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State Behavioral Scale: a sedation assessment instrument for infants and young children supported on mechanical
Martha A Q Curley1, Sion Kim Harris, Karen A Fraser
1Critical Care and Cardiovascular Program, Children's Hospital Boston, Boston, MA, USA.
Insights
The State Behavioral Scale reliably describes sedation/agitation in young ventilated pediatric patients. This scale identifies five distinct behavioral profiles, aiding clinical assessment and management.
Area of Science:
- Pediatric critical care medicine
- Psychometric evaluation
- Nursing science
Background:
- Assessing sedation and agitation in young intubated patients on mechanical ventilation is challenging.
- Existing scales may lack reliability and validity for this specific population.
Purpose of the Study:
- To develop and validate the State Behavioral Scale for assessing sedation/agitation in pediatric patients requiring mechanical ventilation.
- To establish the reliability and validity of the scale through psychometric evaluation.
Main Methods:
- Prospective psychometric evaluation involving pairs of trained nurses assessing 91 pediatric patients (6 weeks to 6 years).
- Utilized eight behavioral dimensions and a numeric rating scale (NRS), with data analyzed for interrater reliability (weighted kappa, intraclass coefficients).
- Hierarchical cluster analysis identified distinct behavioral profiles, with construct validity assessed via NRS scores.
Main Results:
- Moderate to good interrater reliability for the scale's dimensions (kappa .44-.76) and high reliability for NRS ratings (intraclass coefficient .79).
- Cluster analysis revealed five distinct sedation/agitation profiles with significantly different mean NRS scores (1.1 to 7.6).
- Empirically derived profiles demonstrated construct validity, supporting the scale's utility.
Conclusions:
- The State Behavioral Scale provides a systematic method for describing the sedation-agitation continuum in young pediatric patients on mechanical ventilation.
- Further research is needed for prospective validation and to evaluate the scale's impact on clinical outcomes, such as sedation quality and ventilation duration.
Objective:
To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation.
Design:
: In this prospective, psychometric evaluation, pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale (NRS) of 0 (extremely sedated) to 10 (extremely agitated). The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive, response to ventilation, coughing, best response to stimulation, attentiveness to careprovider, tolerance to care, consolability, and movement after consoled, each with 3-5 levels.
Setting:
An 18-bed pediatric medical-surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children's hospital.
Patients:
A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations (interquartile range, 1-3) for a total of 198 sets of observations. Excluded were postoperative patients or those receiving neuromuscular blockade.
Interventions:
Patients were observed for 1 min, and then incremental levels of stimulation were applied until patient response. After 2 mins of consoling, the state behavioral assessment and NRS were completed.
Measurements:
Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings. Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage. Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance.
Main Results:
Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76, indicating moderate to good interrater reliability. The intraclass coefficient of .79 was high for NRS ratings. Cluster analysis revealed five distinct state profiles, with mean NRS ratings of 1.1, 2.5, 4.0, 5.3, and 7.6, all of which differed significantly from each other (F = 75.8, p < .001), supporting the profiles' construct validity.
Conclusions:
Based on empirically derived state behavior profiles, we have constructed the State Behavioral Scale to allow systematic description of the sedation-agitation continuum in young pediatric patients supported on mechanical ventilation. Further studies including prospective validation and describing the effect of State Behavioral Scale implementation on clinical outcomes, including the quality of sedation and length of mechanical ventilation, are warranted.
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