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Use of magnetic resonance imaging (MRI) as a tool to aid in neuroprognostication after cardiac arrest (CA) has been described, yet details of specific indications, timing, and sequences are unknown. We aim to define the current practices in use of brain MRI in prognostication after pediatric CA.A survey was distributed to pediatric institutions participating in three international studies. Survey questions related to center demographics, clinical practice patterns of MRI after CA, neuroimaging resources, and details regarding MRI decision support.Response rate was 31% (44 of 143). Thirty-four percent (15 of 44) of centers have a clinical pathway informing the use of MRI after CA. Fifty percent (22 of 44) of respondents reported that an MRI is obtained in nearly all patients with CA, and 32% (14 of 44) obtain an MRI in those who do not return to baseline neurological status. Poor neurological examination was reported as the most common factor (91% [40 of 44]) determining the timing of the MRI. Conventional sequences (T1, T2, fluid-attenuated inversion recovery, and diffusion-weighted imaging/apparent diffusion coefficient) are routinely used at greater than 97% of centers. Use of advanced imaging techniques (magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI) were reported by less than half of centers.Conventional brain MRI is a common practice for prognostication after CA. Advanced imaging techniques are used infrequently. The lack of standardized clinical pathways and variability in reported practices support a need for higher-quality evidence regarding the indications, timing, and acquisition protocols of clinical MRI studies.

AIM: The mathematical method used to calculate chest compression (CC) rate during cardiopulmonary resuscitation varies in the literature and across device manufacturers. The objective of this study was to determine the variability in calculated CC rates by applying four published methods to the same dataset. METHODS: This study was a secondary investigation of the first 200 pediatric cardiac arrest events with invasive arterial line waveform data in the ICU-RESUScitation Project (NCT02837497). Instantaneous CC rates were calculated during periods of uninterrupted CCs. The defined minimum interruption length affects rate calculation (e.g., if an interruption is defined as a break in CCs ≥ 2 seconds, the lowest possible calculated rate is 30 CCs/min). Average rates were calculated by four methods: 1) rate with an interruption defined as ≥ 1 second; 2) interruption ≥ 2 seconds; 3) interruption ≥ 3 seconds; 4) method #3 excluding top and bottom quartiles of calculated rates. American Heart Association Guideline-compliant rate was defined as 100–120 CCs/min. A clinically important change was defined as ± 5 CCs/min. The percentage of events and epochs (30 second periods) that changed Guideline-compliant status was calculated. RESULTS: Across calculation methods, mean CC rates (118.7 – 119.5/min) were similar. Comparing all methods, 14 events (7%) and 114 epochs (6%) changed Guideline-compliant status. CONCLUSION: Using four published methods for calculating CC rate, average rates were similar, but 7% of events changed Guideline-compliant status. These data suggest that a uniform calculation method (interruption ≥ 1 second) should be adopted to decrease variability in resuscitation science.

Pediatric critical care has continued to advance since our last article, “Pediatric Critical Care in Resource-Limited Settings—Overview and Lessons Learned”was written just 3 years ago. In that article, we reviewed the history, current state, and gaps in level of care between low- and middle-income countries (LMICs) and high-income countries (HICs). In this article, we have highlighted recent advancements in pediatric critical care in LMICs in the areas of research, training and education, and technology. We acknowledge how the COVID-19 pandemic has contributed to increasing the speed of some developments. We discuss the advancements, some lessons learned, as well as the ongoing gaps that need to be addressed in the coming decade. Continued understanding of the importance of equitable sustainable partnerships in the bidirectional exchange of knowledge and collaboration in all advancement efforts (research, technology, etc.) remains essential to guide all of us to new frontiers in pediatric critical care.

