Questionnaires to Assess Facilitators and Barriers of Early Mobilization in Critically Ill Patients; Which One to Choose? A Systematic Review

Implementing and performing early mobilization is a complex process requiring multidisciplinary input and cooperation. To gain insight in its facilitators and barriers, various surveys have been developed. A systematic review was conducted, to identify the psychometric properties, feasibility and suitability of questionnaires to assess facilitators and barriers of early mobilization in critically ill patients. Data were extracted regarding a.o. definition of early mobilization, development, psychometric properties, content and themes, question format. The search identified 537 publications of which 13 unique questionnaires were included. The questionnaires showed wide variation in extensiveness of development. Only six questionnaires actually assessed validity and reliability. Which questionnaire to choose depends on the aim of its use, required level of detail and specifics of the ICU, though three questionnaires were recommended as their definition of early mobilization covered a broad range of activities, including nursing related mobility activities. International consensus on what constitutes early mobilization is desirable

Increased B-type natriuretic peptide and decreased proteinuria might reflect decreased capillary leakage and is associated with a better outcome in patients with severe burns

INTRODUCTION: It is difficult to adjust fluid balance adequately in patients with severe burns due to various physical changes. B-type natriuretic peptide (BNP) is emerging as a potential marker of hydration state. Proteinuria is used as a predictor of outcome in severe illness and might correlate to systemic capillary leakage. This study investigates whether combining BNP and proteinuria can be used as a guide for individualized resuscitation and as a predictor of outcome in patients with severe burns. METHODS: From 2006 to 2009, 38 consecutive patients (age 47 ± 15 years, 74% male) with severe burns were included and followed for 20 days. All had normal kidney function at admission. BNP and proteinuria were routinely measured. Ordered and actually administered fluid resuscitation volumes were recorded. The Sequential Organ Failure Assessment (SOFA) score was used as the measure of outcome. RESULTS: BNP increased during follow-up, reaching a plateau level at Day 3. Based on median BNP levels at Day 3, patients were divided into those with low BNP and those with high BNP levels. Both groups had comparable initial SOFA scores. Patients with high BNP received less fluid from Days 3 to 10. Furthermore, patients with a high BNP at Day 3 had less morbidity, reflected by lower SOFA scores on the following days. To minimize effects of biological variability, proteinuria on Days 1 and 2 was averaged. By dividing the patients based on median BNP at Day 3 and median proteinuria, patients with high BNP and low proteinuria had significantly lower SOFA scores during the entire follow-up period compared to those patients with low BNP and high proteinuria. CONCLUSIONS: Patients with higher BNP levels received less fluid. This might be explained by a lower capillary leakage in these patients, resulting in more intravascular fluid and consequently an increase in BNP. In combination with low proteinuria, possibly reflecting minimal systemic capillary leakage, a high BNP level was associated with a better outcome. BNP and proteinuria have prognostic potential in severely burned patients and may be used to adjust individual resuscitation

Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands

textabstractBackground: Early accurate assessment of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment, which is the least expensive, but not the most accurate.Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. The actual effect on therapeutic decisions, cli

A taxonomy to assess the interaction between nurses and children:Development and reliability

Aims and objectives The aim of this study was to develop a valid and reliable instrument to assess the nurse-child interaction during medical or nursing interventions. Background Communication is an important competency for the professional practice of nurses and physicians. The nurse-patient relationship is fundamental for high-quality care. It has been suggested that if nurses have more skills to interact with children, care will be less distressing and less painful for the children. Design A qualitative observational psychometric study; the GRRAS checklist was used. Methods In-depth video-analyses, taxonomy development (19 videos) and testing it is psychometric properties (10 videos). Three observers micro-analysed video recordings of experienced nurses changing children's wound dressing in a specialised Burn Centre. Results The nurse-child interaction taxonomy (NCIT) was developed to observe and score the interactional behaviour between nurse and child. The taxonomy has three main patterns: being considerate, attuning oneself, and procedural interventions, subdivided in eight dimensions. These dimensions contain 16 elements that can be observed and scored on a 7-point scale. Intra-rater, inter-rater reliability and agreement were good. Conclusions This study shows that interaction between nurses and children can be assessed reliably with the NCIT by an experienced observer or alternatively, scoring by two observers is recommended. Relevance to clinical practice The development of the taxonomy is an important step to find evidence for the best way for nurses to interact with children during nursing interventions or medical events and as such, ultimately, contributes to providing the best care possible

Stromal vascular fraction-enriched fat grafting as treatment of adherent scars:study design of a non-randomized early phase trial

