Restore Resilience in Critically Ill Children (R2)

April 24, 2026 updated by: Martha A.Q. Curley, PhD, RN, University of Pennsylvania
The study design will allow investigators to describe usual care in each PICU and identify the facilitating and restraining factors impacting the implementation of R2 at each PICU. The purpose of this pilot study is to improve the care, environment, daily routine and sleep patterns of children in the PICU. The goal of this study is to learn what can be improved to support a critically ill child's healing and circadian rhythms.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Hospitals should do the sick no harm. That noted, modern day pediatric intensive care units (PICUs) are not healing milieus. Immediately upon admission to the PICU, the child's daily routine and sleep patterns are replaced by a well-intended but not patient-centered PICU routine. The interprofessional investigative team believes that PICU care and environments can be modulated to sustain a young child's circadian rhythm (CR) and support their physiological resilience and capacity to heal. The first step in this program of research is to pilot-test RESTORE resilience (R2), a 7-item individualized bundle that we hypothesize will restore CR in critically ill children using a pre-posttest design. Two separate PICUs will each enroll 10 baseline subjects followed by 20 intervention subjects, 6 months to 18 years of age, who are intubated and mechanically ventilated for acute respiratory failure. Specifically, as soon as possible after PICU admission, parents will be interviewed to create an individualized chronotherapeutic bundle to include (1) focused effort to replicate the child's pre-hospitalization daily routine (bedtime/wake time, bedtime/arousal routine, nap time, feeding schedule, active periods), (2) cycled day-night lighting and modulation of sound to match the child's routine, (3) minimal yet effective sedation using a nurse-implemented goal-directed sedation plan (RESTORE), (4) night fasting with bolus enteral daytime feedings, (5) early, developmentally-appropriate, progressive exercise and mobility (PICU Up!), (6) continuity in nursing care, and (7) parent diaries. The overall objective of this study is to pilot-test an intervention that can be implemented in any PICU that will improve sleep-wake patterns with restoration/maintenance of circadian rhythms in critically ill children with acute respiratory failure. Results of this pilot study will be used to inform the design of an adequately powered multicenter randomized trial of R2.

Study Type

Interventional

Enrollment (Actual)

56

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Maryland
      • Baltimore, Maryland, United States, 21287
        • Johns Hopkins University - Charlotte Bloomberg Children's Center
    • Pennsylvania
      • Philadelphia, Pennsylvania, United States, 19104
        • Children's Hospital of Philadelphia

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

2 years to 13 years (Child)

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • PICU admission at one of the study sites in which elements of R2 are typically but sporadically implemented
  • Transferred to the PICU from another hospital unit/ward with ≤4 nights in the hospital (≤2 nights in PICU)
  • Between the ages 6 months and 18 years at the time of enrollment (has not had their 18th birthday)
  • Intubated and mechanically ventilated for acute airway or parenchymal disease within last 48 hours
  • Expected to be intubated for more than 12 hours past enrollment
  • Parent/Guardian providing consent, provides primary care for subject

Exclusion Criteria:

  • A baseline cognitive dysfunction, measured by the Pediatric Cerebral Performance Category (PCPC ≥4)
  • A history of an uncontrolled seizure disorder (seizure within past 3 months), cerebral hypertension, neuromuscular respiratory failure, ventilator dependence (excluding BiPAP or CPAP at night)
  • A history of inability to tolerate bolus enteral feeds (full J-Tube fed patients)

  • The presence of any of the following within 24 hours of admission:

    • Modal pain scores greater than 4
    • Persistent hypotension/hypertension unresponsive to standard therapies
    • Use of High Frequency Oscillatory Ventilation or Extracorporeal Membrane Oxygenation
  • Administered melatonin within the past week
  • Has an active do-not-resuscitate plan

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Supportive Care
  • Allocation: Non-Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Intervention
R2 Bundle
Other: R2 Bundle

During the intervention phase subjects will receive R2.

  1. Focused effort to replicate the child's pre-hospitalization daily routine (bedtime/wake time, bedtime/arousal routine, nap time, feeding schedule, active periods),
  2. Cycled day-night lighting and modulation of sound to match the child's routine,
  3. Minimal yet effective sedation using a nurse-implemented goal-directed sedation plan (RESTORE),
  4. Night fasting with bolus enteral daytime feedings,
  5. Early, developmentally-appropriate, progressive exercise and mobility (PICU Up!),
  6. Continuity in nursing care, and
  7. Parent diaries.
No Intervention: Baseline
Usual care