Many populations experience high seasonal temperatures. Pregnant women are considered vulnerable to extreme heat because ambient heat exposure has been linked to pregnancy complications including preterm birth and low birthweight. The physiological mechanisms that underpin these associations are poorly understood. We reviewed the existing research evidence to clarify the mechanisms that lead to adverse pregnancy outcomes in order to inform public health actions. A multi-disciplinary expert group met to review the existing evidence base and formulate a consensus regarding the physiological mechanisms that mediate the effect of high ambient temperature on pregnancy. A literature search was conducted in advance of the meeting to identify existing hypotheses and develop a series of questions and themes for discussion. Numerous hypotheses have been generated based on animal models and limited observational studies. There is growing evidence that pregnant women are able to appropriately thermoregulate; however, when exposed to extreme heat, there are a number of processes that may occur which could harm the mother or fetus including a reduction in placental blood flow, dehydration, and an inflammatory response that may trigger preterm birth. There is a lack of substantial evidence regarding the processes that cause heat exposure to harm pregnant women. Research is urgently needed to identify what causes the adverse outcomes in pregnancy related to high ambient temperatures so that the impact of climate change on pregnant women can be mitigated.

Summary Background Progress in reducing maternal and neonatal deaths and stillbirths is impeded by data gaps, especially regarding coverage and quality of care in hospitals. We aimed to assess the validity of indicators of maternal and newborn health-care coverage around the time of birth in survey data and routine facility register data. Methods Every Newborn-BIRTH Indicators Research Tracking in Hospitals was an observational study in five hospitals in Bangladesh, Nepal, and Tanzania. We included women and their newborn babies who consented on admission to hospital. Exclusion critiera at admission were no fetal heartbeat heard or imminent birth. For coverage of uterotonics to prevent post-partum haemorrhage, early initiation of breastfeeding (within 1 h), neonatal bag-mask ventilation, kangaroo mother care (KMC), and antibiotics for clinically defined neonatal infection (sepsis, pneumonia, or meningitis), we collected time-stamped, direct observation or case note verification data as gold standard. We compared data reported via hospital exit surveys and via hospital registers to the gold standard, pooled using random effects meta-analysis. We calculated population-level validity ratios (measured coverage to observed coverage) plus individual-level validity metrics. Findings We observed 23 471 births and 840 mother–baby KMC pairs, and verified the case notes of 1015 admitted newborn babies regarding antibiotic treatment. Exit-survey-reported coverage for KMC was 99·9% (95% CI 98·3–100) compared with observed coverage of 100% (99·9–100), but exit surveys underestimated coverage for uterotonics (84·7% [79·1–89·5]) vs 99·4% [98·7–99·8] observed), bag-mask ventilation (0·8% [0·4–1·4]) vs 4·4% [1·9–8·1]), and antibiotics for neonatal infection (74·7% [55·3–90·1] vs 96·4% [94·0–98·6] observed). Early breastfeeding coverage was overestimated in exit surveys (53·2% [39·4–66·8) vs 10·9% [3·8–21·0] observed). “Don’t know” responses concerning clinical interventions were more common in the exit survey after caesarean birth. Register data underestimated coverage of uterotonics (77·9% [37·8–99·5] vs 99·2% [98·6–99·7] observed), bag-mask ventilation (4·3% [2·1–7·3] vs 5·1% [2·0–9·6] observed), KMC (92·9% [84·2–98·5] vs 100% [99·9–100] observed), and overestimated early breastfeeding (85·9% (58·1–99·6) vs 12·5% [4·6–23·6] observed). Inter-hospital heterogeneity was higher for register-recorded coverage than for exit survey report. Even with the same register design, accuracy varied between hospitals. Interpretation Coverage indicators for newborn and maternal health care in exit surveys had low accuracy for specific clinical interventions, except for self-report of KMC, which had high sensitivity after admission to a KMC ward or corner and could be considered for further assessment. Hospital register design and completion are less standardised than surveys, resulting in variable data quality, with good validity for the best performing sites. Because approximately 80% of births worldwide take place in facilities, standardising register design and information systems has the potential to sustainably improve the quality of data on care at birth. Funding Children's Investment Fund Foundation and Swedish Research Council.

