POSTINTENSIVE CARE SYNDROME PEDIATRICS

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Reducing Postintensive Care Syndrome – Pediatrics in the Child with Congenital Heart Disease
by Addressing Delirium

Laura J. Kawasaki
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Laura J. Kawasaki is a graduate student in the Edson College of Nursing and Health
Innovation at Arizona State University. She is a cardiovascular intensive care unit nurse at
Phoenix Children’s, located in Phoenix, Arizona. She has no known conflict of interest to
disclose. Correspondence concerning this article should be addressed to Laura J. Kawasaki,
Edson College of Nursing and Health Innovation, Arizona State University, 550 N. 3rd Street,
Phoenix, AZ 85004 email: lkawasak@asu.edu

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Abstract
Advances in healthcare are decreasing mortality but increasing morbidity. As a result of the
advanced treatment, recognition of a cluster of long-term complications known as
postintensive care syndrome – pediatrics, or PICS-p, has developed. PICS-p impacts four areas
of health: psychological, cognitive, physical, and social. The literature revealed best practices
for reducing PICS-p complications in patients with congenital heart disease (CHD). Based on the
standard bundle for best practices to prevent PICS-p, the ABCDEF bundle, a quality
improvement project was conducted with an emphasis on identifying and recognizing delirium
in the child with CHD while admitted to an inpatient cardiology unit. Nurses caring for these
patients were invited to attend an education session regarding PICS-p and delirium, including
how to accurately score for delirium using the Cornell Assessment of Pediatric Delirium (CAPD)
(Traube et al., 2014) tool. Pre and post tests were given prior to and after the educational
session to assess baseline CAPD and PICS-p awareness. Scores were compared to assess
knowledge acquisition. CAPD scores were tracked, and three separate points were chosen to be
measured. Data analysis showed an increase in CAPD scoring and an overall reduction of CAPD
scores by nearly 50%. Increased CAPD scoring and reduction in overall scores decrease a
patient’s risk of developing PICS-p related to delirium once they are discharged. Additionally, an
increase in nursing awareness of PICS-p and delirium can benefit patients with overall delirium
reduction.
Keywords: Postintensive Care Syndrome-pediatrics, delirium, CAPD scores, congenital
heart disease

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Reducing Postintensive Care Syndrome – Pediatrics in the Child with Congenital Heart Disease
by Addressing Delirium
Mortality in the pediatric population has decreased substantially with advancements in
medical technology and treatment options. With the improvement in medical technology, more
children are being treated for severe illness, injuries, and congenital defects than in decades
prior. Pediatric cardiovascular intensive care unit (CVICU) admissions often come with invasive
ventilatory support, sedation and analgesia medications, prolonged decreased mobility, and an
increased risk for delirium. These necessary treatment components are not without long-term
complication risks after discharge. As a result of decreasing mortality, morbidity has increased.
Problem Statement
Pediatric patients are often treated in the CVICU and cardiac step-down units for
extended periods of time. Modalities of care frequently include intubation and mechanical
ventilation, requiring sedation and analgesia medications (Ekim, 2020; Hartman et al., 2020;
Tang et al., 2021; Watson et al., 2018).
It is no longer sufficient to only measure mortality as a mark of success in the pediatric
population given the high levels of care and treatment they receive. In recent years, a new
clinical syndrome has emerged called postintensive care syndrome-pediatrics (PICS-p) because
patients are surviving and experiencing long term consequences contributing to intensive care
unit (ICU) morbidity. Ekim (2020) defines PICS-p as new or worsening impairment in physical,
cognitive, or mental health status after critical illness, that persists beyond hospitalization.
These new or worsening impairments can hinder the success of treatment for patients and
increase suffering in the post-hospital course.

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Purpose and Rationale
Patients with congenital heart defects (CHD) treated in the CVICU and cardiac stepdown unit are already at a high risk for significant physical and cognitive complications because
of their cardiac pathology. The surgical procedures, medical treatments, and potential
complications also increase their risk for developing PICS-p. The purpose of this paper is to
establish the significance of the compounding complications associated with care in the CVICU
and step-down unit and explain the importance of identifying and treating delirium to reduce
PICS-p complications.
Background and Significance
The recognition of PICS-p is a relatively new concept in the pediatric population even
though PICS has been widely studied and diagnosed in adult populations for the last two
decades. The Society of Critical Care Medicine (SCCM) (n.d.) has a global initiative known as
THRIVE that provides resources and education for ICU survivors and their families. While this
information and initiative is designed for adult patients, the information is applicable to
pediatric ICU patients and their families. Pediatric patients treated in ICU settings suffer many
of the same psychological, cognitive, physical, and sleep disturbance complications seen in
adult ICU survivors (Ekim, 2020; Fink et al., 2020; Hartman et al., 2020; Herrup et al., 2017; Tang
et al., 2021; Watson et al., 2018).
One of the complications increasing the development of PICS-p in pediatric patients is
delirium. The incidence of pediatric delirium (PD) among patients with an ICU stay greater than
48 hours can be as high as 69% (Ista & van Dijk, 2020). Common treatments increasing the
development of PD include restraint use, sleep schedule disruption, mechanical ventilation,

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benzodiazepine exposure, and poorly treated pain. Delirium scoring using the Cornell
Assessment of Pediatric Delirium (CAPD) tool can identify patients positive for delirium,
allowing for the quick initiation of treatment (Staveski et al., 2020; Traube et al., 2014).
Pediatric Cardiovascular Intensive Care Unit Patients
Critical congenital heart defects (CCHD) are anomalies that arise during the
development of the fetal heart. Fetal developmental abnormalities can impact the structure of
the heart through valve, vessel, or heart chamber malformations (Centers for Disease Control
and Prevention [CDC], 2023). Many of these patients will require life-saving surgery within the
first few days of life, along with several other surgeries, procedures, and hospitalizations
throughout their lives (American Heart Association, 2022). Patients with CHD will require critical
care treatment in the CVICU for a varied length of time depending on the severity of their
condition and any complications in treatment (CDC, 2023).
Prior to their surgeries, patients with the most severe CHDs require continuous
medication infusions via central lines to maintain hemodynamic stability. Many also require
respiratory support, either through noninvasive measures or through mechanical ventilation.
Because of the very tenuous state of these neonates, or the level of support they require, many
parents are unable to participate in normal newborn care they would otherwise be a part of,
like diaper changes and feeding. There can be a severe sense of loss of what the expected
newborn period should be (A. Estravit, personal communication, March 10, 2023).
PICS-p Complications
Families with loved ones undergoing care in the CVICU experience exceptional
emotional and physical stressors. With the knowledge of PICS in adults, and the stressors

