Tehran University Medical Journal

Background: Infant mortality is important as a standard indicator for the development of health, educational and social health systems in each country. Considering the fact that in different studies of the country there are different statistics on the prevalence of infant mortality in the intensive care unit and the general statistics on the prevalence of mortality in neonates in the country are unclear and unclear, the aim of this study was systematic review and meta-analysis for determine the prevalence of mortality in infants admitted to the intensive care unit (ICU) of hospitals in Iran.
Methods: A meta-analysis was performed for relevant articles in scientific databases including scientific information database (SID) and Magiran, ScienceDirect, Scopus, Medline (PubMed) and Google Scholar. Entrance criteria included cross-sectional studies between March 2000 to September 2018. The search process in these databases was performed using keywords: Neonatal, Intensive Care Unit, Mortality, and Iran. Non-relevant articles included review articles, interventions, cohorts and case-control studies, excluded from the study list. Heterogeneity of study was checked using I2 index and the possibility of publication bias by funnel plot and Egger test. Data were analyzed using the comprehensive meta-analysis software, version 3 (Biostat, Englewood, NJ, USA).
Results: The overall prevalence of infant mortality in ICU hospitals was 21.8% (95% CI 14.4-31.6%), the highest prevalence of infant mortality in Isfahan was 64.4% percentage (95% CI 57.5-70.9%) and the lowest mortality rate in babies in Babol's intensive care unit with 5.1% (95% CI 3.8-6.7%). The results of the study showed that the prevalence of infant mortality was significantly reduced with increasing sample size (P<0.05). Also, with an increase in years of research, the frequency of infant mortality in the intensive care unit increases, which is also statistically significant respectively (P<0.05).
Conclusion: Considering the high prevalence of infant mortality in ICU hospitals in Iran, health policy makers need to take effective measures to raise awareness of parents as well as effective measures to reduce infant mortality.

Background: Congenital heart diseases are the second group of congenital anomalies in infants. These disorders are a major cause of death in the first year of a child's life. Early detection helps to treat these diseases better. In this study cardiology consultations of hospitalized infants in the neonatal intensive care unit were evaluated.
Methods: In this cross-sectional study, two hundred and fifty pediatric cardiology consultations conducted in Shahid Beheshti Hospital in the year 2012 were reviewed. Information such as the cause of consulting, delivery type, age of parents, relative couples, family history of congenital heart disease, maternal medications, maternal background diseases, the final diagnosis, and prognosis follow-up of the patients were recorded in a designed questionnaire. Finally, the data were entered into the SPSS software, version 16 (IBM SPSS, Armonk, NY, USA) and analyzed using descriptive statistics and chi-square test. P-value of less than 0.05 was considered significant.
Results: The mean age of the consulted neonates was 4.845±5.14 days with a gestational age of 33.933±3.65 weeks. Male sex and cesarean section were the most frequent. Fifty-six percent of consulted infants were male. The present study revealed that prematurity (76%), murmurs (30.8%), respiratory distress syndrome (14.4%) and cyanosis (13.2%) were the most common causes of the cardiac consultation seeking among infants. Seventy-six percent of infants were consulted due to prematurity. Eighty-four percent of infants had a normal conditions. Septal defects (ventricular or atrial septal defect) and patent ductus arteriosus were the most common disease diagnosed with the prevalence of 27.5 and 17.5%, respectively. There was a significant relationship between preterm labor and congenital heart disease (P<0.001). Additionally, prematurity associated with respiratory distress syndrome and using assisted reproductive techniques.
Conclusion: The higher prevalence of congenital heart disease in the present study, compared with other studies, reflects the fact that cardiology consultation based on clinical suspicion leads to the more identification of congenital heart disease that means the right referral of newborns for consultation was accompanied with a higher incidence of heart failure.

