State Behavioral Scale: A Sedation Assessment Instrument
State Behavioral Scale: A Sedation Assessment Instrument
Objective: To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation.
Design: In this prospective, psychometric evaluation, pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale (NRS) of 0 (extremely sedated) to 10 (extremely agitated). The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive, response to ventilation, coughing, best response to stimulation, attentiveness to careprovider, tolerance to care, consolability, and movement after consoled, each with 3-5 levels.
Setting: An 18-bed pediatric medical-surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children's hospital.
Patients: A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations (interquartile range, 1-3) for a total of 198 sets of observations. Excluded were postoperative patients or those receiving neuromuscular blockade.
Interventions: Patients were observed for 1 min, and then incremental levels of stimulation were applied until patient response. After 2 mins of consoling, the state behavioral assessment and NRS were completed.
Measurements: Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings. Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage. Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance.
Main Results: Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76, indicating moderate to good interrater reliability. The intraclass coefficient of .79 was high for NRS ratings. Cluster analysis revealed five distinct state profiles, with mean NRS ratings of 1.1, 2.5, 4.0, 5.3, and 7.6, all of which differed significantly from each other (F = 75.8, p < .001), supporting the profiles' construct validity.
Conclusions: Based on empirically derived state behavior profiles, we have constructed the State Behavioral Scale to allow systematic description of the sedation-agitation continuum in young pediatric patients supported on mechanical ventilation. Further studies including prospective validation and describing the effect of State Behavioral Scale implementation on clinical outcomes, including the quality of sedation and length of mechanical ventilation, are warranted.
Ensuring the comfort of critically ill infants and children is integral to the practice of pediatric critical care. Humane pediatric intensive care often includes the administration of sedatives after pain, physiologic imbalance, and environmental stressors have been addressed. More than 90% of infants and children supported on mechanical ventilation receive some form of sedative therapy. Sedation in this patient population is required for anxiolysis, amnesia, facilitation of care, patient safety in avoidance of adverse events, and for decreasing oxygen consumption. For most young patients supported on mechanical ventilation, the goal of sedation is to attain a calm but responsive state that protects the young patient from self-harm. Inadequate sedation is associated with potentially dangerous complications such as unplanned endotracheal extubation. High-dose, long-term, and continuous intravenous sedation has been associated with prolonged weaning from mechanical ventilation and withdrawal syndrome. Therefore, insufficient or excessive sedation is likely to add to the personal and financial burden of intensive care.
Variability complicates the use of sedation in the pediatric intensive care unit (ICU) setting. First, a patient's sedative needs vary depending on the nature and course of the illness, drug interaction with concomitant therapies, and response to therapy. Some patients require deep sedation to tolerate synchronous modes of mechanical ventilation, whereas others seem to be comfortable with light sedation, even when supported on unconventional modes of ventilatory support. Next, from a systems perspective, multidisciplinary staff with varying levels of expertise change several times over the working day. This means that patients are exposed to multiple subjective assessments of their sedation requirements, by several staff members, which may result in patients receiving varying dosages of sedation, depending on who performed the assessment.
Valid and reliable tools that standardize the description of a pediatric patient's behavioral state while supported on mechanical ventilation would enhance systematic assessment and documentation of a patient's response to sedation, allow patient-specific alterations in the therapeutic regimen, and help avoid insufficient or excessive sedative use. Such an assessment tool would enhance interdisciplinary agreement on the desired level of sedation, provide a foundation for the development of guidelines that would decrease unnecessary variation in the care and permit objective study of the pharmacodynamics of sedative agents in the pediatric population. From a research perspective, Kollef et al. suggest that sedation practices should be standardized in any investigation employing the duration of mechanical ventilation as an outcome variable.
Although desirable, tools assessing the sedation-agitation continuum in the pediatric patient have not been adequately tested or have conceptual flaws. Specifically, the psychometrics of the Ramsay scale an often-cited sedation scale used in the adult population, has never been evaluated in an ICU setting. In addition, Ramsay's six levels of sedation are neither mutually exclusive nor clearly defined. The COMFORT scale, the most commonly used tool in the pediatric population was designed to assess distress in ventilated children, but distress was operationalized to include the constructs of both pain and agitation. Noting that the eight dimensions of the COMFORT scale are often included in other pain instruments, van Dijk et al. supported the use of the COMFORT scale to assess postoperative pain in infants. From a clinical perspective, separate valid and reliable pain and agitation assessment tools would allow more targeted therapeutic management.
The purpose of this study was to empirically construct and demonstrate preliminary construct validity and interrater reliability of a pediatric sedation assessment scale, the State Behavioral Scale (SBS), for use in young critically ill pediatric patients supported on mechanical ventilation.
Objective: To develop and test the reliability and validity of the State Behavioral Scale for use in describing sedation/agitation levels in young intubated patients supported on mechanical ventilation.
