The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R2): Pilot Testing in a Two-Phase Cohort Study, 2017–2021

Abstract

Objectives: Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R2). 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: R2 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 R2 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 R2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.