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Background Aim Study Design Results Conclusions Relevance to Clinical Practice Re‐deployment of medical, nursing and Allied Health Professional workforce became a more prevalent feature in filling workforce gaps during the Covid‐19 pandemic; however, very little evidence exists surrounding the impact of this re‐deployment of registered nursing workforce. Prior to the Covid‐19 pandemic and subsequently in an attempt to address nursing shortages across paediatric ward areas, there is a growing trend to utilize registered nursing staff more flexibly to meet the demands of the whole organization.The aim of this study was to explore the incidence impact of re‐deployment to cover workforce shortages in the registered paediatric critical care nursing workforce.This is a cross‐sectional electronic survey of paediatric critical care nurses registered with the Paediatric Critical Care Society as nursing members (n = 688). Anonymous quantitative and qualitative data were collected between January and March 2023. Quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically.There were 225 participant responses representing 21 of the 26 paediatric critical care units within the United Kingdom. This represents a response rate of 33%. The frequency of re‐deployment ranged from zero to two occurrences per month (n = 195; 87%). Thirty percent (n = 67) of respondents felt that re‐deployment to other wards to cover staffing shortfalls impacted the safety of care delivered to the patients. Five themes were identified: Quality of Care, Wellbeing, Teamwork, Training and Support and Leadership.This study demonstrates the significant impact that re‐deployment has on the paediatric critical care nurse population. With retention of experienced critical care nurses at crisis point, it is essential that we identify factors that contribute to this poor retention and address these factors accordingly. Re‐deployment is a significant factor.This study has provided a greater understanding of the impact of re‐deploying paediatric critical care to cover workforce shortages throughout acute hospital settings. [ABSTRACT FROM AUTHOR]

Background: Paediatric critical care nurses face challenges in promptly detecting patient deterioration and delivering high-quality care, especially in low-resource settings (LRS). Patient monitors equipped with data-driven algorithms that monitor and integrate clinical data can optimise scarce resources (e.g. trained staff) offering solutions to these challenges. Poor algorithm output design and workflow integration, however, are important factors hindering successful implementation. This study aims to explore nurses' perspectives to inform the development of a data-driven algorithm and user-friendly interface for future integration into a continuous vital signs monitoring system for critical care in LRS. Methods: Human-centred design methods, including contextual inquiry, semi-structured interviews, prototyping and co-design sessions, were carried out at the high-dependency units of Queen Elizabeth Central Hospital and Zomba Central Hospital in Malawi between March and July 2023. Triangulating these methods, we identified what algorithm could assist nurses and used co-creation methods to design a user interface prototype. Data were analysed using qualitative content analysis. Results: Workflow observations demonstrated the effects of personnel shortages and limited monitor equipment for vital signs monitoring. Interviews identified four themes: workload and workflow, patient prioritisation, interaction with guardians, and perspectives on data-driven algorithms. The interviews emphasised the advantages of predictive algorithms in anticipating patient deterioration, underlining the need to integrate the algorithm's output, the (constant) monitoring data, and the patient's present clinical condition. Nurses preferred a scoring system represented with familiar scales and colour codes. During co-design sessions, trust, usability and context specificity were emphasised as requirements for these algorithms. Four prototype components were examined, with nurses favouring scores represented by colour codes and visual representations of score changes. Conclusions: Nurses in the LRS studied, perceived that data-driven algorithms, especially for predicting patient deterioration, could improve the provision of critical care. This can be achieved by translating nurses' perspectives into design strategies, as has been carried out in this study. The lessons learned were summarised as actionable pre-implementation recommendations for the development and implementation of data-driven algorithms in LRS. [ABSTRACT FROM AUTHOR]