Design: In this prospective, psychometric evaluation, pairs of trained pediatric critical care nurse evaluators simultaneously and independently assessed a convenience sample of pediatric intensive care unit patients along eight state/behavioral dimensions and a numeric rating scale (NRS) of 0 (extremely sedated) to 10 (extremely agitated). The eight dimensions were derived from the sedation/agitation literature and expert opinion and included respiratory drive, response to ventilation, coughing, best response to stimulation, attentiveness to careprovider, tolerance to care, consolability, and movement after consoled, each with 3-5 levels.
Setting: An 18-bed pediatric medical-surgical intensive care unit and 26-bed pediatric cardiovascular intensive care unit in a university-affiliated academic children's hospital.
Patients: A total of 91 intubated mechanically ventilated patients 6 wks to 6 yrs of age provided a median of two observations (interquartile range, 1-3) for a total of 198 sets of observations. Excluded were postoperative patients or those receiving neuromuscular blockade.
Interventions: Patients were observed for 1 min, and then incremental levels of stimulation were applied until patient response. After 2 mins of consoling, the state behavioral assessment and NRS were completed.
Measurements: Weighted kappa and intraclass coefficients were generated to assess interrater reliability of the eight dimension and NRS ratings. Distinct state behavior profiles were empirically identified from the dimension ratings using hierarchical cluster analysis using a squared Euclidean distance measure and between-groups linkage. Construct validity of these profiles was assessed by comparing group mean NRS scores using one-way analysis of variance.
Main Results: Weighted kappa scores for all 198 dimension ratings ranged from .44 to .76, indicating moderate to good interrater reliability. The intraclass coefficient of .79 was high for NRS ratings. Cluster analysis revealed five distinct state profiles, with mean NRS ratings of 1.1, 2.5, 4.0, 5.3, and 7.6, all of which differed significantly from each other (F = 75.8, p < .001), supporting the profiles' construct validity.
Conclusions: Based on empirically derived state behavior profiles, we have constructed the State Behavioral Scale to allow systematic description of the sedation-agitation continuum in young pediatric patients supported on mechanical ventilation. Further studies including prospective validation and describing the effect of State Behavioral Scale implementation on clinical outcomes, including the quality of sedation and length of mechanical ventilation, are warranted.
Ensuring the comfort of critically ill infants and children is integral to the practice of pediatric critical care. Humane pediatric intensive care often includes the administration of sedatives after pain, physiologic imbalance, and environmental stressors have been addressed. More than 90% of infants and children supported on mechanical ventilation receive some form of sedative therapy. Sedation in this patient population is required for anxiolysis, amnesia, facilitation of care, patient safety in avoidance of adverse events, and for decreasing oxygen consumption. For most young patients supported on mechanical ventilation, the goal of sedation is to attain a calm but responsive state that protects the young patient from self-harm. Inadequate sedation is associated with potentially dangerous complications such as unplanned endotracheal extubation. High-dose, long-term, and continuous intravenous sedation has been associated with prolonged weaning from mechanical ventilation and withdrawal syndrome. Therefore, insufficient or excessive sedation is likely to add to the personal and financial burden of intensive care.
Variability complicates the use of sedation in the pediatric intensive care unit (ICU) setting. First, a patient's sedative needs vary depending on the nature and course of the illness, drug interaction with concomitant therapies, and response to therapy. Some patients require deep sedation to tolerate synchronous modes of mechanical ventilation, whereas others seem to be comfortable with light sedation, even when supported on unconventional modes of ventilatory support. Next, from a systems perspective, multidisciplinary staff with varying levels of expertise change several times over the working day. This means that patients are exposed to multiple subjective assessments of their sedation requirements, by several staff members, which may result in patients receiving varying dosages of sedation, depending on who performed the assessment.
Valid and reliable tools that standardize the description of a pediatric patient's behavioral state while supported on mechanical ventilation would enhance systematic assessment and documentation of a patient's response to sedation, allow patient-specific alterations in the therapeutic regimen, and help avoid insufficient or excessive sedative use. Such an assessment tool would enhance interdisciplinary agreement on the desired level of sedation, provide a foundation for the development of guidelines that would decrease unnecessary variation in the care and permit objective study of the pharmacodynamics of sedative agents in the pediatric population. From a research perspective, Kollef et al. suggest that sedation practices should be standardized in any investigation employing the duration of mechanical ventilation as an outcome variable.
Although desirable, tools assessing the sedation-agitation continuum in the pediatric patient have not been adequately tested or have conceptual flaws. Specifically, the psychometrics of the Ramsay scale an often-cited sedation scale used in the adult population, has never been evaluated in an ICU setting. In addition, Ramsay's six levels of sedation are neither mutually exclusive nor clearly defined. The COMFORT scale, the most commonly used tool in the pediatric population was designed to assess distress in ventilated children, but distress was operationalized to include the constructs of both pain and agitation. Noting that the eight dimensions of the COMFORT scale are often included in other pain instruments, van Dijk et al. supported the use of the COMFORT scale to assess postoperative pain in infants. From a clinical perspective, separate valid and reliable pain and agitation assessment tools would allow more targeted therapeutic management.
The purpose of this study was to empirically construct and demonstrate preliminary construct validity and interrater reliability of a pediatric sedation assessment scale, the State Behavioral Scale (SBS), for use in young critically ill pediatric patients supported on mechanical ventilation.
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