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caregivers experience and report, it can be assumed that those same conditions will impact the
pediatric population. Herrup et al. (2017) summarized multiple studies that looked at patients
after pediatric intensive care unit (PICU) admissions, some as short as eight hours. One of the
first complications assessed was sleep disturbance and fatigue. The study found that 72% of
PICU patients were at risk for sleep disorder after discharge. In other areas they reported that
49% of critically ill children (n=150) had affected mobility up to one year post discharge.
Cognitively, many patients of varying ages self-reported difficulty in school that was
corroborated by their teachers in follow up surveys. Surveys showed more deterioration in
academic performance in patients treated for sepsis, resulting in long-term difficulty and
attention problems.
Given these significant findings in PICU patients, it is important to identify those patients
at greatest risk for complications early and intervene prior to discharge. Those who spent
significant time mechanically ventilated, on long term sedation and analgesia infusions, or with
extended limited mobility were at significant risk of PICS-p (Ekim, 2020; Fink et al., 2020;
Hartman et al., 2020; Herrup et al., 2017; Turkel, 2017; Watson et al., 2018).
Nonpharmacological Delirium Treatment
Aside from medications to treat delirium, there are several nonpharmacological
interventions that can reduce the development of delirium and decrease the severity and
duration. Maintaining natural sleep/wake cycles, massage, promoting good sleep, listening to
music, early mobilization, avoiding overstimulation, and encouraging family presence are all
nonpharmacological treatment options for preventing and treating delirium in all patients (Ista

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& van Dijk, 2020; Michel et al., 2022). These methods are easy to implement by nursing as part
of their bedside cares.
Decrease PICS-p Complications
Early identification of those at greatest risk for PICS-p can help implement nursing
bundles quickly and work to reduce PICS-p complications. Studies show some of the best ways
to identify those at risk is through effective, standardized screening, early mobility practices,
and adherence with effective bundles in nursing practice (Mejia, 2017).
Through acknowledgement of the ABCDEF bundle, nursing and medical staff can help
reduce PICS-p complications for their patients. The components of the ABCDEF bundle include
assessing, preventing, and managing pain, both spontaneous awakening and breathing trials to
extubate quickly and safely, choice of analgesia and sedation, delirium assessment and
prevention, early mobility and exercise, and family engagement and empowerment (Lin et al.,
2023). Managing these elements can promote healthy transition from intensive care to stepdown unit to discharge and beyond.
Common Themes
From the literature, it is evident that the complications from critical care treatment can
be life altering for both patients and families and persist well beyond the discharge period.
These complications do not account for the complications related directly to their condition.
Following the ABCDEF bundle and focusing on identification, treatment, and reduction of
delirium in patients with CHD, providers and nursing staff can work to reduce the development
of PICS-p and the complications associate with it.
Internal Data

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A free-standing pediatric hospital in the Southwest region of the United States has
separate, dedicated CVICU and cardiology inpatient step-down floors. The CVICU is a 24-bed
unit and cares for all patients with CHD that are admitted for surgical intervention, surgical
complications, or overall worsening condition related to their heart defects. There is also a 24bed step-down unit that cares for less critical patients or those preparing for discharge. The
mission of this facility is patient and family centered, encouraging family participation in cares
and medical decisions. This facility receives patients from multiple states in the Southwest
region and is the only cardiac program in the state, resulting in hundreds of admissions each
year. The level and volume of care the facility provides makes the goal of reducing long-term
complications directly related to inpatient care paramount to its mission and goals.
PICO Question
A review of the literature led to the development of the clinically relevant PICO
question: In pediatric patients that received treatment for congenital heart disease (P), how
does educating nurses on delirium and implementing a nonpharmacological nursing bundle (I)
compared to current practice (C) reduce delirium scores, thereby reducing PICS-p complications
(O)?
Search Strategy
An exhaustive literature search was conducted using the research databases:
Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, and Academic
Search Premier. Because of the very recent recognition of PICS-p within the medical
community, use of Boolean terms within the databases did not increase the number of articles
returned. All three databases provided at least one article that contributed to the development

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of the PICO question. Additional literature searches for pediatric delirium were conducted using
the same three databases.
Keyword Selection
Keywords used across the three databases included: postintensive care syndrome, postintensive care syndrome, PICS-p, PICS, congenital heart defects, delirium, pediatric delirium,
CAPD, CVICU, and PICU. In the literature there were different presentations of the word
postintensive. Some sources presented it as hyphenated; others left it as one word. For the
sake of literature search, both options were entered. As mentioned above, the already limited
field of search results became even more limited when too many of the keywords were used at
once. Limiting the use of the keywords to postintensive care syndrome and pediatrics yielded
the best field of related articles across all three databases.
Initial and Final Search Yields
The search for post-intensive care syndrome AND pediatrics with a year range of 2019 to
present in CINAHL yielded 23 results, ten results in Academic Search Premier, and 78 in
PubMed. Those numbers decreased to a range of zero to 11 across all databases when
additional Boolean search terms were added beyond those listed above. Because of the larger
number of results from PubMed, instead of narrowing search terms, advanced search options
were used to include only studies that were randomized controlled, clinical trial, and metaanalysis. This reduced the results to three articles.
Of the combined total 111, critical appraisal was performed on 18 articles that were
considered primary research, and ten were selected for further review. Of those ten, two were

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randomized control trials, three were cohort studies, two were correlational, and three were
systematic reviews.
Limitations, Inclusion, and Exclusion Criteria
The inclusion criteria concentrated on studies published from 2019 to present. Some
were published from countries outside the United States, and they were included, but those
that did not have English translations were not considered. While the main purpose of the
literature search was to find information on pediatric PICS, there was some widening of the
scope of research to include general adult related PICS to strengthen the evidence since
pediatric literature is limited. Many of the articles returned were not primary research, and
although they provided excellent information for the literature review, they were not
considered in the critical appraisal.
Critical Appraisal and Synthesis of Evidence
The quality and level of evidence was evaluated and determined using rapid critical
appraisal (RCA) tools (Melnyk & Fineout-Overholt, 2019). A combination of both qualitative
(Appendix A, Table A1) and quantitative (Appendix A, Table A2) studies were included in
evaluation and synthesis tables (Appendix A, Table A3) because of the evidence regarding the
impacts of PICS-p on patients and families.
The studies evaluated had a wide range of the number of participants. The total number
of participants ranged from 14 in one study to 183 in another. The demographics varied greatly
from being measured in inpatient units, to outpatient clinics, using adult participants because
of the limited pediatric studies, to those featuring pediatric participants. Some of the studies
were single event studies, where others were conducted over a period of months. One-third of