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
DARE (Daytime Activity Ratio Estimate), Post Extubation
Time Frame: From immediately after endotracheal extubation to PICU discharge, assessed for up to 28 days
DARE = Daytime Activity Ratio Estimate after endotracheal extubation; DARE was calculated by dividing daytime (07:00-18:59) activity count by 24-hour activity count. A DARE of 50% indicates equal amount of activity between daytime and nighttime periods (loss of circadian rhythm), while a higher DARE indicates increased daytime activity and nighttime sleep consolidation.
From immediately after endotracheal extubation to PICU discharge, assessed for up to 28 days

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Delta Between Average Nighttime and Average Daytime Salivary Melatonin Levels
Time Frame: Day 5 of PICU hospitalization
Delta between average nighttime (19:00 to 06:59) and average daytime (07:00 to 18:59) salivary melatonin levels
Day 5 of PICU hospitalization
Percentage of Study Days Where Light and Sound Were Modulated
Time Frame: From date of enrollment until the date of PICU discharge, assessed for up to 28 days
Percentage of study days where light and sound were modulated to reflect day-night variation in light and sound levels; 0 = no study days where light and sound were modulated; 100% = light and sound modulated on all study days
From date of enrollment until the date of PICU discharge, assessed for up to 28 days
Percentage of Study Days Where the Patient Not Fed Enterally After Bedtime
Time Frame: From date of enrollment until the date of PICU discharge, assessed for up to 28 days
Percentage of study days where the patient was not fed enterally after bedtime
From date of enrollment until the date of PICU discharge, assessed for up to 28 days
Continuity in Nursing Care
Time Frame: From date of enrollment until the date of PICU discharge, assessed for up to 28 days
Continuity in Nursing Care Index (CINC) defined as (N nurses/N shifts)*100. Score range 0-100, lower scores are better.
From date of enrollment until the date of PICU discharge, assessed for up to 28 days
Pain Free Days
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Percentage of PICU days where pain was assessed (0-10 pain scale) without pain (Pain score <4)
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Agitation Free Days
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Percentage of PICU days without agitation (Agitation = State Behavioral Scale [SBS; range -3 to +2] >/= 1)
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Delirium Free Days
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Percentage of PICU days, where delirium was assessed, without delirium (using the CAPD, pCAM-ICU or psCAM-ICU; cut score determined by instrument)
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Iatrogenic Withdrawal Syndrome (IWS) Free Days
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Percentage of PICU days without IWS (Withdrawal Assessment Tool - version 1 [WAT-1]; range of scores 0-12 where no IWS = WAT-1 < 3)
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Peak Daily Dose of All Opioid Sedative Agents
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Highest daily mg/kg dose of all opioid sedative agents
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Cumulative Dose of All Opioid Sedative Agents
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Total PICU mg/kg dose of all opioid sedative agents received
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Total PICU Days of Opioid Sedation
Time Frame: From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
Total number of PICU days exposed to opioid sedation
From date of PICU admission until the date of PICU discharge, assessed for up to 28 days
PICU Length of Stay
Time Frame: From date and time of PICU admission until the date and time of PICU discharge
Time between the start and stop of PICU care
From date and time of PICU admission until the date and time of PICU discharge
Parent Perception of Being well-cared-for
Time Frame: On the date of PICU discharge, assessed once within an average of 2 weeks post PICU admission
Percent match on the 7-item family-centered care scale (FCCS); range from 0-100% match; where higher scores indicate a better match
On the date of PICU discharge, assessed once within an average of 2 weeks post PICU admission
DARE (Daytime Activity Ratio Estimate), Acute Phase
Time Frame: From study enrollment to endotracheal extubation
DARE = Daytime Activity Ratio Estimate after endotracheal extubation; DARE was calculated by dividing daytime (07:00-18:59) activity count by 24-hour activity count. A DARE of 50% indicates equal amount of activity between daytime and nighttime periods (loss of circadian rhythm), while a higher DARE indicates increased daytime activity and nighttime sleep consolidation.
From study enrollment to endotracheal extubation

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University of Pennsylvania

Collaborators

Johns Hopkins University
Children's Hospital of Philadelphia
Boston Children's Hospital

Investigators

  • Principal Investigator: Martha AQ Curley, RN, PhD, University of Pennsylvania

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

September 5, 2017

Primary Completion (Actual)

December 31, 2021

Study Completion (Actual)

December 31, 2021

Study Registration Dates

First Submitted

December 22, 2020

First Submitted That Met QC Criteria

December 31, 2020

First Posted (Actual)

January 5, 2021

Study Record Updates

Last Update Posted (Actual)

May 11, 2026

Last Update Submitted That Met QC Criteria

April 24, 2026

Last Verified

April 1, 2024

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 828061

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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