Feasibility of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

PURPOSE: The purpose of this study was to evaluate the feasibility of a new Web-based intermittent catheter self-management intervention. DESIGN: We tested the acceptability and usability of intervention components, which included multiple Web-based materials (an online urinary diary adapted for mobile phone use and an educational booklet), 3 phone calls with a nurse, and a peer-led discussion forum. SUBJECTS AND SETTING: Thirty adults with spinal cord injury using intermittent catheterization for bladder drainage were enrolled; 26 participants received the nurses' phone-based consultations. METHODS: Preliminary effectiveness of new self-efficacy and self-management scales were evaluated using baseline and 3-month online surveys. Participants' perceived value of the intervention components, self-management changes, and suggestions were assessed with data from the 3-month surveys, followed by brief tape-recorded interviews. RESULTS: Several catheter practices improved somewhat over 3 months. The frequency of catheterizations every 4 to 6 hours increased from 71% to 77%. Self-management of neurogenic bladder dysfunction increased significantly (P = .032); participant comments indicated that fluid intake was the biggest change. Catheter-related self-efficacy and quality-of-life scores increased but not significantly. The frequency of urinary tract infection and pain did not change significantly. For feasibility, intervention components, with the exception of the forum, were rated highly by the majority of participants for usefulness, satisfaction (desired information), and Web-based usability. CONCLUSION: Further testing of this intervention is recommended in a multisite randomized clinical trial.

Testing a Model of Self-Management of Fluid Intake in Community-Residing Long-term Indwelling Urinary Catheter Users.

BACKGROUND: Urinary tract infection and blockage are serious and recurrent challenges for people with long-term indwelling catheters, and these catheter problems cause worry and anxiety when they disrupt normal daily activities. OBJECTIVE: The goal was to determine whether urinary catheter-related self-management behaviors focusing on fluid intake would mediate fluid intake-related self-efficacy toward decreasing catheter-associated urinary tract infection (CAUTI) and/or catheter blockage. METHODS: The sample involved data collected from 180 adult community-living, long-term indwelling urinary catheter users. The authors tested a model of fluid intake self-management related to fluid intake self-efficacy for key outcomes of CAUTI and blockage. To account for the large number of zeros in both outcomes, a zero-inflated negative binomial (ZINB) structural equation model was tested. RESULTS: Structurally, fluid intake self-efficacy was positively associated with fluid intake self-management, suggesting that higher fluid intake self-efficacy predicts more (higher) fluid intake self-management; however, fluid intake self-management was not associated with either the frequency of CAUTIs or the presence or absence of CAUTI. Fluid intake self-efficacy was positively related to fluid intake self-management, and fluid intake self-management predicted less frequency of catheter blockage, but neither fluid intake self-efficacy nor fluid intake self-management predicted the presence or absence of blockage. DISCUSSION: Further research is needed to better understand determinants of CAUTI in long-term catheter users and factors which might influence or prevent its occurrence. Increased confidence (self-efficacy) and self-management behaviors to promote fluid intake could be of value to long-term urinary catheter users to decrease catheter blockage.

Self-care management questionnaire for long-term indwelling urinary catheter users.

AIMS: Self-management is believed to be an important behavioral capacity in people with chronic illness, and self-efficacy is an important component contributing to self-management. Two new and related measures for urinary catheter self-efficacy (C-SE) and self-management (C-SMG) were developed based on existing tools and tested for psychometrics for use in a randomized clinical trial (RCT) teaching urinary catheter self-management. METHODS: The instruments were evaluated at baseline (intake face to face interview) with 202 persons and with 158 of the same individuals 6 months later by telephone interviews. Exploratory factor analysis was conducted in an iterative process related to items' theoretical and statistical appropriateness. To assess construct validity and goodness of fit for model testing, confirmatory factor analysis was conducted with the samples at intake and 6 months. Also, bivariate analyses were conducted of the measures in relation to each other. RESULTS: Both scales were modified reducing the items to 13 in each, with four factors in C-SE and three factors in C-SMG. Reliability testing (Cronbach's alpha) was viewed as satisfactory for both scales, though some of the subscale (factors) reliabilities were lower in the self-management measure. Confirmatory factor analysis was adequate. Correlation of the two instruments (r = 0.25, P < 001) suggests that they are related scales. CONCLUSION: With a change in the C-SMG scale from 3- to 5-level responses and subsequent testing, both new scales are appropriate for use separately or together as a questionnaire related to catheter self-care management in intervention research with long-term indwelling urinary catheter users. Neurourol. Urodynam. 35:492-496, 2016. © 2015 Wiley Periodicals, Inc.