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them measured the impact on three of the four paradigms of a PICS-p diagnosis, while another
one-third of them measured two of the four paradigms. One measured only one, and two
others did not specify which of the paradigms their study impacted or measured.
Discussion
The impact of inpatient treatment is long-lasting and goes well beyond when a patient is
discharged from the hospital. To improve long-term outcomes, hospitals need to acknowledge
these potential complications and the risk of developing PICS-p in their patients. Providing
nursing staff education on PICS-p and the ways to address it while patients are still admitted
can help reduce the associated long-term complications. It can also help to create nursing
bundles that can be incorporated into their daily cares to prevent PICS-p. Arming them with the
knowledge is the easiest way to reduce long term complications.
Theoretical Framework Application
As mentioned, children with CHD are CVICU patients for a lifetime because of the
complexity and nature of their anatomy and physiology. They will undergo treatment for their
chronic condition indefinitely as there is no cure for CHD, only palliation surgical options. As a
result, the concept framework of the chronic care model (CCM) was chosen because of its
applicability and ability to demonstrate the addition of community services to aid in patient’s
treatment (Appendix B, Figure B1). The initial framework was designed in 1996 and has since
been able to adapt with the changing healthcare landscape. For instance, chronic care
treatment can now include telehealth medicine, and self-care can include wearable diagnostic
technology (Berwick, 2019), both items used in the treatment of patients with CHD. Telehealth
options can increase the likelihood some families will be adherent with follow up

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appointments. The CCM can continue to adapt and apply to chronic care treatment as the
ability to treat chronic conditions improves.
Implementation Framework
The Steven’s Star Model of Knowledge Transformation (Appendix B, Figure B2) is an
evidence-based project (EBP) model often used in healthcare to provide a framework for
systematically developing and putting EBP concepts into practice. There are five steps, or points
of a star, to the Steven’s Star Model: knowledge discovery, evidence synthesis, translation into
practice recommendation, implementation into practice, and evaluation (Stevens, 2013). In
practice, the steps look like discovering primary research articles on a selected topic,
synthesizing all available knowledge into a single statement, like a systematic review,
translating that into action or creating EBP clinical practice guidelines, integrating that into
practice, and evaluating the outcomes the change has on patients and health outcomes. This is
applicable to creating change in navigating and working to have an impact on the prevalence of
PICS-p by knowledge discovery, identifying ways to create change based in EBP, implementing
them, and evaluating the impact they have on current patients as they are preparing for and
discharged from the hospital, as well as future patients undergoing treatment in the CVICU.
Implications for Practice Change
Based on the evidence provided by the critical appraisal and the exhaustive literature
search, an ideal way for hospitals to address PICS-p complications is through staff education on
PICS-p. This education can focus on the ways their daily cares can impact or influence the
development of PICS-p. Picking some of the elements of the ABCDEF bundle and ensuring there
are steps and programs in place to address them can help prevent complications. Creating

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nonpharmacological nursing bundles that can be implemented based on CAPD scores can help
identify and treat delirium. By doing that well, it will help reduce PICS-p development and
complications.
Creating educational resources for nursing can increase the awareness of the signs and
symptoms of PICS-p, to better help recognize when something is a potential complication – like
a change from the patient’s baseline that could be attributed to the treatment course. Proper
education and assessment would allow for recognition of changes to the patient in any of the
four paradigms impacted by PICS-p: psychological, cognitive, physical, and social.
Potential Outcomes
The cost of adding educational resources for staff is minimal to the organization, but the
benefits they could provide are exponential. CHD patients will always be placed in the CVICU
and cardiac step-down unit for any hospital admission. If they come in with issues secondary to
their cardiac anatomy, they will be back in the CVICU. Those repeat or bounce back admissions
can cost the organization. Even more so than that, the cost to families to have to find care and
resources long beyond their hospital admission is something that needs to be considered.
Helping nursing staff understand how they can reduce PICS-p with their daily cares is
easy to implement and will have a substantial impact on patients. This not only benefits the
child greatly by getting resources started early, but it allows for family centered care, which is in
alignment with the organization’s mission and values.
Methods
Based on the findings of the literature search and information gleamed from the
background and significance discovery, it was evident that there is room for improvement in

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the assessment and treating of pediatric delirium in the patient with CHD. Reduction in delirium
occurrence should reduce the incidence of PICS-p and the associated complications.
Project Description
The goal of this DNP project was to improve nursing knowledge of delirium and to
improve overall screening for delirium in CHD patients admitted to the step-down unit as a
steppingstone for prevention of PICS-p. An educational session was offered that provided
nursing staff the opportunity to learn about PICS-p and how their daily care of patients impacts
the development of it, especially as it relates to delirium. Attendees completed a pre and post
survey about their baseline knowledge of PICS-p and delirium prior to the education session,
and after to assess knowledge acquired. After the session was completed and disseminated to
other nursing staff in the CVICU and the cardiology step-down unit, CAPD scores were gathered
from a chart audit process. CAPD scores were tracked for qualified patients and three various
points (baseline, midpoint, and final) were obtained for data analysis. CAPD scoring was used as
an adjunct for knowledge acquisition of the importance of delirium screening and prevention.
Participants and Setting
The goal for the project was to have at least 50 nurses attend the educational session
via in person or through a virtual option. These are nurses that currently work in the CVICU or
on the inpatient cardiology unit. The information was also disseminated to house-wide, critical
care float pool, and PICU nurses for their knowledge as they often float to the cardiology unit
and care for these patients.

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It was projected to have between 25 and 100 patient charts to review that have baseline
CAPD scores to track and analyze. This was dependent on the patient census during the time of
data collection and nurse follow through with completing CAPD scoring.
Ethical Considerations and IRB Approval
Prior to beginning the implementation of the project, institutional review board (IRB)
approval was required from the project site and Arizona State University (ASU). This process
ensured that no patient harm would occur because of the project and that all ethical
considerations are met to ensure subject safety. For this project, it was important that patients
remained deidentified to protect their private health information, and only information
deemed necessary for the data analysis was collected. The project was deemed a quality
initiative and approved by both college and project site.
Instrument
The CAPD screening tool is a valid and reliable observational tool for screening delirium
in the ICU and other inpatient units (Traube et al., 2014). The overall sensitivity of the CAPD is
94.1% with a specificity of 79.2%, indicating good internal consistency. The questions on the
screening can be done and answered rapidly, allowing for quick identification of patients at risk
for delirium (Traube et al., 2014).
There are eight questions on the CAPD, and they use a Likert scale for answers
(Appendix C). The components assessed include: the child making eye contact with the
caregiver, their actions being purposeful, the child being aware of their surroundings, do they
communicate their wants and needs, are they restless, are they inconsolable, are they
underactive while awake, and does it take a long time for them to respond to interactions? A

