Perceived Barriers To Anthropometric Measurements In Critically Ill Children

A multidisciplinary team of PICU-specific registered dieticians, critical care advanced practice nurses, a pediatric gastroenterologist board certified in nutrition, and a pediatric intensivist at Children’s Hospital of Philadelphia (CHOP) used Survey Monkey (http://www.surveymonkey.com) to create a 21-item survey (see  Appendix). Survey items were constructed to identify perceived and actual challenges to obtaining anthropometric measurements in PICU patients. The survey covered the broad themes of the PICU environment and provider characteristics, initial and subsequent times of obtaining anthropometric measurements, sources of anthropometric data (if actual measurements were not obtained), and patient- and provider-specific barriers perceived by respondents. The survey was tested locally for feedback on the clarity of the questions and for construct validity. After approval from the CHOP institutional review board, the survey was distributed via electronic mail link to 6 professional organizations with members who care for critically ill children in a variety of international PICU settings: Advanced Nursing Practice in Acute and Critical Care, American Society of Parenteral and Enteral Nutrition–Pediatrics, Pediatric ICU Advanced Practice Nursing, PICU Nursing Science, Society for Critical Care Medicine, and World Federation of Pediatric Intensive and Critical Care Societies. Participation was voluntary, and consent was implied once respondents began the survey. Eligible respondents included ordering providers and nurses. Ordering providers included physicians and advanced practice providers (nurse practitioners and physician assistants). For the purpose of this study, the term PICU health care providers included both ordering providers and nurses. The survey was active for 14 weeks, from June through September 2012; periodic reminders were sent to the listserv of each organization throughout the study period.

Characteristics of the respondents and PICUs are summarized as counts and percentages. Summary data are presented as categorical variables. Differences between ordering providers and nurses were analyzed by using χ² analysis or the Fisher exact test. All P values are 2-sided and were considered significant if P < .05. The STATA 11.0 statistical package (StataCorp LP) was used for analysis.

A total of 376 respondents participated in the survey; among these, complete data were available for 318 respondents. After data from respondents who were not ordering providers or nurses (eg, registered dieticians, administrators, clinical educators, and clinical nurse specialists) were excluded, data from 258 pediatric clinicians were included for final analysis (Figure 1). Of the 258 eligible PICU care providers, 119 were ordering providers: 77 attending physicians (30%), 27 advanced practice providers (10%), and 15 fellow trainees (6%). Demographic characteristics of clinicians and PICU settings are described in Table 1. The majority of ordering providers (60%) had more than 5 years of experience caring for critically ill children. In contrast to ordering providers, 56% of nurse respondents had 5 years or less of PICU experience. Almost half (49%) of the 258 respondents worked in medical-surgical PICUs; the majority (64%) worked in PICUs with 20 or more beds. More respondents were from North America (90%) than any other continent.

Although 84% of the 258 respondents agreed that anthropometric measurements were important, only 3% indicated that such measurements were “always” obtained upon admission to the PICU (Table 2). The majority of the 258 respondents (66%) stated that initial anthropometric measurements should be obtained within 12 hours of admission to the PICU. Most (71%) thought that subsequent anthropometric measurements were obtained during the night shift. More ordering providers than nurses thought that orders were consistently placed to obtain anthropometric measurements both at admission (76% vs 49%; P < .001) and at prescribed intervals during the PICU stay (41% vs 30%; P = .002). Parents’ or caregivers’ estimates of anthropometric measurements were most commonly used (72%) when actual measurements were not obtained (Figure 2).

The majority of respondents (50%) favored obtaining daily weights in infants (< 1 year old), whereas 41% of clinicians favored weekly weight measurements for children 1 year old or older (Table 3). Although the 258 respondents were evenly divided between obtaining stature measurements at weekly and monthly intervals in infants (40% each), the majority (55%) preferred to obtain monthly measurements of stature in children. Most respondents thought that anthropometric measurements were reviewed by attending physicians (77%) and the nutrition support team (79%); medical records (93%) were identified as the main source used to retrieve this information. Fewer than half (43%) thought that the measurements were reviewed daily in the PICU.

For all anthropometric measurements combined, the most commonly perceived patient-specific barriers were presence of medical devices (57%), need for extracorporeal life support (54%), and unstable hemodynamic status (52%). Figure 3 depicts commonly perceived barriers to individual anthropometric measurements by weight, stature, and head circumference. Perceived differences in patient-specific barriers to individual anthropometric measurements between ordering providers and nurses are presented in Table 4. Significant differences between ordering providers and nurses in perception of barriers to obtaining anthropometric measurements for patient-specific clinical variables were detected for osteopenia or fragile bones (for weight), dialysis and obesity (for stature), and traumatic brain injury and existing medical devices (for head circumference).