Development of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

While Web-based interventions have proliferated recently, information in the literature is often lacking about how the intervention was developed. In response to that gap, this is a report of the development of a Web-based self-management intervention for intermittent urinary catheter users and pretesting with four adults with spinal cord injury living in the community. Two Web sites were created, one for recruitment and the other for the intervention itself. The intervention involved developing new Web-based technology, including an interactive urinary diary (with fluid intake/urine output and a journal), extensive catheter products information, three intervention nurse phone call consultations, and user-community discussion forums. Study participants completed an online survey and were interviewed twice about the enrollment process and their perceptions of their involvement in the intervention. Suggestions from the pretesting participants were used to revise the Web site applications prior to the next stage of research (a feasibility study). Numerous recommendations and comments were received related to content, interactivity of components, and usability. This article provides a description of how the Web sites were developed (including the technology and software programs used), issues encountered and what was done to address them, and how the Web-based intervention was modified for improvements.

A Web-Based Self-Management Intervention for Intermittent Catheter Users.

A new Web-based self-management intervention was developed for persons with spinal cord injury who use intermittent urinary catheters. Included are a description of the components, examples from the educational book, and multiple screen shots of the online urinary diary.

A hybrid process fidelity assessment in a home-based randomized clinical trial.

A process fidelity assessment was conducted as a nested study within a home-based randomized clinical trial teaching self-management to 101 long-term indwelling urinary catheter users in the treatment group. Our hybrid model combined external assessments (outside observations and tape recordings) with internal evaluation methods (through study nurse forms and notes) for a comprehensive process fidelity assessment. Barriers, patient-related issues, and nurse perspectives were identified demonstrating the complexity in home care intervention research. The complementary and synergistic approaches provided in-depth information about the context of the delivery and the impact of the intervention on study outcomes.

Self-management intervention for long-term indwelling urinary catheter users: randomized clinical trial.

BACKGROUND: People using long-term indwelling urinary catheters experience multiple recurrent catheter problems. Self-management approaches are needed to avoid catheter-related problems. OBJECTIVES: The aim was to determine effectiveness of a self-management intervention in prevention of adverse outcomes (catheter-related urinary tract infection, blockage, and accidental dislodgement). Healthcare treatment associated with the adverse outcomes and catheter-related quality of life was also studied. METHODS: A randomized clinical trial was conducted. The intervention involved learning catheter-related self-monitoring and self-management skills during home visits by a study nurse (twice during the first month and at 4 months-with a phone call at 2 months). The control group received usual care. Data were collected during an initial face-to-face home interview followed by bimonthly phone interviews. A total of 202 adult long-term urinary catheter users participated. Participants were randomized to treatment or control groups following collection of baseline data. Generalized estimating equations were used for the analysis of treatment effect. RESULTS: In the intervention group, there was a significant decrease in reported blockage in the first 6 months (p = .02), but the effect did not persist. There were no significant effects for catheter-related urinary tract infection or dislodgment. Comparison of baseline rates of adverse outcomes with subsequent periods suggested that both groups improved over 12 months. DISCUSSION: A simple-to-use catheter problems calendar and the bimonthly interviews might have functioned as a modest self-monitoring intervention for persons in both groups. A simplified intervention using a self-monitoring calendar is suggested-with optimal and consistent fluid intake likely to add value.

The development of an automated device for asthma monitoring for adolescents: methodologic approach and user acceptability.