Background Aim Study Design Results Conclusion Relevance to Clinical Practice Children with medical complexity (CMC) are at increased risk of admission in intensive care. Despite improvements in mortality rates, there remains a burden of morbidity, long‐term health care needs and hospital readmissions. Beyond clinical factors, socio‐demographic determinants could impact utilization of acute services.To identify risk factors that can differentiate CMC who are admitted to the paediatric intensive care unit (PICU).A 6‐year longitudinal retrospective cohort study evaluated clinical, socio‐demographic and health care utilization.A total of 248 CMC were included, with a median age of 13 years (9.75–17.00). Intensive care admission rate was 47.2%. The risk of PICU admission was higher for children undergoing surgical interventions (HR = 1.58, 95% CI 1.34–1.86, p < .001) and those using medical devices (HR = 1.81, 95% CI 1.54–2.13, p < .001). Mother's higher educational level was a protective factor (HR = 0.66, 95% CI 0.55–0.79, p < .001). Multivariable analysis revealed significant associations between risk of admission and the presence of malignancy, comorbidities, home medical devices, surgical procedures and higher health care utilization. Children's age and higher maternal educational level acted as protective factors.Socio‐demographic factors should be considered in the provision of care to CMC. Individualized assessments to guide supportive interventions adapted to socio‐economic factors may prevent PICU admissions.This study highlights the importance of integrating individualized assessments of socio‐demographic risk factors, such as maternal educational level, into the clinical practice of paediatric nurses. Moreover, targeted interventions, including educational resources and community support programmes, may optimize care. [ABSTRACT FROM AUTHOR]

Abstract Background Paediatric critical care nurses face challenges in promptly detecting patient deterioration and delivering high-quality care, especially in low-resource settings (LRS). Patient monitors equipped with data-driven algorithms that monitor and integrate clinical data can optimise scarce resources (e.g. trained staff) offering solutions to these challenges. Poor algorithm output design and workflow integration, however, are important factors hindering successful implementation. This study aims to explore nurses’ perspectives to inform the development of a data-driven algorithm and user-friendly interface for future integration into a continuous vital signs monitoring system for critical care in LRS. Methods Human-centred design methods, including contextual inquiry, semi-structured interviews, prototyping and co-design sessions, were carried out at the high-dependency units of Queen Elizabeth Central Hospital and Zomba Central Hospital in Malawi between March and July 2023. Triangulating these methods, we identified what algorithm could assist nurses and used co-creation methods to design a user interface prototype. Data were analysed using qualitative content analysis. Results Workflow observations demonstrated the effects of personnel shortages and limited monitor equipment for vital signs monitoring. Interviews identified four themes: workload and workflow, patient prioritisation, interaction with guardians, and perspectives on data-driven algorithms. The interviews emphasised the advantages of predictive algorithms in anticipating patient deterioration, underlining the need to integrate the algorithm’s output, the (constant) monitoring data, and the patient’s present clinical condition. Nurses preferred a scoring system represented with familiar scales and colour codes. During co-design sessions, trust, usability and context specificity were emphasised as requirements for these algorithms. Four prototype components were examined, with nurses favouring scores represented by colour codes and visual representations of score changes. Conclusions Nurses in the LRS studied, perceived that data-driven algorithms, especially for predicting patient deterioration, could improve the provision of critical care. This can be achieved by translating nurses’ perspectives into design strategies, as has been carried out in this study. The lessons learned were summarised as actionable pre-implementation recommendations for the development and implementation of data-driven algorithms in LRS.

Abstract Background Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. Methods A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. Results The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. Conclusion Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.

Abstract Critical illness-related corticosteroid insufficiency or CIRCI is characterized by acute and life-threatening disfunction of hypothalamic–pituitary–adrenal (HPA) axis observed among intensive care unit- staying patients. It is associated with increased circulating levels of biological markers of inflammation and coagulation, morbidity, length of ICU stay, and mortality. Several mechanisms are involved in CIRCI pathogenesis: reduced CRH-stimulated ACTH release, peripheral resistance to glucocorticoids, altered cortisol synthesis, impaired cortisol-free fraction and bioavailability. Diagnostic and therapeutic management of this condition in children is still debated, probably because of the lack of agreement among intensive care specialists and endocrinologists regarding diagnostic criteria and prevalence of CIRCI in paediatric age. In the present narrative review, we focused on definition of CIRCI in paediatric age and we advise on how to diagnose and treat this poorly understood condition, based on current literature data.