More ordering clinicians than nurses thought that nurse workload was a barrier to obtaining anthropometric measurements (51% vs 33%, P < .001). Other common care provider–specific barriers to anthropometric measurements include patient/parent request not to be disturbed (38%) and lack of importance (31%). Table 5 depicts differences in perception of barriers between ordering providers and nurses. Perceptions significantly differed between the groups for nurses’ workload, lack of importance, and correct measurement techniques.

Our study is the first international survey to characterize barriers to anthropometric measurements in critically ill children. In addition to identifying barriers to obtaining anthropometric measurements in the PICU, we also determined differences in these perceived barriers between ordering providers and nurses. Our findings have important implications for education, clinical care, and patient safety. Most of the respondents in our survey agreed that obtaining anthropometric measurements in the PICU is important. However, few thought that such measurements are obtained on admission to the PICU; instead parental and/or staff estimates are often used to derive this information. This finding most likely reflects the lower priority accorded to anthropometric measurements compared with other time-sensitive and effort-intensive critical interventions necessary to stabilize a child upon admission to the PICU. Reports^4,11–13  indicate that estimates of anthropometric measurements by a patient’s parent or caregiver or by PICU staff are erroneous, often by wide margins. Although records from referring hospitals or outpatient clinic visits are an additional source of information, the weight, stature, and head circumference listed in those records may also have been estimates made by a patient’s parent or caregiver or by health care providers. In addition, variability in clinical standards, wide inconsistencies in staff training, and lack of equipment accuracy make the reliability of anthropometric measurements questionable.

A striking finding from our data is the discordance of perceptions between ordering providers and nurses for orders placed to obtain anthropometric measurements upon PICU admission and at prescribed intervals during the PICU stay. This discrepancy presents an opportunity to improve concordance between ordering providers to prescribe and nurses to obtain anthropometric measurements. Although our data indicate that ordering providers thought anthropometric measurements are important for providing patient care, placing orders to obtain measurements of weight, stature, and head circumference at admission and during the PICU stay is not routine practice. Use of “forcing functions” such as prechecked orders within a standard order set in the electronic medical record and establishing (if not already usual practice) nursing standards specific to obtaining these measurements will improve the likelihood that the prescribing behavior of the ordering providers will align with the delivery of nursing care.¹⁴  The combination of prechecked orders in an order set, ready availability of appropriate tools and equipment, and well-trained staff will greatly enhance the ability to obtain anthropometric measurements in critically ill children.¹⁴ 

However, simply obtaining measurements of weight, stature, and head circumference without thoughtful discussion among the clinical team and use in patient care can lead to diminished perception of the importance of the measurements. This can result in inconsistency in obtaining anthropometric measurements or in not obtaining them at all. Giving performance feedback to ordering providers and nursing staff on prescribing and obtaining anthropometric measurements is important to dissuade estimation of these measurements, aid clinical care, and enhance patient safety.

The respondents in our study also perceived the need to obtain daily weights in infants and weekly weights in older children. This finding appears to acknowledge providers’ concerns about growth in infants, but the concern may be misplaced because weights obtained at less frequent intervals will establish trends in weight change and may be equally effective for tracking adequate growth. The purpose of monitoring growth, particularly weight, is often detection of abnormalities of growth in healthy children so appropriate interventions can be made.¹⁵  Obtaining daily weight in critically ill children, a common practice, may be useful to evaluate fluid balance, address changes in medication dosing, and prescribe therapies, but the measurements may not reflect sustainable changes in body mass.¹⁶  Moreover, during an average PICU admission, with median length of stay less than 3 days,¹⁷  the focus should not be on growth or weight gain. Rather, care should be directed toward stabilization of weight and resolution of the acute illness with minimal decrease in muscle mass.

We found key differences between ordering providers and nurses in their perception of patient-specific and provider-specific barriers. Compared with ordering providers, nurses thought that anthropometric measurements were less important (Table 2). This finding is surprising because the essence of nursing practice is to optimize delivery of care while balancing the risks and benefits of specific assessments and interventions.¹⁸  Frequently regarded as a standard of practice for nursing care in the PICU, weight is often measured as soon as possible upon admission to the unit for use as baseline information for care delivery.^19,20  Further, we found that ordering providers consistently overestimated the frequency with which orders were placed to obtain anthropometric measurements. These demonstrated gaps in perceptions between the 2 groups suggest that differences exist in workplace roles and expectations.

