysis of heart murmurs (spectral vibrocardiography). Forty-four patients with clinical signs of aortic stenosis underwent cardiac catheterization to measure the transvalvular pressure difference. In a double blind prospective study, precordial vibrations were measured prior to catheterization using a dedicated heart sound analyzer (Vibrocard 2000) to calculate the spectral ratio of murmur energy between 100-500 Hz and 20-500 Hz. Three different weighting filters were used to compensate for individual differences in the transthoracic attenuation of murmurs. The square root of the murmur energy ratio correlated linearly with the mean transvalvular pressure difference (r = 0.80, SEE = 13 mmHg) and with the peak transvalvular pressure difference (r = 0.81, SEE = 16 mmHg). The use of individual compensation filters improved the correlation. This study shows that it is possible to estimate the transvalvular pressure difference in patients with aortic valve stenosis by spectral analysis of heart murmurs. It is a fast, simple and cost effective technique, which requires less skill than conventional methods.