BACKGROUND: Many adolescents suffer serious asthma related morbidity that can be prevented by adequate self-management of the disease. The accurate symptom monitoring by patients is the most fundamental antecedent to effective asthma management. Nonetheless, the adequacy and effectiveness of current methods of symptom self-monitoring have been challenged due to the individuals' fallible symptom perception, poor adherence, and inadequate technique. Recognition of these limitations led to the development of an innovative device that can facilitate continuous and accurate monitoring of asthma symptoms with minimal disruption of daily routines, thus increasing acceptability to adolescents. OBJECTIVE: The objectives of this study were to: (1) describe the development of a novel symptom monitoring device for teenagers (teens), and (2) assess their perspectives on the usability and acceptability of the device. METHODS: Adolescents (13-17 years old) with and without asthma participated in the evolution of an automated device for asthma monitoring (ADAM), which comprised three phases, including development (Phase 1, n=37), validation/user acceptability (Phase 2, n=84), and post hoc validation (Phase 3, n=10). In Phase 1, symptom algorithms were identified based on the acoustic analysis of raw symptom sounds and programmed into a popular mobile system, the iPod. Phase 2 involved a 7 day trial of ADAM in vivo, and the evaluation of user acceptance using an acceptance survey and individual interviews. ADAM was further modified and enhanced in Phase 3. RESULTS: Through ADAM, incoming audio data were digitized and processed in two steps involving the extraction of a sequence of descriptive feature vectors, and the processing of these sequences by a hidden Markov model-based Viterbi decoder to differentiate symptom sounds from background noise. The number and times of detected symptoms were stored and displayed in the device. The sensitivity (true positive) of the updated cough algorithm was 70% (21/30), and, on average, 2 coughs per hour were identified as false positive. ADAM also kept track of the their activity level throughout the day using the mobile system's built in accelerometer function. Overall, the device was well received by participants who perceived it as attractive, convenient, and helpful. The participants recognized the potential benefits of the device in asthma care, and were eager to use it for their asthma management. CONCLUSIONS: ADAM can potentially automate daily symptom monitoring with minimal intrusiveness and maximal objectivity. The users' acceptance of the device based on its recognized convenience, user-friendliness, and usefulness in increasing symptom awareness underscores ADAM's potential to overcome the issues of symptom monitoring including poor adherence, inadequate technique, and poor symptom perception in adolescents. Further refinement of the algorithm is warranted to improve the accuracy of the device. Future study is also needed to assess the efficacy of the device in promoting self-management and asthma outcomes.

Successful recruitment methods in the community for a two-site clinical trial.

Effective screening and recruitment are essential to the success of randomized clinical trials. This report is to describe key screening and recruitment strategies in a two site randomized clinical trial (RCT) conducted in community settings with a vulnerable chronically ill population and to suggest valuable approaches when planning trials. Differences between sites in a complex study with two considerably different environments (academic versus home care) and their participant pools presented challenges which required different screening and recruitment methods. A high level of communication between sites, creative problem solving and the ability to be flexible when problems were encountered were needed for successful screening and recruitment.

Symptoms, feelings, activities and medication use in adolescents with uncontrolled asthma: lessons learned from asthma diaries.

This study was to describe symptoms, feelings, activities and medication use reported by adolescents with uncontrolled asthma on their 24-hour asthma diaries. Adolescents with uncontrolled asthma (13-17 years, N=29) completed asthma diaries and audio-recorded symptom sounds for 24 hours. A variety of symptoms were reported, and the most frequently reported symptoms were coughing followed by wheezing. Most self-reported coughing and wheezing were verified by audio-recordings. Participants reported predominantly negative feelings and low levels of activities. High discordance between self-reports and medical records in medications was noted, raising a concern of poor treatment adherence in this vulnerable group.

Perceived value of a urinary catheter self-management program in the home.

A long-term indwelling urinary catheter intervention was tested in a randomized trial that is described in this article. The perceived value of the intervention to the catheter users, one of the study's specific aims, was assessed at the end of their 12-month participation and is reported here. Study participants' responses, our findings, and implications for home healthcare are discussed.

Long-term urinary catheter users self-care practices and problems.