Many of these perceived barriers could be overcome by establishing standardized guidelines for ordering providers and nurses. For example, the availability of newer technologies such as patient beds with the capability of measuring weight and the use of overhead lifts enable members of the clinical team to work together to order and obtain weights in a timely manner at PICU admission. Education on the importance of stature in clinical care and the use of appropriate tools and techniques to measure stature should be encouraged. Critically ill children with contractures of long bones pose special challenges for measurements of stature. In such circumstances, skilled providers such as registered dieticians should be consulted to obtain limb-length measurements as an alternative method to determine stature.^21,22  Last, specific criteria and guidelines for measuring head circumference should be clarified.

Our data also indicate that most anthropometric measurements occurred on the night shift. This practice may be an important barrier (or potential barrier) to consider in achieving higher compliance with obtaining measurements; patients or patients’ families may be sleeping and more likely to refuse measurements at night. Partnering with patients and their families to determine an optimal time of day for obtaining measurements, while aligning with unit practice, may help reduce yet another barrier to obtaining anthropometric measurements in the PICU.

Our study has limitations. First, the respondents may not be representative of the worldwide community of PICU clinicians; we had only 258 eligible respondents and most were in North America. Data on the composition and practice setting (academic center vs community hospital) of the respondents were not obtained. We were unable to determine duplicate responses or to determine if several respondents worked in the same PICU setting and were similarly biased in perceptions and beliefs. In addition, we did not specifically survey registered dieticians or ask if respondents worked in PICU settings with unit-specific registered dieticians, whose presence and involvement in patient care is likely to strongly influence perceptions of anthropometric measurements.²²  Our limited sample size precluded the ability to perform more detailed analysis to evaluate perceived differences by level of training and scope of practice within each group.

Of note, perceptions and beliefs stated by respondents may differ from the respondents’ actual practice, resulting in disparity between what is perceived and what is actually carried out in the PICU.¹¹  We did not attempt to ascertain specific examples of medical or nursing errors or harm to patients related to lack of obtaining accurate anthropometric measurements in PICU patients. This aspect should be further explored in future surveys and quality-improvement projects. Nevertheless, we think our study is the first in which barriers to anthropometric measurements in PICU patients and differences in perception of these barriers between ordering providers and nurses were determined.

Our findings have major implications for educating clinicians about the importance of obtaining timely anthropometric measurements in PICU patients. Targeted strategies with evidence-based guidelines and practice standards are necessary to dispel myths about common barriers to obtaining anthropometric measurements. Specific unit and organizational support with documented policies and procedures is necessary to establish and test quality improvement initiatives that will enhance obtaining anthropometric measurements in the PICU.

Specific barriers to obtaining anthropometric measurements exist in the PICU and have major implications for clinical care and patient safety. Perceptions of these barriers differ between ordering providers and nurses, suggesting the need for targeted education and development of solutions to overcome the barriers. Obtaining timely and serial anthropometric measurements during critical illness in children can markedly influence therapies and interventions that in turn affect clinical outcomes and prevent harm.

This research was performed at Children’s Hospital of Philadelphia. We gratefully acknowledge the assistance and support of Judy Verger, RN, PhD, CRNP, and Madeline Perkel, rn, msn, with creation and dissemination of the survey. In addition to the primary authors, members of the CHOP intensive care unit pediatric nutrition team include Judy Verger, Madeline Perkel, Martha Sisko, rn, bsn, Beth Connor, rn, bsn, and Jennifer Hewlett, pharmd.

• 1. Do you practice in pediatrics?

• 2. How pertinent are accurate growth parameters in the care of the patient in the ICU?

• 3. Are growth parameters (weight, length/height, head circumference) collected on each patient on admission to the ICU?

• 4. How soon after admission to the ICU are you expected to obtain growth measurements?

• 5. If an actual weight or length/height is not measured on admission, how do you obtain an estimate?

• 6. How frequently should weight measurements be obtained in children < 1 year of age in the ICU?

• 7. How frequently should weight measurements be obtained in children > 1 year old in the ICU?

• 8. How frequently should length measurements be obtained in children < 1 year old in the ICU?

• 9. How frequently should height/length measurements be obtained in children > 1 year old in the ICU?

• 10. How frequently should head circumference be obtained in children < 2 years old in the ICU?

• 11. In subsequent measurements, when are growth measurements usually obtained?

• 12. Who reviews growth parameters in the ICU?

• 13. How often are growth parameters reviewed by the ICU care team?

• 14. Which of the following would you consider barriers to obtaining growth measurements on patients in the ICU?

• 15. Do you routinely place weight, height, and head circumference orders for each patient in the ICU on admission and during the ICU stay to ensure growth measurements are obtained?

• 16. How are the growth (weight, height/length, head circumference) data shared with the care team?

• 17. What unit do you primarily work in?

• 18. What is your role in the ICU?

• 19. How many years have you been in this position?

• 20. How many beds does the unit where you primarily work have?

• 21. Where is your hospital located?