• CurleyMartha A QMAQ0000-0001-5228-6694Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA.Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philade, Onella S Dawkins-Henry, Laura Beth Kalvas, Mallory A Perry-Eaddy, Georgia Georgostathi, Ian Yuan, David Wypij, Lisa A Asaro, Athena F Zuppa, and Sapna R Kudchadkar.
• Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
• Pediatr Crit Care Me. 2024 Nov 1; 25 (11): 105110641051-1064.

ObjectivesPilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R 2 ).DesignA two-phase cohort study was carried out from 2017 to 2021.SettingTwo similarly sized and organized PICUs in the United States.PatientsChildren 6 months to 17 years old who were mechanically ventilated for acute respiratory failure.InterventionsR 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 ResultsChildren 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).ConclusionsIn 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.Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

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