Recent nursing shortages have been particularly felt in specialist areas, like Critical Care, which require higher staffing quotas; leading to increased recruitment of Newly Qualified Nurses in an area once reserved for the more experienced. This qualitative systematic review aimed to explore the experiences of Newly Qualified Nurses working in Critical Care, as their first job post-registration. A systematic search was undertaken between December 2017 and May 2018, yielding eight studies for inclusion in this review. Eligibility criteria included a qualitative design; Newly Qualified Nurses with less than two years post-registration experience, working in adult Intensive Care Units. Data were extracted and synthesised using the Thematic Synthesis approach. Five main themes emerged from the data: Intensive Care Unit Readiness; An Emotional Spectrum; Developing Relationships; The Journey to Self-Satisfaction and Intensive Care Unit Commitment. Conclusions are that an undergraduate placement in Critical Care should be facilitated where possible, consistent mentorship enhances Newly Qualified Nurse satisfaction, peer support is an important coping mechanism and opportunities for socialisation should be facilitated.

In 2012, The Royal College of Physicians (RCP) developed a National Early Warning Score (NEWS) as a standardised approach to assessment and response to critical illness. This paper reports the authors' experiences whilst implementing NEWS across one large inner London NHS Trust. NEWS was introduced to all adult areas between November 2013 and January 2014. All healthcare staff completed the RCP's online e-learning module and received scenario-based teaching. One of the challenges was the Trust's geographical location over three sites. Comparisons across all sites will be made over time as data become available. Introducing NEWS has been a challenging but exciting initiative.

Randomised controlled trials (RCTs) involving diverse population groups in complex health care settings can be difficult to successfully undertake and pose practical and methodological challenges. For this reason, undertaking a pilot study is recommended by the Medical Research Council prior to conducting a definitive trial. This paper reports a pragmatic review of the challenges encountered by the research team during a single centre pilot RCT and discusses how feasible it was to deliver and evaluate a complex intervention in practice. The psycho-social intervention designed for this trial was a ‘user-centred critical care discharge information pack’. The pack was designed to support patients and their families during and after their discharge from a critical care unit. It consisted of two written booklets, one for the patient and one for the family member. In total, 221 patients met our inclusion criteria, of whom 158 (71%) were recruited. The pilot RCT identified important lessons for the design of future trials. Challenges included those associated with the recruitment of potential participants, assessing capacity and obtaining informed consent. Problems with attrition, intervention delivery and the choice of data collection tools and time-points were also apparent. Our findings demonstrate that the evaluation of complex interventions is feasible in clinical practice. The importance of adhering to a robust research protocol, maintaining efficient and effective communication between researchers and clinical staff is emphasised. Findings further support the importance of conducting a pilot study prior to embarking on a definitive RCT.

Aim To present an overview of the main components of randomised controlled trials and identify issues for consideration during their design and management. Background Randomised controlled trials (RCTs) are considered to be the gold standard for determining causality and can provide high quality evidence to inform nursing practice. Data sources A search of online databases and websites was undertaken to identify relevant contemporary literature to inform the discussion. Discussion/Conclusion Conducting a robust randomised controlled trial can present researchers with numerous challenges and practical considerations. The importance of taking account of the Consort guidelines during their design, conduct and reporting is emphasised. Implications for research/practice Evidence from well conducted RCTs contributes to the development of effective nursing interventions. To avoid bias and ensure valid results, the design, conduct and reporting of RCTs should follow the Consort guidelines. Service users should be involved in the design and management of RCTs.

Aim: This article proposes a radical new approach to the monitoring and governance of services, and the education and training of nurses to meet ‘failure to rescue’ requirements. Background: Healthcare policy in the UK that seeks to ensure safe and effective services for the acutely ill has largely failed, resulting in adult patients dying unnecessarily. Despite grand rhetoric, UK governments have distanced themselves from implementation, resulting in patchy localised developments and creating inconsistent service responses. Design and data sources: This article draws on a review of research and UK policy literature and best international practice to propose a new national framework approach that combines competency development, governance and performance monitoring to address ‘failure to rescue’ shortcomings. Implications for nursing: Paramount is a nationally agreed and fit-for-purpose competency tool using simulation to assess staff in order to improve recognition of the deteriorating patient. Service improvements should include increased investment in telemedicine; service performance should be communicated through publicly available ratings and overseen by patient panels; and governance will require strengthening through enhanced Care Quality Commission/Monitor input, which should be linked to the maintenance of foundation trust status. Conclusion: Health professional bodies, regulators, providers and the Government must work together to strengthen the safety and effectiveness of acute services. This will require investment in staff competency and enhancement of the governance to ensure services consistently meet public expectations and reduce unnecessary deaths.