AIMS AND OBJECTIVES: To characterise a sample of 202 adult community-living long-term indwelling urinary catheter users, to describe self-care practices and catheter problems, and to explore relationships among demographics, catheter practices and problems. BACKGROUND: Long-term urinary catheter users have not been well studied, and persons using the device indefinitely for persistent urinary retention are likely to have different patterns of catheter practices and problems. DESIGN: The study was a cross-sectional descriptive and exploratory analysis. METHODS: Home interviews were conducted with catheter users who provided information by self-reported recall over the previous two months. Data were analysed by descriptive statistics and tests of association between demographics, catheter practices and catheter problems. RESULTS: The sample was widely diverse in age (19-96 years), race and medical diagnosis. Urethral catheters were used slightly more often (56%) than suprapubic (44%), for a mean of six years (SD 7 years). Many persons were highly disabled, with 60% having difficulty in bathing, dressing, toileting and getting out of the bed; 19% also required assistance in eating. A high percentage of catheter problems were reported with: 43% experiencing leakage (bypassing of urine), 31% having had a urinary tract infection, 24% blockage of the catheter, 23% catheter-associated pain and 12% accidental dislodgment of the catheter. Treatments of catheter-related problems contributed to additional health care utilisation, including extra nurse or clinic visits, trips to the emergency department or hospitalisation. Symptoms of catheter-associated urinary tract infections were most often related to changes in the colour or character of urine or generalised symptoms. CONCLUSIONS: Catheter-related problems contribute to excess morbidity and health care utilisation and costs. RELEVANCE TO CLINICAL PRACTICE: More research is needed in how to minimise catheter-associated problems in long-term catheter users. Information from this study could help inform the development of interventions in this population.

Navigating tensions: integrating palliative care consultation services into an academic medical center setting.

CONTEXT: Despite rapid proliferation of hospital-based palliative care consultation services (PCCSs) across the country, there is little description of the dynamic processes that the PCCS and the non-PCCS hospital cultures experience during the institutionalization of a successful PCCS. OBJECTIVES: To describe the institutionalization of a new PCCS in a quaternary care academic medical center (AMC) and highlight two themes, cost and quality, that pervaded the dynamics involved from the inception to the successful integration of the service. METHODS: Ethnography using longitudinal field observations, in-depth interviews, and the collection of artifacts. The study was performed in a 750-bed quaternary care AMC in the northeastern region of the U.S. Participants were a purposefully selected sample (n=79) of 1) senior-level institutional administrators, including clinical leaders in nursing, medicine, and social work, 2) clinicians who used the PCCS, either commonly or rarely, and 3) members of the PCCS core and extended teams. RESULTS: Key infrastructure components that contributed to the successful integration of the PCCS included top level interprofessional administrative buy-in to the quality and cost arguments for PCCS, PCCS leadership selection, robust data collection strategies emphasizing quality outcome data, the adoption of the "physician referral only" rule, and incremental and sustainable growth. The PCCS service grew an average of 23% per year from 2003 to 2009. CONCLUSION: An in-depth understanding of the dynamic interaction of the infrastructures and processes of a successful institutionalization, in their unique complexity, may help other PCCSs identify and negotiate attributes of their own circumstances that will increase their chances for successful and sustainable implementation.

Maternal anxiety and depression after a premature infant's discharge from the neonatal intensive care unit: explanatory effects of the creating opportunities for parent empowerment program.

BACKGROUND: Understanding the processes through which interventions work for mothers of premature infants is necessary for the advancement of science and the translation of efficacious interventions into clinical practice settings. OBJECTIVE: To test a theoretical model examining the processes through which an educational-behavioral intervention program (Creating Opportunities for Parent Empowerment [COPE]) influences mothers' anxiety and depression 2 months after discharge of their premature infants from the neonatal intensive care unit (NICU). METHODS: A secondary analysis was conducted using data from a randomized controlled trial with 246 mothers of low-birth-weight preterm infants who were assigned randomly to COPE or placebo control conditions. Measures included mothers' stress in the NICU, mothers' anxiety and depression, and mothers' beliefs about their infants and their role. Observers blind to study group condition also rated the quality of mother-infant interaction in the NICU. RESULTS: Structural equation modeling suggested that the model tested provided a reasonable fit to the data, chi2(64) = 97.67, p = .004, root mean square error of approximation = .046, comparative fit index = .97. Participation in COPE was both directly and indirectly, via associations with increased maternal beliefs and less maternal depression and anxiety in the NICU, related to mothers' decreased posthospital depression and anxiety. Participation in the COPE program also was associated with higher mother-infant interaction scores. CONCLUSION: Implementation of COPE could lessen postdischarge maternal anxiety and depression, which may improve outcomes for both mothers and preterm infants.

Testing the theoretical framework of the COPE program for mothers of critically ill children: an integrative model of young children's post-hospital adjustment behaviors.

