Clinical Reasoning Behind Antibiotic Use in PICUs: A Qualitative Study.

OBJECTIVES: To describe the reasoning processes used by pediatric intensivists to make antibiotic-related decisions. DESIGN: Grounded theory qualitative study. SETTING: Three Canadian university-affiliated tertiary medical, surgical, and cardiac PICUs. PATIENTS: Twenty-one PICU physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We conducted field observation during morning rounds followed by semistructured interviews with participants to examine the clinical reasoning behind antibiotic-related decisions (starting/stopping antibiotics, or treatment duration) made for patients with a suspected/proven bacterial infection. We used a grounded theory approach for data collection and analysis. Thematic saturation was reached after 21 interviews. Of the 21 participants, 10 (48%) were female, 15 (71%) were PICU attending staff, and 10 (48%) had greater than 10 years in clinical practice. Initial clinical reasoning involves using an analytical approach to determine the likelihood of bacterial infection. In case of uncertainty, an assessment of patient safety is performed, which partly overlaps with the use of intuitive clinical reasoning. Finally, if uncertainty remains, physicians tend to consult infectious diseases experts. Factors that override this clinical reasoning process include disease severity, pressure from consultants, and the tendency to continue antibiotic treatment initiated by colleagues. CONCLUSIONS: Antibiotic-related decisions for critically ill children are complex, and pediatric intensivists use several clinical reasoning strategies to decrease the uncertainty around the bacterial etiology of infections. However, disease severity and patient safety concerns may overrule decisions based on clinical evidence and lead to antibiotic use. Several cognitive biases were identified in the clinical reasoning processes.

The experience of critically ill children: A phenomenological study of discomfort and comfort.

BACKGROUND: Emerging evidence indicates that critically ill children are particularly at risk for incurring significant psychological harm. Little is known about these children's actual experiences. AIM: The aim of the study was to examine children's experience of critical illness. The research question was: What are a critically ill child's sources of discomfort and comfort? DESIGN: Interpretive phenomenology was selected as the study's method. Children's accounts were examined to identify what they considered meaningful, in terms of their experienced discomfort and comfort. Data sources included formal and informal interviews with child-participants, drawings provided by some participants, and field-notes documenting observed non-verbal data. SAMPLE: Twelve children were enrolled in the study, ranging from 3 to 17years of age; including four girls and eight boys. FINDINGS: Although all participants were able to discuss the discomfort and comfort they experienced, they reported difficulties in remembering part or most of their experience. Some participants characterized their Pediatric Intensive Care Unit stay quite favourably or as "not that bad", while some described their experience unfavourably. Diverse types of discomforts were reported, including fears and worries, hurt and pain, invasive interventions, missing significant people, noise, food or eating problems, boredom, physical symptoms, as well as four additional discomforts reported by individual participants. Several sources of comfort were described, including parents, visitors and friends, hospital staff (principally nurses), stuffed animal/favourite blanket, entertainment and play, food, selected medical interventions, thinking of going home, being able to walk or run, sleep, waking up, gifts, along with two other comforts reported by individual participants. Embodiment and a tension between aloneness and being with were identified as the principal phenomena underlying these children's experiences. CONCLUSION: The findings complement existing knowledge regarding the psychological impact of critical illness by highlighting how children regard specific phenomena as discomforting or comforting. This sheds light on future directions for practice and research development in pediatric critical care.

Transitioning from stiff chest tubes to soft pleural catheters: prospective assessment of a practice change.

BACKGROUND: Tube thoracostomies in children are required for multiple indications and can be associated with significant discomfort. In 2010, a multidisciplinary team at our institution developed a protocol to replace stiff chest tubes with 8.5-French soft pleural catheters in children requiring pleural drainage. METHODS: Before initiating the protocol, an audit sheet was developed to prospectively capture data regarding insertion, removal, complications, and success. After 8 months of new protocol utilization, these data were reviewed, along with a retrospective review of the patients' charts. RESULTS: Twenty-three patients had 33 pleural catheters inserted over an 8-month period. Mean age was 6.7 years (1 day to 17 years). Indications for insertion were pneumothorax (24%), simple effusion (24%), chylothorax (27%), parapneumonic effusion/empyema (21%), and malignant effusion (3%). Complications included premature dislodgment (33%), blockage (15%), pneumothorax (3%), and bleeding (3%). Mean duration of pleural drainage was 7.27 days (0 to 37 days). Pleural drainage was successful in 91% of patients. CONCLUSION: Soft pleural catheters are an acceptable alternative to traditional stiff chest tubes in the pediatric population. Premature dislodgment was the most common problem. Prospective audits are extremely valuable in assessing new procedural protocols and practice changes.

Struggling to do what is right for the child: pediatric life-support decisions among physicians and nurses in France and Quebec.

This study examined (a) how physicians and nurses in France and Quebec make decisions about life-sustaining therapies (LSTs) for critically ill children and (b) corresponding ethical challenges. A focus groups design was used. A total of 21 physicians and 24 nurses participated (plus 9 physicians and 13 nurses from a prior secondary analysis). Principal differences related to roles: French participants regarded physicians as responsible for LST decisions, whereas Quebec participants recognized parents as formal decision-makers. Physicians stated they welcomed nurses' input but found they often did not participate, while nurses said they wanted to contribute but felt excluded. The LST limitations were based on conditions resulting in long-term consequences, irreversibility, continued deterioration, inability to engage in relationships and loss of autonomy. Ethical challenges related to: the fear of making errors in the face of uncertainty; struggling with patient/family consequences of one's actions; questioning the parental role and dealing with relational difficulties between physicians and nurses.

Should I stay or should I go? Parental struggles when witnessing resuscitative measures on another child in the pediatric intensive care unit.

OBJECTIVE: The aim of this study was to examine the experiences of parents encountering the critical deterioration and resuscitative care of other children in the pediatric intensive care unit where their own child was admitted. DESIGN: Grounded theory qualitative methodology. SETTING: Pediatric intensive care unit of a pediatric tertiary care center in Montreal, Canada. SUBJECTS: Ten parents of critically ill children who witnessed resuscitative measures on another child. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Semistructured interviews were conducted. While witnessing resuscitation, parents struggled with "Should I stay or should I go?" Their decision depended on specific contributing factors that were intrinsic to parents (curiosity or apprehension, the child's sake, trust or distrust) or extrinsic (limited space). These parents were not "spectators." Despite using coping strategies, the experiences were distressing in the majority of cases, although sometimes comforting. The impact on witnessing critical events had divergent effects on parental trust with healthcare professionals. CONCLUSIONS: Pediatric intensive care unit teams have to be attentive to the benefits and burdens for parents to be present when resuscitative measures are required for another child to arrange for the provision of psychosocial support by pediatric intensive care unit physicians, nurses, and/or psychosocial consultants.