This article provides a critical discussion examining why adult patients continue to unnecessarily deteriorate and die despite repeated healthcare policy initiatives. After considering the policy background and reviewing current trends in the data, it proposes some solutions that, if enacted, would, the authors believe, have a direct impact on survival rates. Health professionals working in hospitals are failing to recognise signs of physiological deterioration. As a result, adult patients are dying unnecessarily, estimated to be in the region of 1000 a month. This is despite international healthcare policy requiring practitioners to be appropriately trained to recognise the deteriorating adult patient and to intervene. A literature review centred on health policy for England from 1999 to 2015 was undertaken, with reference to international policy and practice. This article also draws on the authors' combined clinical experience, which is underpinned by relevant research and theory. The implications for nursing could be significant. Change is urgently required otherwise people will continue to die unnecessarily. Health professionals, healthcare organisations and international governments working together can prevent unnecessary deaths from happening within acute hospitals.

Objectives: This review identifies the most significant factors, which impact upon the user experience of progress and recovery from critical illness during the first month after discharge from critical care, and discusses these in relation to the development of effective critical care discharge support strategies. Design: Meta-synthesis of qualitative primary research. Data sources: Qualitative research published in English between 1990 and 2009 was identified using online databases: CINAHL, MEDLINE, EMBASE, British Nursing Index, CDSR, ACP Journal Club, Cochrane library, Social Policy and Practice and PsycInfo. Studies of adult patients, relatives/carers/significant others, which focused on experiences after discharge from an intensive care or high dependency unit to a general ward were retrieved. Review methods: Following screening against inclusion/exclusion criteria, methodological appraisal of studies was conducted using a published framework. Ten studies met the criteria for inclusion. Results: Five key themes emerged from the meta-synthesis: physical and psychological symptoms; making progress; the need to know; and safety and security. Conclusions: Findings from this meta-synthesis and other related literature supports the existence of physical and psychological problems in the immediate period following discharge from critical care to the ward, and suggests that patients and their families have a desire for more control over their recovery. However, this desire is countered by a need to feel safe and protected, culminating in an expression of dependence on healthcare staff. Any effective support strategy needs to take account of these findings.

ObjectivesTo evaluate the feasibility and effectiveness of an information pack, based on self-regulation theory, designed to support patients and their families immediately before, during and after discharge from an intensive care unit. Design and settingProspective assessor-blinded pilot cluster randomized controlled trial (in conjunction with a questionnaire survey of trial participants’ experience) in two intensive care units in England. ParticipantsPatients (+/- a family member) who had spent at least 72 hours in an intensive care unit, declared medically fit for discharge to a general ward.RandomizationCluster randomization (by day of discharge decision) was used to allocate participants to one of three study groups. InterventionA user centred critical care discharge information pack (UCCDIP) containing two booklets; one for the patient (which included a personalized discharge summary) and one for the family, given prior to discharge to the ward. Primary outcomePsychological well-being measured using hospital anxiety and depression scores (HADS), assessed at 5+/-1 days post unit discharge and 28 days/hospital discharge. Statistical significance (p ? 0.05) was determined using Chi Square (?2) and Kruskal Wallis (H).Results One hundred and fifty eight patients were allocated to: intervention (UCCDIP) (n=51), control 1: ad-hoc verbal information (n=59), control 2: booklet published by ICUsteps (n=48). There were no statistically significant differences in the primary outcome. The a priori enrolment goal was not reached and attrition was high. Using HADS as a primary outcome measure, an estimated sample size of 286 is required to power a definitive trial.ConclusionsFindings from this pilot RCT provide important preliminary data regarding the circumstances under which an intervention based on the principles of UCCDIP could be effective, and the sample size required to demonstrate this.