OBJECTIVE: To test a theoretical model examining processes through which a parent-focused educational-behavioral intervention [Creating Opportunities for Parent Empowerment (COPE)] relates to children's post-hospital adjustment problems. METHODS: Mothers (n = 143) and their 2-7-year-old children, unexpectedly hospitalized in two pediatric intensive care units, were randomized to COPE or control conditions. Maternal measures included parental beliefs, anxiety, negative mood, and child adjustment 3 months post discharge. Observers rated maternal support of their children during hospitalization. RESULTS: Structural equation modeling suggested that the model tested provided a reasonable fit to the data [chi2 (97 df) = 129.43; p = .016; root mean square error of approximation = .048; comparative fit index = .95]. COPE effects on children's post-hospital externalizing behaviors were indirect, via associations with parental beliefs and maternal negative mood state. Furthermore, COPE participation was associated with more maternal support of their children, which was also associated with less internalizing and externalizing behaviors 3 months post discharge. CONCLUSION: Implementing COPE may help avert future mental health problems in this high risk population. Understanding the processes by which an already empirically validated program relates to child outcomes is likely to aid clinicians and administrators in the widespread uptake of the COPE program.

Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized, controlled trial.

OBJECTIVE: Although low birth weight premature infants and parents are at high risk for adverse health outcomes, there is a paucity of studies that test early NICU interventions with parents to prevent the development of negative parent-infant interaction trajectories and to reduce hospital length of stay. Our objective was to evaluate the efficacy of an educational-behavioral intervention program (ie, Creating Opportunities for Parent Empowerment) that was designed to enhance parent-infant interactions and parent mental health outcomes for the ultimate purpose of improving child developmental and behavior outcomes. DESIGN, SETTING, AND PARTICIPANTS: A randomized, controlled trial was conducted with 260 families with preterm infants from 2001 to 2004 in 2 NICUs in the northeast United States. Parents completed self-administered instruments during hospitalization, within 7 days after infant discharge, and at 2 months' corrected age. Blinded observers rated parent-infant interactions in the NICU. INTERVENTION: All participants received 4 intervention sessions of audiotaped and written materials. Parents in the Creating Opportunities for Parent Empowerment program received information and behavioral activities about the appearance and behavioral characteristics of preterm infants and how best to parent them. The comparison intervention contained information regarding hospital services and policies. MAIN OUTCOME MEASURES: Parental stress, depression, anxiety, and beliefs; parent-infant interaction during the NICU stay; NICU length of stay; and total hospitalization were measured. RESULTS: Mothers in the Creating Opportunities for Parent Empowerment program reported significantly less stress in the NICU and less depression and anxiety at 2 months' corrected infant age than did comparison mothers. Blinded observers rated mothers and fathers in the Creating Opportunities for Parent Empowerment program as more positive in interactions with their infants. Mothers and fathers also reported stronger beliefs about their parental role and what behaviors and characteristics to expect of their infants during hospitalization. Infants in the Creating Opportunities for Parent Empowerment program had a 3.8-day shorter NICU length of stay (mean: 31.86 vs 35.63 days) and 3.9-day shorter total hospital length of stay (mean: 35.29 vs 39.19 days) than did comparison infants. CONCLUSIONS: A reproducible educational-behavioral intervention program for parents that commences early in the NICU can improve parent mental health outcomes, enhance parent-infant interaction, and reduce hospital length of stay.

Creating opportunities for parent empowerment: program effects on the mental health/coping outcomes of critically ill young children and their mothers.