Critical illness-related corticosteroid insufficiency or CIRCI is characterized by acute and life-threatening disfunction of hypothalamic–pituitary–adrenal (HPA) axis observed among intensive care unit- staying patients. It is associated with increased circulating levels of biological markers of inflammation and coagulation, morbidity, length of ICU stay, and mortality. Several mechanisms are involved in CIRCI pathogenesis: reduced CRH-stimulated ACTH release, peripheral resistance to glucocorticoids, altered cortisol synthesis, impaired cortisol-free fraction and bioavailability. Diagnostic and therapeutic management of this condition in children is still debated, probably because of the lack of agreement among intensive care specialists and endocrinologists regarding diagnostic criteria and prevalence of CIRCI in paediatric age. In the present narrative review, we focused on definition of CIRCI in paediatric age and we advise on how to diagnose and treat this poorly understood condition, based on current literature data. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to assess the incidence, nature, preventability and severity of adverse drug events (ADEs) across three paediatric intensive care units (PICUs) in England. Methods: A prospective observational cohort study was conducted across three PICUs over a three‐month period during 2019. Included patients were aged ≤18 years and stayed in PICU for a minimum of 24 hours. Identification of suspected ADEs was performed by trained PICU pharmacists. A multidisciplinary expert panel assessed causality, preventability and severity of events. Results: A total of 302 patients were included and 62 ADEs were confirmed (definite/probable causality). One in six patients experienced one or more ADEs. The estimated incidence of ADEs were 20.5 per 100 patients (95% CI 15.3–27.5) and 16.7 per 1000 patient‐days (95% CI 9.3–29.9). The majority of ADEs were judged preventable by the expert panel (36/62, 58.1%). ADEs were commonly involved with medicines prescribing (29/62, 46.8%) and caused temporary patient harm (42/62, 67.7%). Medications for the central nervous system (14/62, 22.6%), infections (13/62, 20.9%) and cardiovascular system (12/62, 19.4%) were commonly implicated with ADEs. Multivariable analysis revealed that patients who stayed in PICU for ≥7 days (OR 6.29, 95% CI 2.42–16.32) were more likely to experience an ADE compared to patients with a stay of 1–6 days. Conclusion: ADEs are common in English PICUs and most of them may be preventable. There is a strong association between ADE occurrence and duration of PICU stay, which represents a target for remedial interventions. Exploring contributory factors of preventable ADEs is now necessary to inform preventive policies. [ABSTRACT FROM AUTHOR]

Abstract Background Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. Methods Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. Results Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. Conclusions GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.

Introduction: Numerous scoring systems have been proposed in an effort to increase the prognostic accuracy and predicting outcome. In order to measure the risk of mortality, scores are employed that establish a numerical scale and in this way, they compare estimated mortality in % with the observed mortality. Known as prognostic scores, these can be used to evaluate the quality of medical care and to optimise the employment of resources, aiming at improving the cost-benefit relationship. Since, they compare mortality adjusted by disease severity these scores can also be used for comparisons between clinical trials and for planning technological resources. Aim: To compare the performance of the Paediatric Risk of Mortality III (PRISM III), the Paediatric Index of Mortality 3 (PIM 3) and Paediatric Logistic Organ Dysfunction-2 (PELOD-2) scores in a Paediatric Intensive Care Unit (PICU) in a tertiary care hospital. Materials and Methods: The present study was prospective observational study which included children from one month to 14 years of age admitted to PICU, and who remained in PICU after 24 hours. Within the first hour of admission PIM 3 was assessed. Further at 24 hours of admission, PRISM III and PELOD-2 score were assessed. Performance of different scores were evaluated. Calibration by HosmerLemeshow goodness-of-fit test {12(p)} Discrimination was assessed by the ROC curve. Standardised Mortality Rate (SMR) was calculated to predict the mortality. Results: Total 281 children were enrolled in the study, out of which 62 patients died. Neurological illness was the most common cause of death (12, 19.35%) followed by respiratory and haemato-onco cases (10, 16.13%) each. The Area Under the ROC Curve-Receiver Operating Characteristics (AUC-ROC) of PELOD-2, PIM 3 and PRISM III were 0.862, 0.847 and 0.838, respectively. Among the three scores PELOD-2 had poor calibration for the study population (2=18.837, p=0.016, d=8). PIM 3 was a better predictor of mortality (with SMR of 1.33) when compared with PRISM III and PELOD-2 (which had SMR of 1.57 and 1.83, respectively). Conclusion: All the three scores had good discrimination, however PELOD-2 had poor calibration for the given study population, with respect to better predictor of mortality all the scores underestimate the mortality. Among these, the better predictor mortality was PIM 3. Since, PIM 3 also had good calibration for the study population and is associated with less variables to monitor there is ease of estimation and hence it is more suitable to score and to assess mortality. [ABSTRACT FROM AUTHOR]