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score of nine or greater indicates a positive screening for delirium. It is important to note that if
a patient is highly sedated or receiving neuromuscular blockade, they cannot be accurately
screened with the CAPD tool.
Data Collection
Data was collected via chart audits using an IRB approved chart audit form. This form
accounted for independent patient identification numbers, plus tracking of their CAPD scores
over time. The data collection tool allowed for the documentation of delirium treatment
medications including scheduled or any as needed (PRN) medications. The data was collected
on a secure, hospital network with a hospital issued computer that has encryption software for
patient information safety.
Data Analysis Plan
At the end of the implementation phase, data was collected and analyzed. The pre and
post nursing surveys were linked by randomly assigned identification numbers. The patients will
also have their own identification number so that all private health information is deidentified.
Pre and post surveys were compared for knowledge acquisition. The CAPD scores were tracked
and measured over the course of data collection.
Budget
Most of the budget (Appendix D) accounted for the educational hours of the nurses
attending the educational session. There was a small cost associated with printed materials for
the pre and post surveys for those attending in person. The most important line item in the
budget was the cost savings to the healthcare system with reduced development or worsening
of delirium for the patient with CHD. By reducing the development of PICS-p and the

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complications associated with it, a significant amount of money in reduced hospital stays,
reduced readmission rates, and reduced need for services once discharged can occur for the
hospital and the patients. No funding was received for the project.
Results
Data for this project was collected and analyzed in the Intellectus Statistics TM software.
Demographic data, baseline, midpoint, and final CAPD scores were run through descriptive
statistics. Of the qualified patients, 11 had trackable CAPD scores. 45% were male (n=5), 55%
were female (n=6). 81% were under 2 years old (n=9).
The CAPD scores were run through an ANOVA test. A Friedman test was run as
supplemental analysis after one or more of the assumptions in the ANOVA test were violated.
The Friedman test examined whether the medians of the three selected points of CAPD scores
were equal. The results were significant based on the chi square equation, χ2(2) = 9.33,
indicating significant differences between the median values. This showed a significant
response in CAPD scores decreasing once nurses received education on CAPD and delirium. The
median baseline CAPD score was 10.91, for midpoint CAPD the median was 7.55, and for the
final CAPD the median score was 4.36.
Impact of the Project & Sustainability
The constant reminder to nurses to complete their CAPD scoring helped increase the
number of patients that received delirium scoring. This also led to nursing awareness of how
their cares impacted the development of delirium and resulted in increased delirium scoring.
Better capturing delirium early allows for better treatment and prevention of worsening
conditions for a prolonged period, and the potential development of PICS-p. Increasing the

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conversation around delirium in pediatric patients has improved the scoring and nursing
knowledge.
Continuing that education is the crux of the sustainability of this project. All current
nurses have received and been made aware of the PICS-p and delirium education. From this
point out, the education should be included in new hire classes for the CVICU and the
cardiology step-down unit. New hire nurses received trainings in a systems-based manner, and
the education on PICS-p and delirium would fit appropriately into the neurology course they
receive, ensuring all nurses on both units are well educated and exposed to proper delirium
scoring.
Discussion
Despite the recognition of delirium in pediatrics being relatively new, there is evidence
to support that it is a significant problem in intensive care units and inpatient units. For delirium
to be addressed, it must be properly identified and screened for. Implementing and ensuring
proper education on delirium is the first step in helping with prevention. It is easy in the
pediatric population to misidentify delirium because other conditions, like drug withdrawal,
pain, or general baby fussiness can make delirium identification challenging. Knowing the
anchor points and components of the CAPD screening tool ensures that the provider or bedside
nurse can differentiate between conditions.
Limitations and Barriers Encountered
Despite strong evidence in CAPD score reduction, there was limited nurse participation
in the educational sessions, resulting in a limited data set for pre and post surveys. Additionally,
it was exceedingly difficult to get nurses to initiate the CAPD scoring for all qualified patients,

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especially on the cardiology unit verses the CVICU. This difficulty was met with multiple email
reminders and in person follow up, but the struggles for buy-in continued.
Another barrier was the nature of patients treated in the CVICU and on the cardiology
unit. They often have clinical changes resulting in frequent transfers between the CVICU and
the step-down unit. These transfers often result in escalation of treatment resulting in exposure
to delirium provoking management, thus increasing their risk for delirium development.
Tracking the CAPD scores of these patients could be impacted by the transfers and their scoring
could be altered by the treatments they received.
Recommendations for Further Study
Continuing to track and monitor CAPD scores for patients is going to help ensure that
the units are doing what they can do reduce the development of PICS-p through addressing
delirium. Because delirium is a significant problem even in pediatric patients, it is good practice
to consistently screen and track these scores. Surveying nurses should be extended to the
residency courses new hires take to continue ensuring adequate exposure to this information.
Conclusion
PICS-p is a potentially serious, life-long collection of complications secondary to
treatment in the CVICU and inpatient unit. While many of these treatments are necessary for
survival in a critical time, there are ways to mitugate them and potentially reduce the risk of
developing PICS-p. By educating bedside nurses about PICS-p and the complications associated
with it, interventions can be put into place. One such way is bringing awareness to delirium in
the pediatric patient and how simple measures can be implemented to reduce it. Patients with
CHD will always require care and treatment in the intensive care unit at this institution, so

POSTINTENSIVE CARE SYNDROME PEDIATRICS
finding ways to reduce complications will ensure they have the best possible outcome once
they are discharged from the hospital.

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PEDIATRIC POST INTENSIVE CARE SYNDROME

27
Appendix A
Evaluation and Synthesis Tables

Table A1
Evaluation Table for Qualitative Studies
Citation

Theoretical/
Conceptual

Design/ Method/
Purpose

Sample/Setting

Country: USA
Funding: Costs
were covered by
the hospital the
study was
conducted at: St.
Louis Children’s
Hospital

PRISM

Measurement/
Instrumentation

Data Analysis

Results/ Findings

Level of Evidence;
Application to
practice;
Generalization

RQ1: How familiar
are parents with
PICS-p?

Data Collection:
1: Demographic
questionnaire

Qualitative
analysis

Level of Evidence:
Level I

RQ2: Can parents
appropriately
identify signs and
symptoms of PICSp?

2: Pre and post
intervention tests

RQ1:
Brochure: 77% had
never heard of
PICS-p
Conversation: 55%
had never heard of
PICS-p
Video: 70% had
never heard of it
PICS-p

Themes/Studies

Framework
Esses, S. A. et al.
(2019). Postintensive care
syndrome:
Educational
interventions for
parents of
hospitalized
children

Major

Definitions
Design: SR, RCT
Purpose: To
establish the ideal
method of
education for
parents of
hospitalized
children in the
PICU on signs and
symptoms of
post-intensive
care syndrome:
pediatrics.

n= 62 total
caregivers
Brochures: 22
Conversation:
20
Video: 20
Demographics:
Demographic
questionnaire
including:
relationship to
patient, sex, age,
marital status,
education level,
type of
insurance,
employment
status, proximity
to hospital, and
previous trauma

RQ3: What is the
ideal educational
method for
teaching parents
about PICS-p?
RQ4: How does
educating parents
impact the
day/role of the
nurse?