Background: Health care associated infections (HAIs) are a class of infections that infect patients during hospital admissions and receive medical services. These infections occurs within 48 to 72 hours of admission and up to 6 weeks after discharge. Surveillance of device-associated infections (DAIs) in intensive care units (ICUs) is substantial in planning healthcare strategies. This study was conducted to determine the device-associated infections' burden and antimicrobial resistance patterns.
Methods: In this descriptive-analytic study, three common device-associated infections included central line-associated bloodstream infection (CLA-BSI), ventilator associated pneumonia (VAP), and catheter-associated urinary tract infection (CA-UTI), were assessed in intensive care units of Besat Hospital in Hamedan from April 2017 to April 2018. In order to determine the incidence of device-associated infections, the number of device-associated infection cases was calculated during the study period and divided into the number of device-days used. The device-days included all days of exposure to that device (vascular catheter, endotracheal tube (ventilator), or urinary catheter) in all patients in the study population.
Results: Out of 1806 intensive care unit admitted cases, 168 patients (9.3%) were device-associated infection with distribution of 92 cases (55%) of ventilator-associated pneumonia (VAP), 56 cases (34%) of catheter-associated urinary tract infection (CA-UTI) and 20 cases (11%) of central line-associated bloodstream infection (CL-BSI). The incidence of VAP, CA-UTI and CL-BSI was 44.7, 17.5, and 21.61 days, respectively. The most organisms were Acinetobacter (27.4%), Klebsiella (18.3%), Escherichia coli (E. coli) (15.4%). Vancomycin-resistant enterococcus (VRE) was 75%. Acinetobacter resistance to colistin and carbapenem was 16.8%. About half of Pseudomonas isolates were resistant to meropenem.
Conclusion: According to the present findings of this study, a high incidence of device-associated infections and resistant organisms in our intensive care units were documented, which represents a need to reinforce the preventive and control programs. Various results in different studies can be due to differences in the level of health care in different centers and countries.

Background: Intravenous (IV) injection of drugs is one of the most common methods of drug prescription in hospitals, which is a complex, potentially hazardous and erroneous method; accordingly, it requires control methods to reduce the potential risks. This study focused on determining the frequency and types of different medication errors while preparing and administering mostly used IV drugs in three intensive care units (ICU) and one general department in AL-Zahra hospital, Isfahan, Iran.
Methods: This cross-sectional observational study was conducted for 6 months from September 2017 to March 2018. To determine the frequency of different medication errors, a quoting sampling method was applied to select and observe 400 cases of IV drug administrations. All nurses from any studied department were included in this study. Different stages of preparation and administration of the observed drugs were compared to an instructed checklist prepared by the clinical pharmacist.

Background: Opioid poisoning is the most common type of poisoning in intensive care units (ICUs). This group usually includes patients who have been drug abusers for a long time and now require hospitalization either because of acute overdose or due to side effects of routine opioid use. This study aimed to compare the severity and prognosis of patients using common mortality predictors Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score (SAPS II), Acute Physiology And Chronic Health Evaluation (APACHE II, APACHE IV) on different days of hospitalization.
Methods: This cross-sectional study was performed on all patients with opioid poisoning admitted to the ICU, Imam Reza Hospital, Mashhad, Iran, from the beginning of April 2016 to March 2017 (Persian Calendar). For all poisoned patients enrolled in the study, the four mortality predicting tools were filled daily in the first three days of hospitalization and then every other day until discharge from the ICU or patient's death.

Background: Infectious diseases in the pandemic stage have significant life-threatening, psychological and social effects. Identifying the characteristics associated with people's cooperation in self-care leads to greater immunity for themselves and others. Therefore, this study was conducted to predict the self-care of the Iranian people according to their individual and social characteristics in face of the Covid-19 pandemic.
Methods: A survey study was conducted on 1056 adults aged 18 and over in different provinces of Iran through a form of answering online researcher-made questions (n=40, α=0.9) in social networks in four days. This paper studies the level of self-care of people against Covid 19 pandemic which was conducted with the support of Isfahan University of Medical Sciences in April 2016. Data were analyzed using Student t-test and variance. Moreover, "decision tree technique" was used to identify communication patterns.