Effective suctioning is an essential aspect of airway management in the critically ill. However, there are many associated risks and complications. These range from trauma and hypoxaemia to cardiac dysrhythmias and, in extreme cases, cardiac arrest and death. This paper identifies the current research recommendations for safer suctioning practices. The literature is reviewed in three parts: prior to suctioning; during suctioning; and post-suctioning. The recommendations prior to suctioning include patient assessment, patient preparation and hyperoxygenation. The recommendations during suctioning include appropriate catheter selection, depth of insertion, negative pressure, duration of procedure and number of suction passes. Measures for maintenance of asepsis, such as hand-washing, wearing gloves, goggles and aprons are other essential considerations, which must not be overlooked. The recommendations post-suctioning include reconnection of oxygen, patient assessment, reduction of oxygen to baseline level, and providing patient reassurance. In order to improve standards of care, it is imperative that nurses are aware of current research recommendations. This will enable nurses to make informed decisions about their own suctioning practices, based on the individual needs of the patient.

Endotracheal suctioning is a frequently performed procedure that has many associated risks and complications. It is imperative that nurses are aware of these risks and are able to practise according to current research recommendations. This study was designed to examine to what extent intensive care nurses' knowledge and practice of endotracheal suctioning is based on research evidence, to investigate the relationships between knowledge and practice, and to evaluate the effectiveness of a research-based teaching programme. This quasi-experimental study was a randomized, controlled, single-blinded comparison of two research-based teaching programmes, with 16 intensive care nurses, using non-participant observation and a self-report questionnaire. Initial baseline data revealed a low level of knowledge for many participants, which was also reflected in practice, as suctioning was performed against many of the research recommendations. Following teaching, significant improvements were seen in both knowledge and practice. Four weeks later these differences were generally sustained, and provide evidence of the effectiveness of the educational intervention. The study raised concern about all aspects of endotracheal suctioning and highlighted the need for changes in nursing practice, with clinical guidelines and focused practice-based education.

Providing patients with information can alleviate or reduce relocation stress, but how best to provide information to patients being discharged from critical care units is unclear. This narrative critical review describes (1) the current evidence base on the use of discharge information for adult critical care patients and (2) the extent of involvement of service users in the design and evaluation of such information. Seven publications reported data from 121 patients, 252 relatives, and 33 nurses. Overall evidence was of low quality but use of individualized information was associated with beneficial physical effects for patients and increased knowledge and satisfaction for their relatives. Findings highlight the significant gaps in our knowledge and understanding. The consequences of such findings for the future development of information that meets service users’ needs are discussed. Results should inform the design of future studies on this topic.

Background Discharge from critical care to a general care unit is a difficult period, and more effective information is needed to support patients and their families at this time. Objectives This study sought the views of patients, relatives and health care staff on (1) the most effective methods of delivering critical care discharge information, (2) the required information content of any proposed strategies, (3) the benefits and limitations of any existing strategies, and (4) potential resource implications. Methods In this qualitative focus group study, 11 adult patients, 8 family members, and 23 health care staff in Eng-land took part in 8 focus group interviews at 2 hospitals. The computer software program NVIVO7 was used for thematic analysis of the data. Results Three key themes were identified from the data: (1) considerations related to effective discharge information, (2) goals of critical care discharge information, and (3) resource implications. Conclusions This focus group study provides unique user insight into what influences successful and unsuccessful information giving. Based on real experiences, it adds to the limited international body of current evidence. Findings will be of value in designing future critical care discharge information and identifying the related resource implications.

Objectives This paper reports on an intervention designed during an ongoing two phase project aimed at improving early critical illness rehabilitation. It focuses specifically on the justification for a newly developed critical care discharge information pack: ‘User Centred Critical Care Discharge Information Pack’ (UCCDIP). The intervention is described in detail and the chosen research methods are discussed. Background Discharge from critical care to a ward is a difficult time for patients and relatives. Research suggests that effective information has the potential to reduce relocation stress and optimise recovery. Methods Using the Medical Research Council framework for the development and evaluation of complex interventions, a phase I focus group study and collaboration with service users/carers informed the development of a new critical care discharge information pack, currently being evaluated in a phase II Randomised Controlled Trial. Conclusion UCCDIP acknowledges the patients’ need to understand what they have been through and the progress they have made. It provides for the different information needs of patients and relatives, recognising their physical and psychological vulnerability. Through its use of reflection and participation, UCCDIP has the potential to optimise support of adult patients and their families during early critical illness rehabilitation.

