Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network.

The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network originated over 20 years ago to foster research to optimize the care of critically ill infants and children. Over this period, PALISI has seen two major evolutions: formalization of our network infrastructure and a broadening of our clinical research focus. First, the network is unique in that its activities and meetings are funded by subscriptions from members who now comprise a multidisciplinary group of investigators from over 90 PICUs all over the United States (US) and Canada, with collaborations across the globe. In 2020, the network converted into a standalone, nonprofit organizational structure (501c3), making the PALISI Network formally independent of academic and clinical institutions or professional societies. Such an approach allows us to invest in infrastructure and future initiatives with broader opportunities for fund raising. Second, our research investigations have expanded beyond the original focus on sepsis and acute lung injury, to incorporate the whole field of pediatric critical care, for example, efficient liberation from mechanical ventilator support, prudent use of blood products, improved safety of intubation practices, optimal sedation practices and glucose control, and pandemic research on influenza and COVID-19. Our network approach in each field follows, where necessary, the full spectrum of clinical and translational research, including: immunobiology studies for understanding basic pathologic mechanisms; surveys to explore contemporary clinical practice; consensus conferences to establish agreement about literature evidence; observational prevalence and incidence studies to measure scale of a clinical issue or question; case control studies as preliminary best evidence for design of definitive prospective studies; and, randomized controlled trials for informing clinical care. As a research network, PALISI and its related subgroups have published over 350 peer-reviewed publications from 2002 through September 2022.

An Intensive, Simulation-Based Communication Course for Pediatric Critical Care Medicine Fellows.

OBJECTIVE: Effective communication among providers, families, and patients is essential in critical care but is often inadequate in the PICU. To address the lack of communication education pediatric critical care medicine fellows receive, the Children's Hospital of Pittsburgh PICU developed a simulation-based communication course, Pediatric Critical Care Communication course. Pediatric critical care medicine trainees have limited prior training in communication and will have increased confidence in their communication skills after participating in the Pediatric Critical Care Communication course. DESIGN: Pediatric Critical Care Communication is a 3-day course taken once during fellowship featuring simulation with actors portraying family members. SETTING: Off-site conference space as part of a pediatric critical care medicine educational curriculum. SUBJECTS: Pediatric Critical Care Medicine Fellows. INTERVENTIONS: Didactic sessions and interactive simulation scenarios. MEASUREMENTS AND MAIN RESULTS: Prior to and after the course, fellows complete an anonymous survey asking about 1) prior instruction in communication, 2) preparedness for difficult conversations, 3) attitudes about end-of-life care, and 4) course satisfaction. We compared pre- and postcourse surveys using paired Student t test. Most of the 38 fellows who participated over 4 years had no prior communication training in conducting a care conference (70%), providing bad news (57%), or discussing end-of-life options (75%). Across all four iterations of the course, fellows after the course reported increased confidence across many topics of communication, including giving bad news, conducting a family conference, eliciting both a family's emotional reaction to their child's illness and their concerns at the end of a child's life, discussing a child's code status, and discussing religious issues. Specifically, fellows in 2014 reported significant increases in self-perceived preparedness to provide empathic communication to families regarding many aspects of discussing critical care, end-of-life care, and religious issues with patients' families (p < 0.05). The majority of fellows (90%) recommended that the course be required in pediatric critical care medicine fellowship. CONCLUSIONS: The Pediatric Critical Care Communication course increased fellow confidence in having difficult discussions common in the PICU. Fellows highly recommend it as part of PICU education. Further work should focus on the course's impact on family satisfaction with fellow communication.

Establishing intensivist-driven ultrasound at the PICU bedside--it's about time*.

OBJECTIVE: To discuss pediatric intensivist-driven ultrasound and the exigent need for research and practice definitions pertaining to its implementation within pediatric critical care, specifically addressing issues in ultrasound-guided vascular access and intensivist-driven echocardiography. CONCLUSIONS: Intensivist-driven ultrasound improves procedure safety and reduces time to diagnosis in clinical ultrasound applications, as demonstrated primarily in adult patients. Translating these applications to the PICU requires thoughtful integration of the technology into practice and would best be informed by dedicated ultrasound research in critically ill children.

Portal hypertension in children: expert pediatric opinion on the report of the Baveno v Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension.

Complications of portal hypertension in children lead to significant morbidity and are a leading indication for consideration of liver transplantation. Approaches to the management of sequelae of portal hypertension are well described for adults and evidence-based approaches have been summarized in numerous meta-analyses and conferences. In contrast, there is a paucity of data to guide the management of complications of portal hypertension in children. An international panel of experts was convened on April 8, 2011 at The Children's Hospital of Pittsburgh of UPMC to review and adapt the recent report of the Baveno V Consensus Workshop on the Methodology of Diagnosis and Therapy in Portal Hypertension to the care of children. The opinions of that expert panel are reported.

An Evaluation of Antimicrobial Prescribing and Risk-adjusted Mortality.