BACKGROUND: In the last decades, autologous fat grafting has been used to treat adherent dermal scars. The observed regenerative and scar-reducing properties have been mainly ascribed to the tissue-derived stromal vascular fraction (tSVF) in adipose tissue. Adipose tissue's components augment local angiogenesis and mitosis in resident tissue cells. Moreover, it promotes collagen remodeling. We hypothesize that tSVF potentiates fat grafting-based treatment of adherent scars. Therefore, this study aims to investigate the effect of tSVF-enriched fat grafting on scar pliability over a 12-month period.METHODS AND DESIGN: A clinical multicenter non-randomized early phase trial will be conducted in two dedicated Dutch Burn Centers (Red Cross Hospital, Beverwijk, and Martini Hospital, Groningen). After informed consent, 46 patients (≥18 years) with adherent scars caused by burns, necrotic fasciitis, or degloving injury who have an indication for fat grafting will receive a sub-cicatricic tSVF-enriched fat graft. The primary outcome is the change in scar pliability measured by the Cutometer between pre- and 12 months post-grafting. Secondary outcomes are scar pliability (after 3 months), scar erythema, and melanin measured by the DSM II Colormeter; scar quality assessed by the patient and observer scales of the Patient and Observer Scar Assessment Scale (POSAS) 2.0; and histological analysis of scar biopsies (voluntary) and tSVF quality and composition. This study has been approved by the Dutch Central Committee for Clinical Research (CCMO), NL72094.000.20.CONCLUSION: This study will test the clinical efficacy of tSVF-enriched fat grafting to treat dermal scars while the underlying working mechanism will be probed into too.TRIAL REGISTRATION: Dutch Trial Register NL 8461. Registered on 16 March 2020.</p

The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections:A Nationwide Dutch Study

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p &lt; .001), and a longer length of stay (median 49 vs 22 days, p &lt; .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p &lt; .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.</p

Predictability of exercise capacity following pediatric burns:a preliminary investigation

Purpose: Describe the course of exercise capacity in pediatric burn patients during the initial 6 months after hospital discharge, and examine whether its recovery can be predicted from burn characteristics, sociodemographic characteristics, and/or prior assessment. Materials and methods: Exercise capacity was assessed at discharge, and 6 weeks, 3 months, and 6 months after discharge using the Steep Ramp Test (SRT). Results: Twenty-four pediatric patients with burns affecting 0.1-34% of total body surface area were included. At group level, exercise capacity was low at discharge and did not reach healthy reference values within 6 months, despite significant improvement over time. At individual level, the course of exercise capacity varied widely. Six months after discharge, 48% of participants scored more than one standard deviation below healthy age- and sex-specific reference values. SRT outcomes at 6 weeks and 3 months were the best predictors of exercise capacity 6 months after discharge, explaining, respectively, 76% and 93% of variance. Conclusions: Forty-eight percent of participants did not achieve healthy reference values of exercise capacity and were therefore considered "at risk" for diminished functioning. Our preliminary conclusion that early assessment of exercise capacity with the SRT can timely identify those patients, needs to be strengthened by further research. IMPLICATIONS FOR REHABILITATION Pediatric burns can be considered as a chronic medical condition because of the lifelong consequences. Exercise capacity is reduced following- even minor -pediatric burns. Recovery patterns vary widely: some pediatric burn patients achieve healthy levels of exercise capacity without specific intervention, while others do not. The Steep Ramp Test can be used to assess exercise capacity, identifying those "at risk" for adverse outcomes at an early stage. Patients "at risk" should be encouraged to play sports and adopt an active lifestyle

Hydrosurgical and conventional debridement of burns:randomized clinical trial

Background: Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting. Methods: A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation. Results: Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P =0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001). Conclusion: One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis

Effect of training in the Emergency Management of Severe Burns on the knowledge and performance of emergency care workers as measured by an online simulated burn incident

OBJECTIVE: To determine the value of training for the Emergency Management of Severe Burns (EMSB) for medical and nursing staff working in emergency care as measured by their performance in a simulated burn incident online program. METHODS: An Internet-based questionnaire, which included a simulated burn incident, was developed. All of the medical and nursing staff in hospital emergency departments and ambulance services in the Netherlands were invited to complete this questionnaire. The effect of EMSB training on the individual's knowledge of and performance in the emergency management of a burn victim was evaluated because some of the respondents had participated in EMSB training, whereas others had not. RESULTS: Of the 280 responses received, 198 questionnaires were included in the analysis. The analyzed questionnaires were submitted by nurses (43%), ambulance workers (33%), and physicians (23%). Only 14% of the people in the study had participated in EMSB training, whereas 78% had received other or additional life support training and 22% of respondents had no additional life support training. Medical and nursing staff who had participated in EMSB training performed better in the following subjects: mentioning hypothermia as a focus of attention (70% versus 53%, p=0.085), correct use of hand size (70% versus 36%, p=0.001) and use of the correct hand percentage in the estimation of total body surface area (TBSA, 82% versus 57%, p=0.015), suspicion of no airway obstruction in an outdoor trauma (93% versus 63%, p = 0.002) and referral of functional area burns to a burn center (22% versus 8%, p = 0.04). However, both groups overestimated the TBSA (34% of the total group overestimated ≥ 20%) and did not know the correct formula for fluid resuscitation (87% of the total group). CONCLUSION: There is some evidence that medical staff members who have participated in EMSB training have a better knowledge of emergency management and are more effective in the management of a simulated burn case. However, both individuals who had participated in EMSB as well as those who had not participated in EMSB needed additional training in EMSB

Splinting the juvenile arthritic wrist: a clinical observation

Hand function in children is very important in the development of skills needed for daily childhood activities; therefore, preserving this function warrants special attention. One of the interventions aiming to preserve functionis splinting of the affected wrist joint. The rationale for the use of splinting is to balance rest and activity, therebypreserving wrist function. However, the evidence-based knowledge to support this rationale is scarce. To determine the validity of “balancing rest and activity of the affected wrists to preserve function,” we reviewed ourown data, data in the literature regarding rheumatic wrist problems in children, and data from a 15-year followup study of rheumatic wrist problems in an adult cohort of our adult rheumatology counterpart within the medicalcenter