Background: The health of pregnant mothers is one of the most important health indicators of each country. The midwifery clinic is one of the first places in which pregnant mothers become familiar with at the time they arrive. Providing health services at a desirable level and improving the quality of services in the midwifery clinic require an accurate understanding of the situation and its complications. This study aimed to assess how well pregnant mothers were satisfied with the midwifery services that they have received at midwifery to improve their quality.
Methods: This cross-sectional study was performed on 364 pregnant women who were referred to the midwifery clinic of Shariati Hospital in Tehran in August and September in 2018. Data were collected using a validated, pre-designed questionnaire and were analyzed using chi-square and multivariate logistic regression.
Results: Among the pregnant women referred to the clinic, 70.2% were satisfied with the care services received and 29.8% of them were not satisfied. This satisfaction level had a significant relationship with pregnancy (P=0.009) and mothers' age (P<0.001) while decreased by the increment in the number of pregnancies and age. Also, in this study, the least satisfaction was related to the crowds and waste of time and lack of access to the parking spot (P<0.001). In this research, the least satisfaction was due to crowding and waste of time, which can be addressed by improvement in the health services in the residential areas, appropriate referrals, informing about the expected time of arrival, and providing information on the alternative of the new hospitals in areas around the city with less traffic congestion and better parking sites.

Conclusion:  The results of our study showed the detailed patient satisfaction factors of an educational medical hospital. In overall the satisfaction.

Background: Infection is a vital problem in intensive care units. Currently, chlorhexidine solution is used to reduce oral colonization. This study aimed to determine the efficacy of chlorhexidine solution on oropharyngeal bacterial colonization in hospitalized patients in the intensive care units.
Methods: This descriptive study (from August 2018 to May 2019) was performed on 60 patients who administered in medical and surgical intensive care units (ICUs) in one of the university hospitals in Semnan city. Patients admitted to (ICUs) were selected according to inclusion criteria. At the time of admission to the intensive care unit, oropharyngeal colonization of patients was assessed. Forty-eight hours after admission and using the chlorhexidine solution 0.2% three times a day, oropharyngeal colonization was assessed again. Data analysis was performed with SPSS software, version. 22 in the significant level of 0.05.

Background: Because deep vein thrombosis (DVT) is one of the most common problems in the intensive care unit, it may lead to complecating the patient's general condition. This study aimed to investigate the predictive factors of DVT in patients admitted to the intensive care unit (ICU) of Amin hospital in Isfahan.
Methods: In this retrospective study, all the records of patients admitted to the ICU ward of Amin Hospital located in Esfahan, from April 2015 to March 2018, were investigated and from all patients with DVT, 20 records were extracted and 40 cases of patients without DVT were also randomly selected. Information such as age, sex, Wells score, Apache score, nutritional status, clinical parameters, cause of hospitalization, length of stay, ICU induced disease and treatment were extracted from these records and compared between both groups with and without DVT.

Conclusion: In the general intensive care unit, the incidence of deep vein thrombosis was higher in internal ward patients. Pneumonia was the most common disease associated with deep vein thrombosis and the risk of deep vein thrombosis was higher in the anemic patient. Patients with upper limited normal levels of potassium were less likely to develop deep vein thrombosis. It seems that potassium in the upper limit of normal reference can play a protective role against deep vein thrombosis. Further studies with larger sample sizes are suggested.

