Kawai, Yu

Objective: The Society of Critical Care Medicine PICU Liberation ABCDEF (A–F) Campaign Collaborative aimed to implement best practices for analgesia (A), breathing (B), comfort/consciousness (C), delirium (D), early mobilization (E), and family engagement and empowerment (F). Our post hoc study of Mayo Clinic data sought to compare the pre-implementation rounding process, which used a nursing script organized by organ systems, with a novel, liberation-focused rounding process emphasizing A–F bundle elements. Design: Secondary analysis of pre- vs. post-implementation surveys collected by independent observers during rounds. Setting: Medical/surgical PICU in a quaternary-care, academic medical center during April to July 2017. Subjects: The observed participants included PICU physicians, nurses, respiratory therapists, pharmacists, and dietitians. Interventions: None. Measurements and Main Results: Survey responses from 145 team members pre-implementation and 67 post-implementation showed improved team satisfaction, communication, and understanding of daily plans (all p < 0.05). Respondents reported an increased frequency of discussions on bundle components A–E (all p < 0.01). Observations of 41 pre-implementation and 46 post-implementation rounds showed an increase in the frequency of discussion of all components of the bundle (all p < 0.01). However, this finding was not at the expense of increased duration of individual rounds since we failed to find a difference in pre- vs. post-implementation duration per patient (480 vs. 544 s per patient, p = 0.20). Conclusions: In 2017, around the time of introducing the nurse-led PICU Liberation rounding process to our practice, we found that after implementation, there was an associated increase in discussions about bundle elements and improved communications and satisfaction in team members.

OBJECTIVES: Many PICU admissions start with presentation in the emergency department (ED). However, we do not know whether there are any ED-related factors associated with the subsequent development of pediatric delirium (PD) within 24 hours of PICU admission. DESIGN: Retrospective cohort study. SETTING: Single-center ED and PICU serving a quaternary referral center in the United States. PATIENTS: Children younger than 18 years old presenting to the ED between January 2022 and December 2023 who required direct admission to the PICU, and who had at least one positive delirium screening within 24 hours of the admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of delirium in the PICU was defined as a Cornell Assessment of Pediatric Delirium (CAPD) score of 9 and higher. We identified 138 patients for the final analysis. Overall, 51 of 138 patients (37%) developed PD within 24 hours of admission. The majority of delirium cases were classified as hypoactive (53%, 27/51) and mixed (31%, 16/51) subtypes, while only 16% (8/51) were identified as hyperactive delirium. Factors associated with greater odds (95% CI) of delirium in the PICU in multivariable analysis were use of mechanical ventilation (odds ratio [OR], 3.42 [95% CI, 1.09–10.78]; p = 0.04) and intermittent urinary catheterization (OR, 3.7 [95% CI, 1.21–11.30]; p = 0.02). Initial CAPD score positively correlated with PICU length of stay (LOS; r = 0.32; p < 0.01), Pediatric Index of Mortality 3 (PIM 3) score ( r = 0.26; p < 0.01), and negatively correlated with emergency severity index (ESI) in the ED ( r = –0.35; p < 0.01). CONCLUSIONS: Mechanical ventilation and intermittent urinary catheterization in the ED are associated with greater odds of PD within 24 hours of PICU admission. CAPD at admission positively correlates with PICU LOS, PIM 3 scores, and negatively correlates with ESI in the ED.

In the published publication [...]