3. Nursing survey

Evaluation
using the
PRISM
framework

RQ2:
Brochure: 77% pre
had no idea the
s/s; post 73% very
familiar with s/s
Conversation: 65%
pre had no idea
the s/s; post 45%
very familiar with
s/s

Strengths: Well
designed, included
nursing, strong
qualitative design
Weakness: Small
sample size, limited
to PICU, excluded
patients old enough
to comprehend
Feasibility: Easily
replicable at other
hospitals/units, easy
to expand sample
size
Application:
Identified ideal

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
Bias: Potential
bias because all
authors are
employees at
the hospital
where it was
conducted.

28

Setting: the
PICU at St. Louis
Children’s
Hospital in St.
Louis, MO

Video: 75% pre
had no idea the
s/s; post 55% very
familiar with s/s
RQ3: The brochure
educational
strategy has the
greatest likelihood
of successful and
sustainable
implementation.

Exclusion:
Parents < 18
years old, nonEnglish speaking,
PICU admissions
< 24h
Attrition: 0%

Annamalai, M. R.
(2022). Postintensive care
syndrome in a
heterogenous
pediatric
population.
Country:
USA
Funding:

Item response
theory

Design:
Retrospective
cohort review
Purpose:
Measure the
incidence of PICSp among children
who received
critical care
treatment and
evaluate patient
characteristics

n = 183
Demographics:
Age, PICU
admission time,
survived
hospitalization
Setting:
The PICU at The
Children’s
Hospital of San
Antonio

RQ1:
What was the
preadmission FSS
score?
RQ2:
What was the
discharge FSS?

Tools:
FSS scores
Validity/
Reliability:
FSS is valid and
reliable, but a
limitation in this
study. It does not
account for 2 of 4
domains in the
PICS-p paradigm.

Linear
regression
was used to
analyze the
relationship
between
change in FSS
and
independent
factors.
Both one and
two tailed t-

RQ4: Nursing
survey showed
workflow was
minimally
disrupted during
PICS-p education
and all 3 methods
were viewed as
important and
useful.
1 in 5 children
treated in the PICU
develop PICS-p.
Lower
preadmission FSS
scores, increased
number of
procedural
interventions,
increased LOS,
fewer ventilation
free days were all

educational method
for parents and
impact on nursing
who will be at the
bedside after
researchers leave
and might be fielding
questions:

Level of Evidence:
Level IV
Strengths:
Easy to duplicate or
complete at other
centers. Utilizing the
FSS is using a
validated tool.
Weakness:
Using only FSS leaves
out 2 of the domains
of PICS-p which

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
The Children’s
Hospital of San
Antonio, Baylor
College of
Medicine

and critical care
interventions
associated with
the development
of PICS-p

Bias:
None

Rohr, M. (2021).
Piloting an ICU
follow-up clinic
to improve
health-related
quality of life in
ICU survivors
after a
prolonged
intensive care
stay (PINA):
Study protocol

29

Exclusion:
Patients in PICU
for < 4 days,
over the age of
18 years, did not
survive
hospitalization.

tests and
Wilcoxon
rank-sum
tests were
used.

Design:
MM, RCT pilot
Purpose:
The concept for
an ICU follow-up
clinic was
developed and
will be tested in a
pilot randomized
controlled trial, to
evaluate the
feasibility and

n = 100
Intervention
Arm = 50
Control Arm = 50
Demographics:
>18 years old,
ICU duration
more than 5
days, SOFA score
> 5, expected
survival time

RQ1:
Is a post-ICU
specialty clinic
beneficial in
identifying/treating
PICS?
RQ2:
How does the
follow up clinic
improve patient
health?

Tools:
Standardized
questionnaires:
Mini-Cog, PHQ-8,
GAD-7, PTSS-10.
Validity/
Reliability:
The
questionnaires
are frequently
used and valid.

Group
allocation will
be masked.
The
treatment
effect to be
assessed
using analysis
of covariance
according to
the intention-

could alter results
significantly. Small
sample size.
Feasibility:
Easily replicated, low
cost due to
retrospective chart
reviews.

Fisher’s exact
test was
used.

Attrition:
0%

Benner’s
novice to
expert theory

associated with
PICS-p.

A post-ICU
specialty clinic
works to improve
the quality of life
and management
of PICS symptoms
by getting patients
to specialists that
can help with
complications.

Level of Evidence:
Level II
Strengths:
The participatory
nature of the
program.
Weakness:
The follow up period
too short, and the
effects of the
intervention might

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
for a pilot
randomized
controlled trial.

additionally the
potential efficacy.

Funding:
Innovation Fund
of the Federal
Joint Committee

to-treat
principle.

appear only after the
follow-up prior of 6
months.
Feasibility:
Feasible in many
instances.

Exclusion:
< 18yo, not
expected to
survive 6
months, unable
to complete
questionnaires,
or have
insufficient
German
language skills.

Bias:
None

Country:
London, UK

greater than 6
months
Setting:
University of
Regensburg,
Germany

Country:
Germany

Atkins, E. K.
(2020). Families’
experiences of
life in the year
after a child’s
critical illness:
Navigating the
road to a “new
normal”.

30

Grounded
theory

Design: Add on
interviews
following a
qualitative study
Purpose: Wanted
to add to the
literature on the
psychological
impact on
families of a PICU
admission.

Attrition:
0%
n = 18 families
n = 9 children
Demographics:
White British,
Asian British.
Setting: The
interviews were
conducted in the
homes of the
participants,
with one or both

Theme 1: Just
getting through.
Families reflected
on feeling they
didn’t have space
or time to think
about or
understand what
they were going
through and were
just trying to
survive.

Tools: The
interview
questions were
created based on
literature and
clinical
experience of the
researchers.
Validity: There’s
no official validity
of the questions
they created on
their own.

Grounded
theory, a
rigorous
qualitative
methodology.

Main points to
consider: 1)
psychosocial
adaptation usually
beings after the
child has largely
recovered
physically. 2) value
exists in
communicating
with each other to
put their story and
experiences
together. 3) with

Level of Evidence:
Level V
Strengths: Insight
from both parents
and patients.
Weakness:
Underrepresentation
of minorities.
Families of younger
children, less than 5,
were not included.

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
Funding: Not
included

parents and the
child present.