Background: Early outcome prediction of hospitalized patients is critical because the intensivists are constantly striving to improve patients' survival by taking effective medical decisions about ill patients in Intensive Care Units (ICUs). Despite rapid progress in medical treatments and intensive care technology, the analysis of outcomes, including mortality prediction, has been a challenge in ICUs. Hence, this study aims to predict the mortality of patients admitted to ICUs using data mining techniques.
Methods: In this study, among the cases of patients who were admitted to ICUs of the Rasoul Akram and Firoozgar hospitals of Tehran City, Iran, from December 2017 to March 2018, the first 24 hours of the ICUs admission data of 874 cases were gathered. A new model based on the standard methodology CRISP was developed. In the modeling section, two well-known data mining techniques called artificial neural network (ANN), K nearest neighbor (KNN) and decision tree (DT) were used. WEKA 3.9.2 open-source software was implemented for data analysis. Finally, according to the accuracy, sensitivity, specificity criteria and AUC-ROC Curve, the superior model was introduced.
Results: Based on the WEKA results, 19 variables had the most impact on the mortality prediction of patients admitted to ICUs including Glasgow Coma Scale (GCS), mechanical ventilation, surgical service at ICUs admission, gender, temperature, serum creatinine, diabetes, Blood urea nitrogen (BUN), age, addiction, International Normalized Ratio (INR), PH, Partial Thromboplastin Time (PTT), albumin, hemoglobin, glucose, pulse rate, hematocrit (HCT), PO2.  Based on the created models, some rules have been extracted which can be used as a pattern to predict the probability of mortality. Although the AUC of the three models was acceptable (KNN 81.5%, ANN 77.5% and DT 74.3%), but the accuracy of decision tree J48 (74.2%) was higher.

Background: Enhanced recovery after surgery (ERAS) is now firmly established as a global surgical quality improvement initiative that results in both clinical improvements and cost benefits to the healthcare system. ERAS guidelines are based on the highest quality evidence available and as such require updating on a regular basis. The ERAS Gynecologic/Oncology guidelines were first published in February 2016. This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.^1,2
Methods: Starting from the original ERAS Gynecologic/Oncology guidelines, the first author and senior authors identified topics for inclusion. International authors known for their expertise in gynecologic/oncology perioperative care were invited to participate in the guideline update. A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with an emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system,³ whereby recommendations are given as follows: Strong recommendations: The panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects, weak recommendations: The desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is less confident.

Background: Determining the rank of important parameters in ranking health care and providing health services to patients in medical centers.
Methods: The research method is descriptive-analytical and applied in terms of classification. The data is from the database of the Faculty of Health and Medicine of the University of Tehran, which was collected as an archive from April 1998 to May 1999. The statistical population were all experts, specialists and experts of the Faculty of Health 29 of whom completed the questionnaire. The weight of the criteria was evaluated using the AHP method and in the next stage, the medical centers were ranked using the DS-VIKOR method. The analysis method in this study consists of the following steps steps:
• Implementing a simple VIKOR method.
• Implementing the Dempster-Shafer and Vicker method.
• Implementing the AHP method
• Implementation of the Topsis method.
• Comparing the proposed methods to review and compare which ones work best.

The model can investigate the effectiveness of giving caring and providing health services to patients in medical centers.
Conclusion: By combining the two methods of Dempster-Shafer and Vicker, the confidence in the whole uncertainty is improved and the results are more reliable. This approach can help reduce the uncertainty caused by people's cognition to increase the level of decision-making, allowing us to overcome the problem of choosing the right level of uncertainty and to deal with uncertainty in a practical and justified way.

Results: The mean age was 52.1±14.1, and there was no difference between the two groups. Demographic characteristics, including sex, body mass index, duration of surgery, kind of intubation, and Acute Physiology and Chronic Health Evaluation (APACHE) II score, were not significantly different. The length of stay in the intensive care unit in the dexamethasone group was significantly longer than the control group (104 vs. 79-hour, P=0.001, CI 95%: 10.995-40.878). The rate of failure in extubation and postoperative stridor was not significantly different between the two groups (P=0.237). Conclusion: Dexamethasone usage seems not to be effective in reducing airway edema, and its routine use is not recommended in reducing stridor after endotracheal tube removal.

