Can Hospitalization Precipitate Toxic Stress?

Shah, Anita N.; Jerardi, Karen; Auger, Katherine A.; Beck, Andrew F.

doi:10.1542/peds.2016-0204

Cited by 13 publications

(12 citation statements)

References 8 publications

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“…This has, in part, driven the recent focus on identifying and mitigating ‘toxic stressors’, defined as experiences that prompt prolonged activation of the physiological stress response in the absence of buffering supports 37 49. Perhaps, defining discharge readiness, and the postdischarge safety net, more broadly, in a way that takes family-level risks and assets into account, may smooth the transition home and prevent the stress of a hospitalisation from becoming ‘toxic’ 6 37 50. Additional connections with buffering community-based mental health and/or social service resources may be considered as discharge plans are developed.…”

Section: Discussionmentioning

confidence: 99%

Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study

et al. 2016

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Background Stress caused by hospitalisations and transition periods can place patients at a heightened risk for adverse health outcomes. Additionally, hospitalisations and transitions to home may be experienced in different ways by families with different resources and support systems. Such differences may perpetuate postdischarge disparities. Objective We sought to determine, qualitatively, how the hospitalisation and transition experiences differed among families of varying socioeconomic status (SES). Methods Focus groups and individual interviews were held with caregivers of children recently discharged from a children's hospital. Sessions were stratified based on SES, determined by the percentage of individuals living below the federal poverty level in the census tract or neighbourhood in which the family lived. An open-ended, semistructured question guide was developed to assess the family's experience. Responses were systematically compared across two SES strata (tract poverty rate of <15% or ≥15%). Results A total of 61 caregivers who were 87% female and 46% non-white participated; 56% resided in census tracts with ≥15% of residents living in poverty (ie, low SES). Interrelated logistical (eg, disruption in-home life, ability to adhere to discharge instructions), emotional (eg, overwhelming and exhausting nature of the experience) and financial (eg, cost of transportation and meals, missed work) themes were identified. These themes, which were seen as key to the hospitalisation and transition experiences, were emphasised and described in qualitatively different ways across SES strata. Conclusions Families of lower SES may experience challenges and stress from hospitalisations and transitions in different ways than those of higher SES. Care delivery models and discharge planning that account for such challenges could facilitate smoother transitions that prevent adverse events and reduce disparities in the postdischarge period. Trial registration number NCT02081846; Pre-results.

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Section: Discussionmentioning

confidence: 99%

Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study

et al. 2016

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“…19 Evidence for successful and sustainable models that systematically identify and address parental distress during pediatric intensive care remains scarce and of critical need. 20…”

Section: Introductionmentioning

confidence: 99%

Co-designed PICU Family Stress Screening and Response System to Improve Experience, Quality, and Safety

Liaw

Cho

Devins

et al. 2019

Pediatric Quality &Amp; Safety

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Objective: Evidence for successful and sustainable models that systematically identify and address family stress in the pediatric intensive care unit (PICU) remains scarce. Using an integrated improvement science and family engagement framework, we implemented a standardized family stress screening tool and response protocol to improve family experience and reduce family crises through the timely coordination of parent support interventions. Methods: We conducted this improvement initiative in the 12-bed PICU of a children’s hospital within a large, urban academic medical center. Our team, which included 2 family advisors, adapted a validated Distress Thermometer for use in pediatric intensive care. A co-designed family stress screening tool and response protocol were iteratively tested, refined, and implemented in 2015–2017. Process and outcome measures included screening and response reliability, parent satisfaction, and security calls for distressed families. Results: Over the 18 months, the percentage of families screened for stress increased from 0% to 100%. Among families who rated stress levels ≥5, 100% received the recommended response protocol, including family support referrals made and completed within 24 hours of an elevated stress rating. From 2015 to 2017, PICU parent satisfaction scores regarding emotional support increased from a mean score of 81.7–87.0 ( P < 0.01; 95% CI). The number of security calls for distressed families decreased by 50%. Conclusions: The successful implementation of a co-designed family stress screening tool and response protocol led to the timely coordination of parent support interventions, the improved family perception of emotional support, and reduced family crises in the PICU.

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“…In summary, the nature and timing of stressors in the NICU predispose the infant to toxic stress in the absence of a supportive caregiver to help regulate the infant. We, along with others, believe that NICU hospitalization constitutes a significant, toxic stressor for infants (Sanders & Hall, 2017;Shah et al, 2016). The longer the NICU hospitalization, the greater chance for prolonged and cumulative exposure to toxic stress.…”

Section: Buffering Of Stressorsmentioning

confidence: 84%

“…The most common infant stress responses provoked by the NICU environment constitutes that of the most dangerous form of stress, toxic stress. While the AAP Report provided several examples of stressors capable of inducing a toxic stress response (e.g., parental neglect, abuse, and maternal depression), others have expanded on the AAP's examples to include childhood hospitalization (Franke, 2014;Shah et al, 2016). Specifically, NICU hospitalization is a significant source of toxic stress for infants due to the nature, timing, and buffering of infant stress within the NICU environment.…”

Section: Levels Of Stress In the Nicumentioning

confidence: 99%

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

Weber

Harrison

2019

Nursing Outlook

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In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically-ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological Neonatal Intensive Unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP Report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric healthcare outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP Report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP Technical Report, but are vital to the health and development of all newborns.

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Can Hospitalization Precipitate Toxic Stress?

Cited by 13 publications

References 8 publications

Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study

Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study

Co-designed PICU Family Stress Screening and Response System to Improve Experience, Quality, and Safety

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

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