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. 2024 Nov 1;25(11):1051-1064.
doi: 10.1097/PCC.0000000000003595. Epub 2024 Aug 12.

The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R 2 ): Pilot Testing in a Two-Phase Cohort Study, 2017-2021

Martha A Q Curley  1   2   3 , Onella S Dawkins-Henry  4 , Laura Beth Kalvas  1 , Mallory A Perry-Eaddy  5   6   7 , Georgia Georgostathi  8 , Ian Yuan  2   3   8 , David Wypij  4   9   10 , Lisa A Asaro  4 , Athena F Zuppa  11 , Sapna R Kudchadkar  12   13   14   15
Affiliations

The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R 2 ): Pilot Testing in a Two-Phase Cohort Study, 2017-2021

Martha A Q Curley et al. Pediatr Crit Care Med. .

Abstract

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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Conflict of interest statement

Drs. Curley’s, Zuppa’s, and Kudchadkar’s institutions received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Drs. Curley’s and Kalvas’s institutions received funding from the National Institute of Nursing Research. Dr. Kalvas’s institution received funding from the National Center for Advancing Translational Sciences. Drs. Curley, Kalvas, Perry-Eaddy, Wypij, Zuppa, and Kudchadkar received support for article research from the National Institutes of Health (NIH). Dr. Yuan received funding from Masimo; his institution received funding from Masimo. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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