The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R 2 ): Pilot Testing
Martha A Q Curley1,2,3, Onella S Dawkins-Henry4, Laura Beth Kalvas1
1Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
Insights
This pilot study shows that a nurse-led chronotherapeutic bundle (RESTORE Resilience or R 2 ) is feasible in the pediatric intensive care unit (PICU). Critically ill children receiving the R 2 bundle demonstrated improved daytime activity consolidation before extubation.
Area of Science:
- Critical Care Medicine
- Pediatric Nursing
- Sleep Science
Background:
- Critically ill children in the pediatric intensive care unit (PICU) often experience disrupted sleep-wake cycles and daily routines.
- This disruption can negatively impact recovery and long-term outcomes.
- Chronotherapy, the application of timed treatments, offers a potential strategy to mitigate these effects.
Purpose of the Study:
- To pilot test the feasibility and preliminary efficacy of the nurse-led RESTORE Resilience (R 2) chronotherapeutic bundle in critically ill children.
- To assess the impact of the R 2 bundle on daytime activity consolidation in mechanically ventilated children.
Main Methods:
- A two-phase cohort study conducted in two US PICUs from 2017 to 2021.
- The R 2 bundle included replicating pre-hospital routines, light/sound modulation, minimal sedation, specific feeding schedules, early mobility, nursing continuity, and parent diaries.
- Outcomes included environmental and patient monitoring, parent surveys, and the Daytime Activity Ratio Estimate (DARE) for post-extubation activity consolidation.
Main Results:
- Compliance with key R 2 elements significantly increased from baseline (18%) to the intervention phase (63%).
- Intervention participants experienced more days with adherence to their routine, light/sound modulation, and early mobility.
- The Daytime Activity Ratio Estimate (DARE) improved pre-extubation in the intervention group (62% vs. 53%).
Conclusions:
- The nurse-led R 2 chronotherapeutic bundle is feasible for implementation in the PICU setting.
- The R 2 bundle led to increased pre-extubation daytime activity consolidation in critically ill children.
- Future research should focus on interprofessional collaboration and pragmatic trial designs to optimize protocol adherence.
Objectives:
Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R 2 ).
Design:
A two-phase cohort study was carried out from 2017 to 2021.
Setting:
Two similarly sized and organized PICUs in the United States.
Patients:
Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure.
Interventions:
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.
Measurements And Main Results:
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).
Conclusions:
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.
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