 

Background: In Iran, a combination of three methods of budget payment, fee for service and case-based payment (known as the global payment system) is used to reimburse the cost of hospital services. The aim of this study was to investigate the costs of 90 services of the Global Hospital Reimbursement System at Tehran University of Medical Sciences.
Methods: This descriptive cross-sectional applied study was performed from March  2017 to March 2019 in the hospitals of Tehran University of Medical Sciences. The billing and record data of all patients whose services were reimbursed on a global payment system basis were extracted from hospital information systems. Data were analyzed using descriptive statistics (frequency mean. std deviation, maximum & minimum) in SPSS 21 and Excel 2016.
Results: During two years in TUMS, the costs of services provided to 143,866 patients have been reimbursed based on the global payment system., which had a cost of 2300 billion rials. 80% of the total services and costs were related to 10 services. 78.46% of the cases were related to two specialized groups of ophthalmology and obstetrics and gynecology. 83.17% of the total costs of services reimbursed globally at the TUMS were related to these two specialized groups. The average cost per service was about 16 million Rials, but varied greatly for different services, ranging from about 1.8 million Rials to 67 million Rials. On average, for a global service, the share of each of the cost subgroups of diagnostic services, hoteling and nursing services, medicine and consumables, operating room and surgery, physician's visit and consultation, respectively 3.1%, 11.6%, 21.4%, 49.9% and 13.9%.

Conclusion: Managers need to focus on high-frequency and high-cost services to reduce the cost and financial losses for services that are under the global payment system. Depending on the specific cost pattern of each service, the strategies adopted to control the costs of that service should also be different.

Background: Coronavirus in 2019 was recognized as one of the leading causes of death worldwide. According to reports, the mortality rate in people who need mechanical ventilation varies from 50 to 97 percent. The aim of this study was to evaluate the outcome of Covid-19 disease based on different characteristics in patients and mechanically ventilated variables.
Methods: This descriptive-analytical study was conducted on 160 patients with a definite diagnosis of Covid-19 who were under mechanical ventilation and admitted to the intensive care unit of Alzahra Hospital in Isfahan from March 2020 to March 2021. Data was collected by checklist. The checklist included demographic information, including age, gender, as well as information such as underlying diseases, disease outcome, length of hospitalization, etc. After collecting the data, they were analyzed in SPSS software version 22 and at a significance level of less than 0.05.

Results: In this study, the overall mortality rate among mechanically ventilated patients was 62.5%. The mean age of patients was 69.99±17.87 years and the mean duration of hospitalization in surviving patients was 15.47±11.73 days and for deceased ones was 55.21±69.14 days. The mean age of the deceased group (65.71±16.59) was significantly higher than the surviving group 53±21.17 was (P=0.0001). The length of hospital stay in the deceased group was significantly longer than the surviving group (P=0.005). As a result, ventilator mode and inotropic agent intake during treatment increased the chance of mortality in patients under mechanical ventilation (P=0.001). There was a significant relationship between underlying diseases of hypertension, kidney disease and autoimmune disease with mortality in patients (P<0.05). Conclusion: Various factors including the length of stay in the hospital, comorbidities such as hypertension, renal disease and autoimmunity may affect the outcome of critically ill ICU patients under mechanical ventilation. Patients who require long-term invasive ventilation and the use of inotropic drugs to maintain their cardiovascular status while hospitalized in the ICU are at higher risk for mortality.

Background: Hypertension is an important and controllable risk factor for heart diseases, stroke, renal failure and peripheral vascular disease. The aim of this study was to determine the level of awareness of patients with hemorrhagic stroke to control blood pressure and to provide solutions to improve patients’ awareness.
Methods: This study is a descriptive cross-sectional study that was conducted to evaluate the knowledge of patients with hemorrhagic stroke about the use of antihypertensives. The study population consists of all patients with hemorrhagic stroke, who were admitted to the intensive care unit of Imam Hossein Hospital in Tehran from September 2020 to March 2021. Data related to blood pressure awareness and drug history was completed by the researcher through the method of direct contact with the patients or their relatives. In this study, 17 patients diagnosed with hemorrhagic stroke due to hypertension who were admitted to the intensive care unit of Imam Hossein Hospital in Tehran, were included. The extent of the exact treatment adherence was assessed using the Morisky questionnaire.