Background : The COVID-19 pandemic profoundly impacted healthcare, emphasizing the need to strengthen future pandemic responses and optimize resource allocation planning and deployment during times of disruption and crisis. Methods : This retrospective, single-center, cross-sectional study included participants ≤17 years-old admitted to the Children’s Hospital (CH) between 01/01/2017 and 12/31/2021. Clinical data was abstracted using Vizient ® Clinical Data Base and the internal data warehouse. Using the International Classification of Disease, 10 th Revision, Clinical Modification (ICD-10-CM) admit diagnosis, frequency and pattern of total admissions during the pre-pandemic phase (2017 Q1-2019 Q4) and intra-pandemic phase (2020 Q1-2021 Q4) were compared. Results : The study included 33,158 admissions. CH SARS-CoV-2 prevalence rate was 0.1% in 2020 and 0.5% in 2021. There was a decrease in overall admissions to the CH (p <0.01) and PICU (p <0.01) at the start of the pandemic. There were significant and variable differences in admission patterns for certain infectious, mental health, and seizure related diagnoses. Seasonality was noted for viral bronchiolitis during the pre-pandemic phase but was disrupted during the intra-pandemic phase with significantly lower admission rates for viral bronchiolitis in 2020 Q4 (p <0.05) and 2021 Q1 (p <0.01), followed by a significant early increase in viral bronchiolitis admissions in 2021 Q3 (p <0.01). Conclusion : The COVID-19 pandemic significantly impacted the number and pattern of admissions despite low SARS-CoV-2 prevalence in our hospital. These changes may be secondary to COVID-19 mitigation strategies implemented in the community. Results can inform anticipated patterns during future pandemics.

Pediatric delirium (PD) is an acute neuropsychiatric syndrome marked by fluctuating disturbances in attention and cognition, frequently observed in pediatric intensive care units (PICUs) and associated with increased morbidity, mortality, and long-term cognitive impairment. Despite its clinical significance, PD remains underdiagnosed due to challenges inherent in assessing consciousness and cognition in children at varying developmental stages. Several bedside tools have been developed and validated in recent years, including the Cornell Assessment of Pediatric Delirium (CAPD), PreSchool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU); Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Sophia Observation Withdrawal Symptoms—Pediatric Delirium Scale (SOS-PD), enhancing early recognition and management of PD in critically ill children. This narrative review explores the historical background, epidemiology, risk factors, pathophysiology, clinical subtypes, diagnostic tools, and current prevention and treatment strategies for PD from newborns to 21 years old. The screening tools available and the integration of non-pharmacological interventions, such as environmental modifications and family-centered care, as well as cautious and selective pharmacological management, are emphasized in this review. Early identification and targeted interventions are essential to mitigate the adverse outcomes associated with PD.

Objective: Delirium is a common problem in the Pediatric Intensive Care Unit (PICU) and is associated with increased length of stay, cost and mortality. This study evaluated the relationship between noise pollution and delirium risk. Design: This is a Quality Improvement (QI) initiative at an academic PICU. Sound levels were monitored and patients were screened for delirium using the Cornell Assessment of Pediatric Delirium (CAPD). Setting PICU Patients: All PICU patients Interventions: None Measurements and Main Results: Over the 83-week study period (2015-2017), the median [IQR] CAPD score was 8 [3 to 14]. Nursing compliance with the CAPD was 72.2%. The proportion of patients screening positive for delirium (CAPD ≥ 9) was 45.9%. A total of 329 711 hly decibel (dB) measurements were collected and reported. Occupied rooms were louder than unoccupied rooms (51.8 [51.6-51.9] dB vs. 49.8 [49.7-49.9] dB, respectively, p < 0.001). Days (10 AM to 4 PM) were louder than nights (11 PM to 5 AM) (52.8 [52.7-53.0] dB vs. 50.7 [49.9-51.5] dB, respectively p < 0.001) in occupied rooms. Winter (Nov-Feb) months were louder than summer (May-Aug) months (52.0 [51.8-52.3] dB vs. 51.5 [51.3-51.7] dB, respectively, p < 0.002) in occupied rooms. Median weekly nighttime noise levels and CAPD scores demonstrated a correlation coefficient of 0.6 ( p < 0.001). Median weekly risk of mortality (ROM) and CAPD scores demonstrated a correlation coefficient of 0.15 ( p < 0.01). Conclusions: Significant noise pollution exists in the PICU with a moderate correlation between nighttime noise levels and CAPD scores. This could potentially implicate noise pollution as a risk factor for the development of delirium.

Objectives: Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. Methods: This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. Results: A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]). Conclusions: Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.