Introduction: Numerous scoring systems have been proposed in an effort to increase the prognostic accuracy and predicting outcome. In order to measure the risk of mortality, scores are employed that establish a numerical scale and in this way, they compare estimated mortality in % with the observed mortality. Known as prognostic scores, these can be used to evaluate the quality of medical care and to optimise the employment of resources, aiming at improving the cost-benefit relationship. Since, they compare mortality adjusted by disease severity these scores can also be used for comparisons between clinical trials and for planning technological resources. Aim: To compare the performance of the Paediatric Risk of Mortality III (PRISM III), the Paediatric Index of Mortality 3 (PIM 3) and Paediatric Logistic Organ Dysfunction-2 (PELOD-2) scores in a Paediatric Intensive Care Unit (PICU) in a tertiary care hospital. Materials and Methods: The present study was prospective observational study which included children from one month to 14 years of age admitted to PICU, and who remained in PICU after 24 hours. Within the first hour of admission PIM 3 was assessed. Further at 24 hours of admission, PRISM III and PELOD-2 score were assessed. Performance of different scores were evaluated. Calibration by HosmerLemeshow goodness-of-fit test {χ2(p)} Discrimination was assessed by the ROC curve. Standardised Mortality Rate (SMR) was calculated to predict the mortality. Results: Total 281 children were enrolled in the study, out of which 62 patients died. Neurological illness was the most common cause of death (12, 19.35%) followed by respiratory and haemato-onco cases (10, 16.13%) each. The Area Under the ROC Curve-Receiver Operating Characteristics (AUC-ROC) of PELOD-2, PIM 3 and PRISM III were 0.862, 0.847 and 0.838, respectively. Among the three scores PELOD-2 had poor calibration for the study population (χ2=18.837, p=0.016, d=8). PIM 3 was a better predictor of mortality (with SMR of 1.33) when compared with PRISM III and PELOD-2 (which had SMR of 1.57 and 1.83, respectively). Conclusion: All the three scores had good discrimination, however PELOD-2 had poor calibration for the given study population, with respect to better predictor of mortality all the scores underestimate the mortality. Among these, the better predictor mortality was PIM 3. Since, PIM 3 also had good calibration for the study population and is associated with less variables to monitor there is ease of estimation and hence it is more suitable to score and to assess mortality.

Background: Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi.Methods: Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed.Results: Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias.Conclusions: GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting. [ABSTRACT FROM AUTHOR]

Abstract Background Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care. Methods In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT. Results Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2). Conclusions Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients. Trial registration clinicaltrials.gov, NCT02612415. Registered on 23 November 2015.

Objectives: Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting. Methods: Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined. Results: Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11–3 years). The median weight was 6.2 kg (IQR 3.7–16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8–3.3; median 3, IQR 2.2–3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03). Conclusion: Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement. [ABSTRACT FROM AUTHOR]

Background: Syringe infusion pumps are used for the precise continuous administration of intravenous drugs. Their compliance and mechanical deficiencies have been found to cause considerable start-up delays, flow irregularities during vertical displacement, as well extensive delays of occlusion alarms at low infusion rates. The aim of this study was to evaluate the performance of several modern syringe infusion pumps at low infusion rates and the impact on drug concentration.Methods: Seven currently marketed syringe infusion pump assemblies were assessed in an in vitro study during start-up, vertical displacement manoeuvres, and infusion line occlusion at a set flow rate of 1 ml h-1. The measured data were used as input for a pharmacokinetic simulation modelling plasma concentration during a standard neonatal continuous epinephrine infusion.Results: The mean time from starting the infusion pump to steady-state flow varied from 89 to 1622 s. The zero-drug delivery time after lowering the pump ranged from 145 to 335 s. In all assemblies tested, occlusion alarm delays and measured flow irregularities during vertical displacement manoeuvres resulted in relevant deviations in plasma epinephrine concentration (>25%) as calculated by the pharmacokinetic simulation model.Conclusion: Problems with the performance of syringe infusion pump assemblies can have considerable impact on plasma drug concentration when highly concentrated short-acting cardiovascular drugs are administered at low flow rates. The problems, which affected all assemblies tested, are mainly related to the functional principle of syringe infusion pumps and will only partially be solved by incremental improvements of existing equipment. [ABSTRACT FROM AUTHOR]