Bias:
None

Inclusion: PICU
stay of more
than 24 hours,
child aged 5 to
16 years,
admission in the
previous 8 to 18,
and biological
parent available
to take part.
Exclusion: Those
admitted for
nonaccidental
trauma or
palliative care.
Attrition:
18/39 = 46%

Hauschildt, K. E.
(2022). Hospital
discharge
summaries are
insufficient
following ICU
stays: A
qualitative study
Country: USA

Attribution
theory

Design: Semi
structured
interviews with
PCPs
Purpose: To
understand and
identify what
other information
PCPs would
benefit from

n = 14
Demographics:
11 board
certified internal
medicine MDs
and 3 board
certified family
medicine MDs (2
with additional
certifications in

31
Theme 2: A
changed person.
Several parents
reported becoming
more protective of
their child post
PICU discharge.
The patients
reported feeling
their identity of
themselves had
shifted as well.
Theme 3: Striving
for normality.
Most families
assumed life would
return to normal
after discharge,
but many found
that their normal
had shifted based
on the condition
their child was
discharged in.
Theme 1: ICU
course of
hospitalization is
often missing from
discharge summary
template.
Theme 2:
Discharge

Tools: RADaR
(rigorous and
accelerated data
reduction)
Validity: RADar is
a valid tool used
by creating tables
and
spreadsheets.

time and
resources, most
will make a good
recovery and
move on but 4)
this journey may
take longer than
they expect. And
finally, 5) concepts
of the “old
normal” and the
”new normal”
early on may be
helpful to families.

Feasibility:
Is feasible in any
location and can be
easily replicated to
further the field of
knowledge.

It is important to
increase the
information about
PICS for effective
follow up by
outpatient
providers, as these
are the ones that
will see and care
for the patient
after discharge.

Level of Evidence:
Level VI
Strengths: It extends
previous research
showing vital
information is often
missing.
Weakness: It was a
single system study,

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
Funding:
Dr. Iwashyna
provided
funding for
transcriptions.

receiving post ICU
discharge.

Bias:
None

pediatrics).
Women = 12,
men = 2. White
= 8, African
American,
Middle Eastern,
Asian = 6.

32
summary is too
wordy/too vague.

focusing on the
physicians’
experiences with
patients discharged
from academic
hospitals.
Feasibility:
Recreation of this
study would be easy
to accomplish across
the US.

Setting: Clinics
across Southeast
Michigan,
connected to a
hospital wide
health system.
Exclusion:
Recruitment was
done via email
and after 14
interviews they
had achieved
response
saturation.

Hampton S. F.
(2022).
Interprofessional
education
module on postintensive care
syndrome for
internal
medicine
residents.

Conditions of
Learning

Design: Singlesite pilot
education
program
Purpose: To
improve internal
medicine
residents’
knowledge of
interprofessional

Attrition: 0%
n = 65
Demographics:
Internal
medicine
residents that
work in ICUs
with physical,
occupational,
speech
therapists

Precourse
Knowledge: 15%
got 1 question
correct on
preassessment,
32% got 2 correct,
35% got 3 correct,
18% got 4 correct,
0 got all 5
questions correct.
77% of

Tools: A 5 point
Likert scale exam
was provided
precourse to
determine the
knowledge base.
5 question quiz
about the
fundamentals of
and treating PICS.
Postcourse

Objective
knowledge
gain was
measured
using a
paired onetailed t-test
analysis of
pre and
postcourse
assessment

Providing short,
direct educational
sessions to
residents
improved their
knowledge and
understanding of
treating PICS, as
well as how to do
it as a
interprofessional

Level of Evidence:
Level IV
Strength: Using
virtual platforms and
videos provide high
yield and interactive
experiences to a
large audience, and
may be reproducible
with minimal effort.

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
Country: USA
Funding:
University of
Washington

roles in the ICU
and their
confidence in
managing PICS

Bias:
Potential
selection bias
was possible due
to being rolled
out at a single
institution.

Setting: ICU in
Washington
Exclusion:
Attrition: 52%
completed both
pre and
postcourse
assessments

33
respondents rated
themselves as
either not very or
not at all confident
in PICS knowledge.
Postcourse
Knowledge: 9% got
2 correct, 18% got
3 correct, 41% got
4 correct, and 32%
got all 5 correct.
94% rated
themselves as
somewhat or very
confident after the
course.

exams were also
given.
Validity: Likert
scale
questionnaires
are excellent
methods of
information
gathering and
knowledge base
rating.

scores. A
McNemar
statistical test
was
performed to
see if their
confidence
significantly
changed. A P
value <0.05
was
considered
significant,
and P <0.001.

collaborative
team.

Weakness: There
was only a 50%
response rate in
evaluations and that
restricted
generalizability and
making results prone
to selection bias.
Feasibility: This is
easily feasible at
many centers. Doing
it with virtual
education modules
allows for a wide
casting of
participants.

Table A2
Evaluation Table for Quantitative Studies

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME

Citation

Theoretical/
Conceptual

Design/ Method/
Purpose

Sample/Setting

Design:
Analytical
observational
prospective cohort
study

n = 45

34

Variables

Measurement/
Instrumentation

Data

Tools:
1. TISS tool
2. FSS tool
3. PedsQL tool
4. DASS tool
5. Family interviews

Normality
tested with
Shapiro-Wilk
test.

Analysis

Results/
Findings

Level of Evidence;
Application to
practice;
Generalization

DV1:
Significant
difference (p
< 0.001) in
children’s
functional
status before
and 3 mos
after ICU.

Level of Evidence:
Level IV

Framework
Yuliarto, S.
(2022). The risk
factors of the
functional
status, quality
of life, and
family
psychological
status in
children with
postintensive
care syndrome:
A cohort study.
Country:
Indonesia
Funding:
Nil
Bias:
None

Assessing
quality of life
for patients
and families
after
treatment in
the PICU

Purpose:
Assess the
functional status
and QOL for
pediatric patients
admitted to the
PICU > 24h at
baseline and 3month post
discharge intervals

Demographics:
Gender, age, family
composition,
socioeconomic
status,
Setting:
The PICU at Saiful
Anwar General
Hospital; PICU
patients 1 month to
18 years old,
admitted for > 24h
Exclusion:
< 1 mo old, > 18 yrs,
admitted for < 24
hours to the PICU
Attrition:
0%

IV1: Admission
and time in the
PICU
DV1:
Functional
status
DV2: Quality of
life
DV3: Family
Depression,
Anxiety, and
Stress score
Definitions:
FSS shows the
condition of 4
domains:
cognition,
psychiatric,
social, physical.

Validity/
Reliability:
TISS: Found to be
valid and reliable for
clinical studies
FSS: Highly valid and
reliable for clinical
trials and studies
PedsQL: Excellent
validity and
reliability; can be
used in clinical trials.
DASS: found to have
good internal
validity and
reliability.