This paper is a report of a study to determine whether individualized performance feedback improved nurses' and physiotherapists' knowledge and practice of tracheal suctioning.Nurses' knowledge and practice of tracheal suctioning is often deficient. Whilst teaching has been shown to improve suctioning knowledge and practice, this is not sustained over time.Ninety-five qualified healthcare professionals (nurses and physiotherapists) in two acute hospitals were randomly allocated to receive either individualized performance feedback or no additional feedback after a standardized lecture and practical demonstration of tracheal suctioning. Randomization was stratified by profession, seniority and site. Data were collected in 2005 in a clinical setting involving patients and a simulation setting. The outcome measures were knowledge and practice of tracheal suctioning, assessed by self-completion questionnaire and structured observation.In both settings, intervention groups performed statistically significantly better in terms of knowledge (P = 0.014) and practice (P = 0.037) at final follow-up. Those who received performance feedback had statistically significantly higher knowledge (P = 0.004) and practice (P0.01) scores than the control group. For practice, there was also a relationship between professions (P0.01), with physiotherapists performing better than nurses overall, and an interaction between group and setting (P0.01), with performance feedback showing a stronger positive effect in the simulation setting.Retention of knowledge and tracheal suctioning practice is improved when training is followed up by tailored feedback on performance. Further research would shed light on how long such improvements are sustained, and whether the improvements seen in a simulated setting can be generalized to clinical settings.

The competency framework developed by the critical care education group of the London Standing Conference aims to serve every grade and level of practitioner. It is neither time specific nor static. The patient is the central focus of the framework and the elements of competence reflect patient need at any critical care level [Comprehensive Critical Care: A Review of Adult Critical Care Services, The Stationary Office, London]. A group of expert nurses have developed the competency framework, with widespread consultation and collaboration. This approach intended to develop consistency for critical care education and practice. It is envisaged that this will reduce pockets of repeated activity, which places huge demands on limited resources. The critical care competency framework was developed using the method of functional analysis. A plan for the future has been identified, including continued collaboration and consultation with Trusts and Higher Educational Institutions and the development of an online manual to support the competency framework. Key points: • Critical care delivery has been under close scrutiny and a number of key contemporary drivers have led to the development of this competency framework. • The development of a consistent pan-London approach to critical care education has been identified. • The patient is the focus of critical care delivery and therefore patient need is central to the critical care competency framework. • Wider collaboration is needed with other agencies and groups to prevent the repetition of work already carried out.

BACKGROUND AND RATIONALE: With an increasing demand for intensive care beds more nurses in acute and high dependency wards will be expected to care competently for patients with tracheostomy tubes. Tracheal suctioning is an essential aspect of effective airway management. However, this has many associated risks and complications, ranging from trauma and hypoxaemia to, in extreme cases, cardiac arrest and death. It is imperative that nurses are aware of these risks and are able to practice according to current research recommendations. Aims. This study was designed to explore nurses' knowledge and competence in performing tracheal suctioning in acute and high dependency ward areas and to investigate discrepancies between knowledge and practice using method triangulation. METHODS: Twenty-eight nurses were observed using nonparticipant observation and a structured observation schedule. Each subject was interviewed and questioned about their tracheal suctioning practices, and subsequently completed a knowledge-based questionnaire. Scores were allocated for knowledge and practice. FINDINGS: The findings demonstrated a poor level of knowledge for many subjects. This was also reflected in practice, as suctioning was performed against many of the research recommendations. Many nurses were unaware of recommended practice and a number demonstrated potentially unsafe practice. In addition, there was no significant relationship between knowledge and practice. However, during the interviews, many nurses were able to provide a rationale for specific aspects of practice that were perhaps not based on current research recommendations. CONCLUSIONS: The study raised concern about all aspects of tracheal suctioning and has highlighted the need for changes in practice, clinical guidelines and focused practice-based education.