Respiratory syncytial virus (RSV) bronchiolitis is a leading cause of global child morbidity and mortality. Every year, seasonal RSV outbreaks put high pressure on paediatric intensive care units (PICUs) worldwide, including in the Netherlands, and this burden appears to be increasing. Weather conditions have a strong influence on RSV activity, and climate change has been proposed as a potential important determinant of future RSV-related health care utilisation. In this national study spanning a total of 13 years with 2161 PICU admissions for RSV bronchiolitis, we aimed (1) to identify meteorological variables that were associated with the number of PICU admissions for RSV bronchiolitis in the Netherlands and (2) to determine if longitudinal changes in these variables occurred over time as a possible explanation for the observed increase in PICU burden. Poisson regression modelling was used to identify weather variables (aggregated in months and weeks) that predicted PICU admissions, and linear regression analysis was used to assess changes in the weather over time. Maximum temperature and global radiation best predicted PICU admissions, with global radiation showing the most stable strength of effect in both month and week data. However, we did not observe a significant change in these weather variables over the 13-year time period. Based on our study, we could not identify changing weather conditions as a potential contributing factor to the increased RSV-related PICU burden in the Netherlands.

Resumen: La unidad de cuidados intensivos pediátricos (UCIP) es una unidad física asistencial hospitalaria independiente especialmente diseñada para el tratamiento de pacientes pediátricos quienes debido su gravedad o condiciones potencialmente letales requieren observación y asistencia médica intensiva integral y continua por un equipo médico que haya obtenido competencia especial en medicina intensiva pediátrica. La aplicación oportuna de terapia intensiva a los pacientes críticos reduce la mortalidad, el tiempo de estancia y los costes asistenciales. Con los objetivos de respetar el derecho del niño al disfrute del más alto nivel posible de salud y a servicios para el tratamiento de las enfermedades y la rehabilitación de la salud y de garantizar la calidad asistencial y la seguridad de los pacientes pediátricos críticos, la Asociación Española de Pediatría (AEP), la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) y la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) han desarrollado y aprobado las guías de ingreso, alta y triage para las UCIP en España. Mediante la aplicación de estas guías se puede optimizar el uso de las UCIP españolas de forma que los pacientes pediátricos reciban el nivel de cuidados médicos más apropiado para su situación clínica. Abstract: A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.

Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted. [ABSTRACT FROM AUTHOR]

Objectives To analyse and provide current data surrounding paediatric critical procedures performed in three EDs of a single Victorian health network. Methods We conducted a retrospective study of every paediatric ED attendance requiring management in a resuscitation cubicle at three Victorian hospitals in 2013. The primary outcome measure was the frequency of each paediatric critical procedure performed in the ED during the 12 month study period. Additional outcome measures included details of the proceduralist and of patient presentations. Results Across the three EDs, there were 54 633 paediatric presentations during the study period. 5895 patients were assessed in a resuscitation cubicle and of these, only 37 presentations required one or more critical procedures (7/10 000 presentations). A total of 53 critical procedures were performed. 83% ( n = 43) of emergency physicians did not perform a single paediatric critical procedure during the study period. Endotracheal intubation was the most commonly performed critical procedure with 40 attempts (74% of procedures); however, 83% of the full-time emergency physicians regularly exposed to paediatric presentations did not attempt or supervise a single paediatric intubation over the 12 months. 49% of patients who received a critical procedure were under 3 years of age and the most common diagnostic categories were seizure, respiratory and trauma. Conclusion Critical procedures in children occur infrequently. Clinical exposure in the ED is therefore unreliable as the sole source of experience for critical procedures. [ABSTRACT FROM AUTHOR]

Background In many health systems, specialist services for critically ill children are typically regionalised or centralised. Studies have shown that high-risk paediatric patients have improved survival when managed in specialist centres and that volume of cases is a predictor of care quality. In acute cases where distance and time impede access to specialist care, clinical advice may be provided remotely by telephone. Emergency retrieval services, attended by medical and nursing staff may be used to transport patients to specialist centres. Even with the best quality retrieval services, stabilisation of the patient and transport logistics may delay evacuation to definitive care. Several studies have examined the use of telemedicine for providing specialist consultations for critically ill children. However, no studies have yet formally examined the clinical effectiveness and economic implications of using telemedicine in the context of paediatric patient retrieval. Methods/Design The study is a pragmatic, multicentre randomised controlled trial running over 24 months which will compare the use of telemedicine with the use of the telephone for paediatric retrieval consultations between four referring hospitals and a tertiary paediatric intensive care unit. We aim to recruit 160 children for whom a specialist retrieval consultation is required. The primary outcome measure is stabilisation time (time spent on site at the referring hospital by the retrieval team) adjusted for initial risk. Secondary outcome measures are change in patient’s physiological status (repeated measure, two time points) scored using the Children’s Emergency Warning Tool; change in diagnosis (repeated measure taken at three time points); change in destination of retrieved patients at the tertiary hospital (general ward or paediatric intensive care unit); retrieval decision, and length of stay in the Paediatric Intensive Care Unit for retrieved patients. The trial has been approved by the Human Research Ethics Committees of Children’s Health Services Queensland and The University of Queensland, Australia. Discussion Health services are adopting telemedicine, however formal evidence to support its use in paediatric acute care is limited. Generalisable evidence is required to inform clinical use and health system policy relating to the effectiveness and economic implications of the use in telemedicine in paediatric retrieval. [ABSTRACT FROM AUTHOR]