Homogeneity
by Levene’s
test
Comparison
of pre-and 3month post:
dependent ttest
Bivariate
association
tested by
MannWhitney,
KruskallWallis test,
or
Spearman’s
correlation
test

DV2:
Significant
difference (p
<0.001) in
children’s QoL
before and 3
mos after ICU.
DV3: Majority
of the families
developed
depression,
anxiety, and
stress during
and shortly
after the ICU
admission.

Strengths: Close
follow up of families,
with broad range of
testing/score
assessments.
Weakness: Very small
sample group, single
center study,
homogenous
demographics
Feasibility:
Easily replicated, low
cost
Conclusion:
Occurrence of PICS
can decrease
functional status of
patients and impact
their QoL.

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME

Jennings, M. L.
(2021). Effect
of animal
assisted
interactions on
activity and
stress response
in children in
acute care
settings.
Country:
USA
Funding:
The Louis
Family
Foundation,
Arizona
Cardinal
Charities, and
PetSmart
Charities
Bias:
Dr. Granger is
the founder
and president
of Salimetrics,
the company
that conducted
the testing

Design:
RCT
Purpose:
Determine the
effects of AAI on
activity and stress
response.

35

AAI Group: n = 44
Wait list control:
n = 36

IV: AAI

Demographics:
Gender, age,
ethnicity, had a pet
in the house

DV2: Activity
level

Setting:
The PICU, CVICU,
and hematology
oncology units at a
tertiary children’s
hospital in Arizona
Exclusion:
Patients taking
glucocorticoids,
catecholamines,
alpha- or betaadrenergic blockers,
and anticholinergic
agents, isolation
precautions,
mechanical
ventilation,
sedation, medical
complications,
fear/allergy to dogs,
mouth or
swallowing issues,
scheduling conflicts
with procedures,

DV1: Cortisol
reactivity

DV3: Mood

Tools:
1. Cortisol testing
prior to AAI visit and
again at 5, 20, and
60 min after end of
visit
2. Lansky play
performance/activity
tool at baseline and
1- and 3-hours post
visit
3. Modified WongBaker faces scale to
measure mood
Validity/
Reliability:
Lansky play
performance is a
valid and reliable
play performance
activity measure for
kids.
The Wong-Baker
faces scale for mood
rates the mood from
“best feeling” to
“worst feeling.”

A power
analysis was
conducted
based on
repeated
measure
ANOVA
design. They
used a two
tailed test for
detecting
intervention
effects.
Linear
regression
was used to
examine if
AAI group
predicted
children’s
activity level.

DV1:
The control
group had
higher levels
of cortisol
with respect
to time,
where
children in
the AAI group
showed a
decrease in
cortisol levels
with respect
to time.
DV2:
AAI group
differed
significantly in
change in
activity level.
Activity levels
were higher
for children in
the AAI group
than children
who did not
receive the
visit.
DV3:
Significant
interaction

Level of Evidence:
Level I
Strengths:
Easy to replicate at
other centers, easy to
increase the
population group size
for further testing.
Weakness:
Medical team
interruptions which
could have impacted
the children’s
mood/attitude/activity
levels. It could have
also impacted the
dog’s reactions during
AAI. Due to the time
component it was
hard to be completely
blind as participants
could figure out which
group they were in.
Feasibility:
Easily replicated, low
cost
Conclusion:
There are short term
benefits of AAI for
children in critical

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME

36

cognitive/behavioral
issues.
Attrition:
0%

Martillo, M.
(2021).
Postintensive
care syndrome
in survivors of
critical illness
related to
Coronavirus
disease 2019:
Cohort study
from a New
York City
critical care
recovery clinic.
Country: USA
Funding:
Friedman Brain
Institute and
Bee
Foundation,
Neurocritical
Care Society
Incline Grant
Bias:

Theory of
Interpersonal
Relations

Design: Singlecenter descriptive
cohort study
Purpose:
Determine the
characteristics of
postintensive care
syndrome in the
cognitive, physical,
and psychiatric
domains in COVID19 ICU survivors.

n = 45
Demographics:
median age 54
years, 73% male,
91% met criteria for
PICS diagnosis.
Setting: Critical care
recovery clinic at
The Mount Sinai
Hospital in New
York City
Exclusions:
Participants who did
not complete the
self-report portion
of the follow up
were excluded
Attrition: 121
patients met
criteria; 72 were not
seen in clinic; 28
couldn’t be
reached; 13 were in

IV: Admission
to ICU
DV1: Physical
domain
DV2: Cognitive
domain
DV3:
Psychiatric
domain

Tools:
Telephone Montreal
Cognitive
Assessment, EQ-5D3L for mobility,
pain/discomfort,
self-care, usual
activities,
anxiety/depression,
Modified Rankin
Scale, Dalhousie
Clinical Frailty Scale,
Neuro-QoL upper
and lower function,
Patient-Reported
Outcome
Measurement
Information System
Fatigue Item Bank,
PHQ, PTSS Checklist,
Insomnia Severity
Index
Validity: All of the
tools used are valid
and used frequently
in research. They are

Study data
were
exported to
REDCap,
(research
electronic
data
capture).
Descriptive
statistics
were
calculated.

between
mood and
group,
indicating the
children in
the AAI group
showed a
more positive
mood.
DV1: 86.7% of
participants
reported at
least one
physical
impairment.
30 patients
had
difficulties in
mobility. 16
reported
problems
with self-care
and 30
reported
problems
with usual
activities.
DV2: Of the
45 patients
only 30
received a
cognitive
screening due
to staff
shortages

care. Repeated AAI
visits may reduce
children’s stress and
increase activity, and
perhaps mobility, in
critical care settings.

Level of Evidence:
Level VI
Feasibility: This study
is feasible to be
recreated in any ICU
setting.
Conclusion: 90% of
ICU survivors reported
symptoms affecting at
least one PICS domain.
The findings highlight
the importance of
planning for
appropriate post-ICU
care for patients who
survive critical illness.
The high prevalence of
PICS suggests a need
for rehab
interventions and
long-term monitoring.

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
None

Sidiras, G.
(2019). Long
term follow-up
of quality of life
and functional
ability in
patients with
ICU acquired
weakness – A
post hoc
analysis.
Country:
Athens, Greece
Funding:
Special Account
for Research
Grants
Bias:
None

37

subacute rehabs; 11
in long-term care; 9
had expired. 49
total were seen in
clinic, and 45 were
included in the
study. All 45
completed.