OBJECTIVE: Increasing numbers of children in the United States (ie, approximately 200 children per 100,000 population) require intensive care annually, because of advances in pediatric therapeutic techniques and a changing spectrum of pediatric disease. These children are especially vulnerable to a multitude of short- and long-term negative emotional, behavioral, and academic outcomes, including a higher risk of posttraumatic stress disorder (PTSD) and a greater need for psychiatric treatment, compared with matched hospitalized children who do not require intensive care. In addition, the parents of these children are at risk for the development of PTSD, as well as other negative emotional outcomes (eg, depression and anxiety disorders). There has been little research conducted to systematically determine the effects of interventions aimed at improving psychosocial outcomes for critically ill children and their parents, despite recognition of the adverse effects of critical care hospitalization on the nonphysiologic well-being of patients and their families. The purpose of this study was to evaluate the effects of a preventive educational-behavioral intervention program, the Creating Opportunities for Parent Empowerment (COPE) program, initiated early in the intensive care unit hospitalization on the mental health/psychosocial outcomes of critically ill young children and their mothers. DESIGN: A randomized, controlled trial with follow-up assessments 1, 3, 6, and 12 months after hospitalization was conducted with 174 mothers and their 2- to 7-year-old children who were unexpectedly hospitalized in the pediatric intensive care units (PICUs) of 2 children's hospitals. The final sample of 163 mothers ranged in age from 18 to 52 years, with a mean of 31.2 years. Among the mothers reporting race/ethnicity, the sample included 116 white (71.2%), 33 African American (20.3%), 3 Hispanic (1.8%), and 2 Indian (1.2%) mothers. The mean age of the hospitalized children was 50.3 months. Ninety-nine children (60.7%) were male and 64 (39.3%) were female. The major reasons for hospitalization were respiratory problems, accidental trauma, neurologic problems, and infections. Fifty-seven percent (n = 93) of the children had never been hospitalized overnight, and none had experienced a previous PICU hospitalization. INTERVENTIONS: Mothers in the experimental (COPE) group received a 3-phase educational-behavioral intervention program 1) 6 to 16 hours after PICU admission, 2) 2 to 16 hours after transfer to the general pediatric unit, and 3) 2 to 3 days after their children were discharged from the hospital. Control mothers received a structurally equivalent control program. The COPE intervention was based on self-regulation theory, control theory, and the emotional contagion hypothesis. The COPE program, which was delivered with audiotapes and matching written information, as well as a parent-child activity workbook that facilitated implementing the audiotaped information, focused on increasing 1) parents' knowledge and understanding of the range of behaviors and emotions that young children typically display during and after hospitalization and 2) direct parent participation in their children's emotional and physical care. The COPE workbook, which was provided to parents and children after transfer from the PICU to the general pediatric unit, contained 3 activities to be completed before discharge from the hospital, ie, 1) puppet play to encourage expression of emotions in a nonthreatening manner, 2) therapeutic medical play to assist children in obtaining some sense of mastery and control over the hospital experience, and 3) reading and discussing Jenny's Wish, a story about a young child who successfully copes with a stressful hospitalization. OUTCOME MEASURES: Primary outcomes included maternal anxiety, negative mood state, depression, maternal beliefs, parental stress, and parent participation in their children's care, as well as child adjustment, which was assessed with the Behavioral Assessment System for Children (parent form). RESn (parent form). RESULTS: COPE mothers reported significantly less parental stress and participated more in their children's physical and emotional care on the pediatric unit, compared with control mothers, as rated by nurses who were blinded with respect to study group. In comparison with control mothers, COPE mothers reported less negative mood state, less depression, and fewer PTSD symptoms at certain follow-up assessments after hospitalization. In addition, COPE mothers reported stronger beliefs regarding their children's likely responses to hospitalization and how they could enhance their children's adjustment, compared with control mothers. COPE children, in comparison with control children, exhibited significantly fewer withdrawal symptoms 6 months after discharge, as well as fewer negative behavioral symptoms and externalizing behaviors at 12 months. COPE mothers also reported less hyperactivity and greater adaptability among their children at 12 months, compared with control mothers. One year after discharge, a significantly higher percentage of control group children (25.9%) exhibited clinically significant behavioral symptoms, compared with COPE children (2.3%). In addition, 6 and 12 months after discharge, significantly higher percentages of control group children exhibited clinically significant externalizing symptoms (6 months, 14.3%; 12 months, 22.2%), compared with COPE children (6 months, 1.8%; 12 months, 4.5%). CONCLUSIONS: The findings of this study indicated that mothers who received the COPE program experienced improved maternal functional and emotional coping outcomes, which resulted in significantly fewer child adjustment problems, in comparison with the control group. With the increasing prevalence of attention-deficit/hyperactivity disorder and externalizing problems among children and the documented lack of mental health screening and early intervention services for children in this country, the COPE intervention could help protect this high-risk population of children from developing these troublesome problems. As a result, the mental health status of children after critical care hospitalization could be improved. With routine provision of the COPE program in PICUs throughout the country, family burdens and costs associated with the mental health treatment of these problems might be substantially reduced.