Results: In this study, the median of patients age was 67 and 10 (58.82%) of them were women. The median systolic and diastolic blood pressures were 170 and 95 mmHg on admission. 4(23.53%) subjects were not aware of the disease. Out of 13 people who were aware of their hypertension, 11(64.71%) were under the supervision of a physician. However, 7(63.64%) of the subjects, despite being under the supervision of a physician and acceptable drug adherence, did not have controlled blood pressure and expired. Conclusion: This study is a warning for patients and health care providers to pay more attention to blood pressure control. Furthermore, educating the community as well as medical staff about the importance of timely diagnosis and accurate treatment of hypertension is highly recommended.

Methods: This study was a systematic review, which was conducted from May 1 to July 31, 1402 at Allameh Tabatabai University and search strategy was written and performed in MEDLINE, Web of Science/PubMed and Scopus databases from the beginning of 2003 to the end of 2022. The inclusion criteria included all quantitative, qualitative, mixed and review studies that focused on the experience of adult patients. Lack of access to the full text of the article and studies in non-English language, clinical trial (randomized and non-randomized), letter to the editor, case report and protocol were excluded from the list of studies. After removing duplicate articles, two research authors reviewed the studies independently according to the inclusion and exclusion criteria, and the differences between them were resolved by discussion. Results: After searching, screening and selecting articles based on inclusion and exclusion criteria, finally 22 articles were included in the study, of which three were review articles, eight were quantitative and 11 were qualitative. Terminally cancer patients experience existential distress, and the data are significant for estimating the prevalence of these symptoms, especially in the severe category. In addition to examining the prevalence of this symptom, patients have described their experience of existential distress in several categories: Feelings of loneliness and isolation (or loss of support system), relationship concerns (concerns about family, changes in relationships, and conflictual relationships), loss of control/autonomy (physical control, cognitive and emotional control), burden on others, loss of sense of continuity (loss of roles, pleasurable activities and sense of self), uncompleted life tasks, hopelessness/helplessness, dissolving of the future, uncertainty and frightening ambiguity, feeling guilt/ regret about the past, lack of meaning, inevitable thoughts of death. Conclusion: It seems that the themes raised beyond cultural differences show the universal human suffering, whose accurate conceptualization can help to develop effective therapeutic interventions to reduce existential distress.

