State Behavioral Scale: a sedation assessment instrument for infants and young children 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.


METHODS
: 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.


METHODS
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.


METHODS
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.


METHODS
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.


METHODS
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.


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.
Curley
Martha A Q
MA
Critical Care and Cardiovascular Program, Children's Hospital Boston, Boston, MA, USA.
Harris
Sion Kim
SK
Fraser
Karen A
KA
Johnson
Rita A
RA
Arnold
John H
JH
D002648:Child; D002675:Child, Preschool; D016292:Procedural Sedation; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007440:Intubation; D009483:Neuropsychological Tests; D009730:Nursing Assessment; D011446:Prospective Studies; D011594:Psychometrics; D011595:Psychomotor Agitation / Q000517:prevention & control* / Q000523:psychology; D015203:Reproducibility of Results; D012121:Respiration, Artificial
D006993:Hypnotics and Sedatives