Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Pediatr Crit Care Med. 2024 Nov 1;25(11):1051-1064. doi: 10.1097/PCC.0000000000003595. Epub 2024 Aug 12.
Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R 2 ).
A two-phase cohort study was carried out from 2017 to 2021.
Two similarly sized and organized PICUs in the United States.
Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure.
R 2 seven-item chronotherapeutic bundle, including: 1) replication of child's pre-hospital daily routine (i.e., sleep/wake, feeding, activity patterns); 2) cycled day-night light/sound modulation; 3) minimal effective sedation; 4) night fasting with bolus enteral daytime feedings; 5) early progressive mobility; 6) nursing care continuity; and 7) parent diaries.
Children underwent environmental (light, sound) and patient (actigraphy, activity log, salivary melatonin, electroencephalogram) monitoring. Parents completed the Child's Daily Routine and Sleep Survey (CDRSS) and Family-Centered Care Scale. The primary outcome was post-extubation daytime activity consolidation (Daytime Activity Ratio Estimate [DARE]). Twenty baseline-phase (2017-2019) and 36 intervention-phase (2019-2021) participants were enrolled. During the intervention phase, nurses used the CDRSS to construct children's PICU schedules. Overall compliance with nurse-implemented R 2 elements 1-5 increased from 18% (interquartile range, 13-30%) at baseline to 63% (53-68%) during the intervention phase ( p < 0.001). Intervention participants were exposed to their pre-hospitalization daily routine ( p = 0.002), cycled day-night light/sound modulation ( p < 0.001), and early progressive mobility on more PICU days ( p = 0.02). Sedation target identification, enteral feeding schedules, and nursing care continuity did not differ between phases. Parent diaries were seldom used. DARE improved during the intervention phase and was higher pre-extubation (median 62% vs. 53%; p = 0.04) but not post-extubation (62% vs. 57%; p = 0.56).
In the PICU, implementation of an individualized nurse-implemented chronotherapeutic bundle is feasible. Children who received the R 2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R 2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.
在危重病儿童中试点测试护士主导的时间治疗捆绑包，即恢复弹性（R2）。
这是一项从 2017 年到 2021 年进行的两阶段队列研究。
美国两个类似规模和组织的 PICU。
因急性呼吸衰竭而接受机械通气的 6 个月至 17 岁的儿童。
R2 七项时间治疗捆绑包，包括：1）复制患儿院前日常活动（即睡眠/觉醒、喂养、活动模式）；2）循环日夜光线/声音调制；3）最小有效镇静；4）夜间禁食和白天经口推注喂养；5）早期渐进性活动；6）护理连续性；7）家长日记。
对患儿进行环境（光线、声音）和患儿（活动记录仪、活动日志、唾液褪黑素、脑电图）监测。家长完成儿童日常作息和睡眠调查（CDRSS）和以家庭为中心的护理量表。主要结局是拔管后白天活动巩固（白天活动比估计值[DARE]）。共纳入 20 名基线期（2017-2019 年）和 36 名干预期（2019-2021 年）患儿。在干预期间，护士使用 CDRSS 为患儿制定 PICU 时间表。护士实施的 R2 要素 1-5 的整体依从性从基线时的 18%（四分位距，13-30%）增加到干预期间的 63%（53-68%）（p < 0.001）。干预组患儿接触到他们的院前日常活动（p = 0.002）、日夜光线/声音调制（p < 0.001），以及更早的 PICU 天渐进性活动（p = 0.02）。镇静目标识别、肠内喂养计划和护理连续性在两阶段之间没有差异。家长日记很少使用。干预期间 DARE 改善，拔管前更高（中位数 62%比 53%；p = 0.04），但拔管后无差异（62%比 57%；p = 0.56）。
在 PICU 中，实施个体化的护士主导的时间治疗捆绑包是可行的。与接受常规护理的患儿相比，接受 R2 捆绑包的患儿拔管前白天活动巩固度更高。鉴于方案依从性的差异，进一步的 R2 测试应包括跨专业合作、实用试验设计和实施科学策略。