roets l., rowe-rowe n. & nel r. (2012) Journal of Nursing Management 20, 624-630 Family-centred care in the paediatric intensive care unit Aim The aim was to assess emotional support given to mothers of children in intensive care units (ICUs) and make recommendations to nurse managers regarding family-centred nursing care in paediatric ICUs in South Africa. Background Family-centred care is an essential component of paediatric care. Nurse managers should enhance implementation and sustainability to ensure quality care. Methods A quantitative descriptive research design was used. Structured interviews using questionnaires were conducted with 62 mothers whose children were nursed in ICUs in Bloemfontein. Findings Fifteen stressors for mothers were identified and emotional support for mothers in ICU's was assessed and described. Analysis indicated that COPE (Creating Opportunities for Parent Empowerment) can be used within the South African context to enhance family-centred paediatric nursing care. Conclusion Competencies of nurse practitioners and other staff involved must be improved and the seriousness and importance of emotional support as part of family-centred care should be emphasized. Implications for nursing management Nurse managers should take responsibility for the training of staff in implementing COPE as a possible empowerment programme in Paediatric ICUs to ensure that emotional support is not neglected. [ABSTRACT FROM AUTHOR]

Summary: Background: Parents consistently express a desire to support their child and retain a care-giving role in the paediatric intensive care unit (PICU). Qualitative data gathered as part of a PICU intervention study were analysed to explore mothers’ experiences using a Touch and Talk intervention to comfort their children during invasive procedures. Objectives: To describe how mothers experienced involvement in their children''s care through a Touch and Talk intervention and whether they would participate in a similar intervention again. Research methodology and setting: A qualitative descriptive design was used and semi-structured interviews conducted with 65 mothers in three Canadian PICUs. Data were subjected to thematic analysis. Results: The overarching theme centred on the importance of comforting the critically ill child. This included being there for the child (the importance of parental presence); making a difference in the child''s pain experience; and feeling comfortable and confident about participating in care. All but two mothers would participate in the intervention again and all would recommend it to others. Conclusions: Giving parents the choice of being involved in their child''s care using touch and distraction techniques during painful procedures can provide an invaluable opportunity to foster parenting and support the child during a difficult PICU experience. [Copyright &y& Elsevier]

Summary: The mechanical ventilation of neonates and children in operating theatres has always posed a challenge for anaesthesiologists. Firstly, the extreme physiological features of neonatal lungs make them very difficult to ventilate with an anaesthesia ventilator. Gattinoni’s “baby lung” concept to describe ARDS lungs in adults comes from the physiological features of neonatal lungs (low dynamic compliance, low pulmonary time constant, low FRC, high closing volume, proneness to atelectasis, high inspiratory airway resistance). Secondly, the performance and technology (peak flow, insufflation power, trigger sensitivity, ventilation modes, etc.) of anaesthesia ventilators is still less advanced than those of critical care ventilators. It is possible to ventilate a normal healthy adult lung with an anaesthesia ventilator, but even today, using circle circuits, ventilating a premature baby, newborn or child in the operating theatre can be a real challenge. Over the last 5 years, great changes have been made to anaesthesia workstations, which now boast better mechanical ventilation performance for children as well as new ventilation modes. However, there is a lack of background knowledge regarding mechanical ventilation in operating theatres, and this limits the advantages that can be derived from this new technology, and thus any potential safety improvements in paediatric surgery. [ABSTRACT FROM AUTHOR]