Nursing Need
Theory

Design:
Prospective cohort
study
Purpose: To assess
the QOL and
functional ability of
patients with
ICUaW 6 months
post hospital
discharge.

n = 128 (assessed at
ICU discharge)
Demographics:
patients ventilated
> 72 hours, able to
answer/follow at
least 3
predetermined
commands.
Setting: Mixed
medical-surgical 24
bed intensive care
unit
Exclusions: < 18 and
> 85 years old,
pregnancy, obesity,
preexisting
neuromuscular
diseases, technical
restrictions
regarding NMES

Intervention
Group:
Received
individualized
rehabilitation
regimen and
NMES daily
until hospital
discharge
Control Group:
Received sham
NMES along
with usual care
until hospital
discharge

appropriate for this
study and the goals.

during the
pandemic.

Reliability: They are
all reliable and valid
to be used in
research. They help
obtain the
information required
for the study.

DV3: 48.9% of
patients
presented
with
psychiatric
impairment,
depression,
followed by
insomnia.
Patients with
ICUaW had
significantly
worse QOL
and
functional
ability at all
time points.
They showed
significant
improvement
at the 6
month follow
up, despite
still remaining
compromised.

Tools: Handgrip
dynamometry,
Functional
Independence
Measure, SF-36
questionnaire,
Nottingham Health
Profile
Validity: All of the
tools used are valid.
Reliability: All of the
tools used are
reliable and a good
way to measure the
intended outcomes
of the study.

Normality of
distribution
was checked
by ShapiroWilk test.
MannWhitney U
test was
employed for
betweengroup
comparisons.
Assessments
repeated > 2
different
times
analyzed by
ANOVA.

Level of Evidence:
Level IV
Feasibility: Feasible
for recreation and
implementation.
However, being
observational doesn’t
allow for
randomization.
Conclusion: ICUaW is
associated with
persistent deficiencies
in functional ability
and QOL, leading to a
prolonged period of
recovery. Although
global muscle strength
improves, functional
recovery takes time.

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME

38

implementation
(burns), terminal
disease, pacemaker
and trauma to the
spine
Attrition: 112
patients assessed at
hospital discharge,
83 at the 3-month
post discharge
mark, and 62 at the
6 month mark. 45%
lost to follow up
through the entity.

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME

39

Table A3
Synthesis Table
Study Author
Year
Design/LOE

Annamalai,
M. R.
2022
Cohort Study
IV

Atkins, E. K.

Esses, S. A.

2020
SR Qualitative
V

2019
SR/RCT
I

183

18
X

Hamptom, S.
F.
2022
Cohort Study
IV

Hauschildt, K.
E.
2022
Qualitative
VI

Jennings, M. L

Martillo, M.

Rohr, M.

Sidiras, G.

Yuliarto, S.

2021
RCT
I

2021
Qualitative
VI

2021
MM/RCT
II

2019
Cohort Study
IV

2022
Obs. Cohort
IV

65

14

80

45

100

128
X

45
X

Demographics
n subjects
ICU admission > 24h
ICU admission > 72h
ICU admission minimum 4
days
ICU admission minimum 7
days
Did not indicate
Setting
PICU/CVICU
Adult ICU
Outpatient Care
Tools
Parent/Family/Healthcare
Education
DASS
FSS
GAD-7
PHQ
PTSS
SF
SOFA
TISS

62
X

X

X
X
X

X

X

X

X
X

X
X

X
X
X

X

X

X
X

X

X
X
X

X
X
X

X
X
X
X
X
X

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POST INTENSIVE CARE SYNDROME
Study Author
Year
QOL
Outcomes/ Themes
PICS diagnosis
Impact on cognitive
domain
Impact on physical
domain
Impact on psychiatric
domain
Impact on social domain

Annamalai,
M. R.
2022

40

Atkins, E. K.

Esses, S. A.

2020

2019

Hamptom, S.
F.
2022

Hauschildt, K.
E.
2022

Jennings, M. L

Martillo, M.

Rohr, M.

Sidiras, G.

Yuliarto, S.

2021

2021

2021

2019

2022

X
X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

≠

X

X

X

X

X
X
X

X

X

≠

KEY: AAI Animal Assisted Interaction, CVICU Cardiovascular Intensive Care Unit, DASS Depression, Anxiety, & Stress Score, FSS Functional Status Score, GAD-7 General Anxiety Disorder, ICUaW Intensive
Care Unit Acquired Weakness LOS Length of Stay, MM Mixed Methods PHQ-8 Patient Health Questionnaire, PICS-p Post-intensive Care Syndrome-pediatrics, PICU Pediatric Intensive Care Unit, PRISM
Practical, Robust Implementation and Sustainability Model, PTSS-10 Post Traumatic Stress Syndrome, QOL Quality of Life, RCT Randomized Control Trial RQ Research Question, SF-36 Short Form SOFA
Sequential Organ Failure Assessment, SR Systematic Review TISS Theoretic Intervention Scoring System

PEDIATRIC POSTINTENSIVE CARE SYNDROME
Appendix B
Models and Frameworks
Figure B1
Chronic Care Model

(Institute for Healthcare Improvement [IHI], n.d.; Turner, 2018)

41

PEDIATRIC POSTINTENSIVE CARE SYNDROME

42

Figure B2
Steven’s Star Model of Knowledge Transformation

Used with permission.

(Stevens, 2013)

PEDIATRIC POSTINTENSIVE CARE SYNDROME

43

Appendix C
CAPD Screening Tool

Copyright Silver, G. (2012).
Written permission for reprint requested.

(Traube et al., 2014)

PEDIATRIC POSTINTENSIVE CARE SYNDROME

44

Appendix D
Phase

Activities

Preparation

Design, print, and post promotional
materials on unit (colored copies, 10
each)
Have IT add method for tracking
CAPD scores in SCM
Design and print evaluation tools and
handouts (50 of each)
Meetings with Site Champion Mandy
Richardson (1hr @ $50 avg x 5 mtgs)
Meeting with CLNA re: delirium
education (1hr @ $40 avg x 1 mtg)
Meetings with Project Mentor Aimee
Bucci (1hr @ $45 avg x 6 mtgs)
Meetings with Dr. Glover (ASU
statistician) (1hr @ $50 avg x2 mtgs)
Rented meeting space – utilize unit
conference room
Staff salary education hours (1hr @
$30 avg x 50 nurses)
Medical provider salary for
educational hours (1hr @ $60 avg x 10
providers)
Light refreshments and supplies for
educational session
Email reminder to complete
postsurvey if not done in person
Student hours for data analysis ($0/hr)

Delivery

Evaluation

Future hours for data analysis
($25/hr x 10h/wk)
Intellectus software – already
accessible to student
Cost Savings Reduced hospitalization due to early
delirium recognition and treatment

Cost

subtotal

Total

$5
$200
$10
$250
$40
$270
$100

$875

$0
$1,500
$600
$50

$2,150

$0
$0
$250
$0
$9,000 $75,000

$250/wk

$3,275