سردبیر محترم
دلیریوم (Delirium) یک سندرم روانی- عصبی شناخته شده است که با اختلال در سطح هوشیاری و توجه بیمار مشخص می‌گردد. علایم آن در مدت زمان کوتاهی بروز کرده و معمولاً با نوسان علایم در طول شبانه‌روز همراه است. این اختلال از جمله دلایل اصلی ایجادگیجی در بیماران بستری در بیمارستان می‌باشد که می‌تواند به‌صورت حالاتی از کم‌تحرکی، بیش‌فعالی و یا ترکیبی از هر دو، در بیماران دیده شود.¹
پرستاران در تعیین و کنترل دلیریوم در جایگاه مهمی قرار دارند. با توجه به اینکه آنها از مراقبین اصلی بیماران به‌شمار می‌آیند، مشاهدات منظم و به‌موقع آنان باعث تشخیص سریع علایم اصلی دلیریوم از جمله عدم توجه و نوسانات سطح هوشیاری در بیماران می شود.²
با این وجود دلیریوم اغلب اوقات به‌دلیل کمبود دانش و سطح آگاهی پرستاران تشخیص داده نشده و یا نادیده گرفته می‌شود. ماهیت متغیر دلیریوم، همپوشانی علایم آن با علایم بیماری فراموشی، کمبود پروتکل‌های ارزیابی و تشخیصی در بیمارستان‌ها و ضعف کارکنـان تـیم درمـان در نحوه استفاده از ابزارهای شناسایی دلیریوم، از جمله دلایل نقص در تعیین ایـن اختلال محسوب می‌شود.³
علیرغم آگاهی پرستاران از وجود دستورالعمل‌های تدوین شده برای کنترل دلیریوم، پرستاران به دلایلی همچون بار زیاد کاری، عدم آشنایی با پروتکل‌های مراقبتی و نبود انگیزه از اصول مراقبتی و دستورالعمل‌ها به‌صورت کامل تبعیت نمی‌کنند.⁴
از سوی دیگر، مراقبت پرستاران از بیماران مبتلا به دلیریوم تحت تاثیر ساختار آموزش پرستاران و فرهنگ مراقبت در سیستم درمانی حاک بر سازمان انجام می‌شود. لذا ضعف پرستاران در تشخیص و مراقبت‌های پرستاری موثر و با کیفیت از دلیریوم می‌تواند ریشه در نقص پیشینه سیستم آموزش داشته باشد.⁵ ماهیت ویژه و منحصر به فرد دلیریوم و عوامل متعدد تاثیرگذار بر آن، پرستاران را در تشخیص و به‌خصوص مراقبت از این بیماران با چالش‌های فروانی روبه‌رو کرده است که از جمله آنها می‌توان به موارد زیر اشاره کرد:
1- بروز رفتار لجام گسیخته در بیمار مبتلا به دلیریوم که باعث بی‌قراری در بیمار شده و به‌دلیل بروز رفتارهای پرخاشگرانه احتمال صدمه و آسیب به بیمار و پرستار بیشتر می‌گردد.⁶
2- غفلت اعضای خانواده بیمار در بروز و یا تشدید دلیریوم، تغییر ناگهانی شرایط جسمی و روحی بیمار مبتلا به دلیریوم و همچنین نمایش رفتارهای غیرمعمول در بیمار باعث می‌شود تا اعضای خانواده بیمار نتوانند شیوه صحیحی را برای ایجاد آرامش در بیمار خود انتخاب نمایند.⁷
3- عدم آگاهی اعضای خانواده در مورد ارایه مراقبت‌هایی مطلوب و رفع نیازهای پایه مانند غذا دادن، اجابت مزاج و غیره عاملی برای بروز دلیریوم می‌باشد. تنهایی بیمار در بیمارستان و یا همراهی افراد غیرآشنا در کنار بیمار می‌تواند زمینه بروز دلیریوم را بیشتر کند.⁸
4- ارتباط ناکارآمد نیز می‌تواند سبب بروز دلیریوم شود. در صورت برقراری ارتباط درست با بیماران می‌توان نیازهای بیماران          را ارزیابی کرد و عوامل مسبب دلیریوم ر ا برطرف نمود. براساس منابع علمی، یکی از مهمترین عوامل مربوط به کیفیت مراقبت          و ایمنی بیمار، مهارت‌های ارتباطی بین پرستاران و بیمارانشان می‌باشد.⁹
5- ترس از ناشناخته‌ها در قالب تـرس بیمار از محیط درمانی، پرسنل و فرایندهای درمانی نیز می‌تواند به‌عنوان ریشه‌های ظهور دلیریوم شناخته شوند.
6- بی‌ثباتی محیط در بروز دلیریوم نقش دارد. دلیریوم در محیط آرام و بی‌سر و صدا مانند بخش CCU بیشتر بروز می‌کند، بروز دلیریوم در بیماران بستری در بخش‌های پر سر و صدا، شلوغ و پر رفت و آمد را نیز می‌توانند مورد انتظار باشد.¹⁰
باتوجه به چالش‌های ذکر شده، به‌دلیل ماهیت چند بعدی و پیچیده دلیریوم، مراقبت از این بیماران را برای پرستاران می‌توان به برزخ مراقبتی تشبیه کرد که با نوعی ابهام و سردرگمی همراه است.  لذا می‌توان با اقداماتی همچون برگزاری دوره‌های آموزشی ویژه‌ای بـرای پرستاران در مورد دلیریوم، ابزارهای تشخیصی آن و روش‌های کنترل و پیشگیری آن، این مشکل را تعدیل کرد. از سوی دیگر با توجه به نقش پرستاران در پیشگیری و کنتـرل دلیریـوم، ضروری اســت گایدلاین‌ها و برنامه‌های پیشگیرانه از دلیریوم مطابق با گایدلاین‌های بین‌المللی تدوین و مورد استفاده پرستاران قرار گیرد.