Objective: The aim of our study was to determine the effect of the irregular spontaneous breathing pattern and posture on the spatial distribution of ventilation in neonates free from respiratory disease by the non-invasive imaging method of electrical impedance tomography (EIT). Scanning of spontaneously breathing neonates is the prerequisite for later routine application of EIT in babies with lung pathology undergoing ventilator therapy.Design: Prospective study.Setting: Neonatal intensive care unit at a university hospital.Patients: Twelve pre-term and term neonates (mean age: 23 days; mean body weight: 2,465 g; mean gestational age: 34 weeks; mean birth weight: 2,040 g).Interventions: Change in body position in the sequence: supine, right lateral, prone, supine.Measurements and Results: EIT measurements were performed using the Göttingen GoeMF I system. EIT scans of regional lung ventilation showing the distribution of respired air in the chest cross-section were generated during phases of rapid tidal breathing and deep breaths. During tidal breathing, 54.5+/-8.3%, 55.2+/-10.5%, 59.9+/-8.4% and 54.2+/-8.5% of inspired air (mean values +/- SD) were directed into the right lung in the supine, right lateral, prone and repeated supine postures respectively. During deep inspirations, the right lung ventilation accounted for 52.6+/-7.9%, 68.5+/-8.5%, 55.4+/-8.2% and 50.5+/-6.6% of total ventilation respectively.Conclusion: The study identified the significant effect of breathing pattern and posture on the spatial distribution of lung ventilation in spontaneously breathing neonates. The results demonstrate that changes in regional ventilation can easily be determined by EIT and bode well for the future use of this method in paediatric intensive care. [ABSTRACT FROM AUTHOR]

Objective: Established techniques used to examine lung function in critically ill infants cannot continuously follow regional aspects of lung ventilation although this information would be beneficial for proper therapy planning. We have studied the applicability and clinical relevance of a relatively new non-invasive radiation-free imaging method, electrical impedance tomography (EIT), in monitoring regional lung function in paediatric intensive care patients.Design: Prospective study.Setting: Neonatal and paediatric intensive care unit (ICU) at a university hospital.Patients: Eight infants (1 day-7 years old) suffering from miscellaneous diseases requiring intensive care therapy.Interventions: Adjustment of ventilator settings, surfactant administration, and postural changes.Measurements and Results: Repeated EIT measurements were performed with the intention to monitor regional lung ventilation in mechanically ventilated and spontaneously breathing infants. The follow-up time ranged between 1 and 11 days. During individual EIT measurements of 100-s duration electrical voltages resulting from repetitive injection of small electrical currents were continuously measured on the thoracic circumference using conventional surface electrodes. Acquired data were used to generate functional cross-sectional thoracic images of regional lung ventilation. A total of 638 EIT measurements were performed. The redistribution of lung ventilation and changes in regional ventilation magnitude resulting from adjusted positive end-expiratory pressure, peak inspiratory pressure, inspiration-expiration ratio, surfactant instillation, and prone or supine positioning were identified.Conclusions: Provided that EIT hardware and software are further developed to guarantee stable and undisturbed measurements in the ICU and that practical handling is improved, this non-invasive method may become a useful bedside monitoring tool of regional lung ventilation in critically ill infants. [ABSTRACT FROM AUTHOR]

Respiratory syncytial virus (RSV) bronchiolitis is a leading cause of global child morbidity and mortality. Every year, seasonal RSV outbreaks put high pressure on paediatric intensive care units (PICUs) worldwide, including in the Netherlands, and this burden appears to be increasing. Weather conditions have a strong influence on RSV activity, and climate change has been proposed as a potential important determinant of future RSV-related health care utilisation. In this national study spanning a total of 13 years with 2161 PICU admissions for RSV bronchiolitis, we aimed (1) to identify meteorological variables that were associated with the number of PICU admissions for RSV bronchiolitis in the Netherlands and (2) to determine if longitudinal changes in these variables occurred over time as a possible explanation for the observed increase in PICU burden. Poisson regression modelling was used to identify weather variables (aggregated in months and weeks) that predicted PICU admissions, and linear regression analysis was used to assess changes in the weather over time. Maximum temperature and global radiation best predicted PICU admissions, with global radiation showing the most stable strength of effect in both month and week data. However, we did not observe a significant change in these weather variables over the 13-year time period. Based on our study, we could not identify changing weather conditions as a potential contributing factor to the increased RSV-related PICU burden in the Netherlands. [ABSTRACT FROM AUTHOR]