Background: Prolonged stay in intensive care unit (ICU) can worsen the patient's prognosis and represents a significant economic burden. Previous studies have reported the effectiveness of early mobilization in reducing length of stay in ICUs for adult patients; However, conflicting results have been reported regarding its effects on pediatric patients. Therefore, this research aimed to investigate the impact of early mobilization on the length of stay in the pediatric intensive care unit (PICU) in ventilated children.
Methods: This pilot quasi-experimental study was conducted on 60 children admitted to the Children's Medical Center hospital from March 2020 to June 2021. For the control group, routine care (standard physiotherapy) was started on the second day of intubation and continued until discharge from the intensive care unit. In this study, we used an early mobilization protocol including active and passive exercises. The intervention was implemented by Pediatric intensive care unit nurses under supervision of a pediatric critical care fellowship physician. In the intervention group, passive exercises were started on the second day of intubation. At each shift, the nurses check the level of sedation and presence of delirium in the patients using the Richmond Agitation-Sedation Scale and the Cornell Assessment of Pediatric Delirium questionnaire. If the results showed that the sedation was not deep and delirium was not present, then active exercises were initiated. If the child did not achieve an adequate score indicating the absence of deep sedation and delirium, the patient remained in the passive exercise phase. The length of stay was recorded based on the patients' records. Descriptive and inferential statistics were used for data analysis using SPSS version 23.

Results:  The results showed that there was no significant difference in the length of stay in the pediatric intensive care unit (PICU) between the control (23.20±6.34 days) and intervention (22.60±6.18 days) groups (P=0.77). Conclusion: The implementation of early mobilization did not significantly reduce the length of PICU stay for pediatric. The researchers are advised to identify and evaluate evidence-based guidelines for implementing early mobilization in children with different diagnoses.

Background: COVID-19 is one of the most recent known human infections that has resulted in a global pandemic, causing high rates of morbidity and mortality worldwide. This study evaluated the clinical and epidemiological characteristics of the waves of the corona epidemic within a university surveillance system in southern Iran.
Methods: This cross-sectional study analyzed data from 24,132 individuals with Covid-19 in the registered waves from the beginning of the Corona epidemic from March 2020 to March 2021 in one of the southern universities of Iran. Information on age, gender, number of infections, severity, hospitalization, recovery rate, dominant strain, and compliance with protocols separately for each wave from 2020 to 2021 was collected from the University's databases. After calculating the cumulative incidence rate, mean and standard deviation and drawing graphs, chi-square, Mann-Whitney and one-way ANOVA were used in SPSS26 at a significance level of 5%.

Results: The cumulative incidence of the disease was 11.36%, with a relative frequency of hospitalization at 11.7% and an average hospital stay of Seven days. The highest percentage of protocol compliance was applied in the initial waves. The highest frequency of infection was in the third wave, where men were more infected than women in all waves except the 4th and 5th waves. High blood pressure was the most common underlying disease in patients and the most lung involvement was observed in the fifth wave. Most of the patients have recovered, and the highest rate of recovery was observed in the sixth wave. Significant associations were found between hospitalization duration, underlying conditions, and clinical symptoms across different waves (P<0.001). Systemic symptoms were the most common, and there was a notable difference in radiological findings between waves (P<0.001). Conclusion: The findings of this study emphasize the significant impact of underlying diseases and the severity of clinical symptoms on hospitalization outcomes. They also highlight the need for appropriate evidence-based management strategies and consideration of clinical changes and radiological patterns when evaluating diseases in different groups.