The Centers for Disease Control and Prevention recommends tracking risk-adjusted antimicrobial prescribing. Prior studies have used prescribing variation to drive quality improvement initiatives without adjusting for severity of illness. The present study aimed to determine the relationship between antimicrobial prescribing and risk-adjusted ICU mortality in the Pediatric Health Information Systems (PHIS) database, assessed by IBM-Watson risk of mortality. A nested analysis sought to assess an alternative risk model incorporating laboratory data from federated electronic health records. METHODS: Retrospective cohort study of pediatric ICU patients in PHIS between 1/1/2010 and 12/31/2019, excluding patients admitted to a neonatal ICU, and a nested study of PHIS+ from 1/1/2010 to 12/31/2012. Hospital antimicrobial prescription volumes were assessed for association with risk-adjusted mortality. RESULTS: The cohort included 953,821 ICU encounters (23,851 [2.7%] nonsurvivors). There was 4-fold center-level variability in antimicrobial use. ICU antimicrobial use was not correlated with risk-adjusted mortality assessed using IBM-Watson. A risk model incorporating laboratory data available in PHIS+ significantly outperformed IBM-Watson (c-statistic 0.940 [95% confidence interval 0.933-0.947] versus 0.891 [0.881-0.901]; P < 0.001, area under the precision recall curve 0.561 versus 0.297). Risk-adjusted mortality was inversely associated with antimicrobial prescribing in this smaller cohort using both the PHIS+ and Watson models (P = 0.05 and P < 0.01, respectively). CONCLUSIONS: Antimicrobial prescribing among pediatric ICUs in the PHIS database is variable and not associated with risk-adjusted mortality as assessed by IBM-Watson. Expanding existing administrative databases to include laboratory data can achieve more meaningful insights when assessing multicenter antibiotic prescribing practices.

Strategies to optimize implementation of novel preceptorship models: Peer-assisted learning and near-peer teaching.

INTRODUCTION: Hospital experiential placements have traditionally used a 1:1 (student to preceptor) ratio. Two models, peer-assisted learning (PAL) and near-peer teaching (NPT), have been described in the literature for education of health professions. This research explored the use of PAL and NPT, as well as advantages, challenges, and strategies to address challenges for implementation. METHODS: This study used an anonymous survey to solicit feedback from staff pharmacists and pharmacy leaders about their use of PAL and NPT models in hospital settings in Alberta, Canada. Using closed and open-ended questions, experience with each model and implementation considerations were explored. RESULTS: The survey was completed by 115 hospital pharmacists (11% response rate). PAL and NPT were utilized by 25% and 8% of respondents, respectively, and 10% had experience with both models. Advantages of these models include promoting teamwork and clinical independence, learners supporting each other, and fostering active learning. The highest ranked challenges were space/technology/computer access limitations and additional time to complete learner assessments. Many strategies were provided to address challenges, and facilitate implementation and utilization. CONCLUSION: In the hospital setting, pharmacists used PAL more commonly than NPT. Feedback from pharmacists and leaders affirmed the advantages and challenges associated with use of these precepting models. Strategies to facilitate and optimize use were provided, which will guide faculty, pharmacy leaders, and preceptors in efforts to support implementation to increase capacity and expand the practice of precepting.

Pharmacy student-led blood pressure clinic as part of a comprehensive approach to teaching blood pressure assessment.

BACKGROUND AND PURPOSE: Hypertension is highly prevalent and sub-optimally controlled in many patients. Strong evidence supports the role of pharmacists in assessing blood pressure (BP) and managing hypertension; however, there is limited literature on curricular activities to prepare pharmacy graduates for this role. EDUCATIONAL ACTIVITY AND SETTING: This study describes the integration of a BP screening clinic at a tertiary-care cardiac centre as part of a second-year pharmacy curriculum and its impact on pharmacy students' perceived ability and confidence in BP measurement and patient education on hypertension. FINDINGS: We analyzed anonymized course feedback from students attending the BP clinic from 2014 to 2017. The response rate was 96.5% (498/516). Over 90% of students greatly/mostly agreed that participating in the BP screening clinic improved both their ability and confidence in manually measuring BP. Additionally, over 75% greatly/mostly agreed that participating in the clinic improved their ability and confidence in educating patients about hypertension prevention and management. In addition to technical aspects of BP measurement such as landmarking and correct positioning, students reported experiences from the clinic enriched several non-technical skills, including communication, information gathering, public engagement, and advocacy. SUMMARY: Implementing a BP screening clinic at a tertiary-care healthcare facility as part of a second-year pharmacy curriculum improved students' self-reported ability and confidence in manually measuring BP and educating members of the public.

Use of computerized interview scheduling program for pediatric surgery match applicants.

BACKGROUND: Pediatric surgery fellowship applicants and programs coordinate over 20 interviews per cycle. We hypothesized that replacing e-mail and phone communication with a computerized-scheduling program (CSP) could benefit both parties. METHODS: We used a CSP to schedule 2016 interviews. Time to schedule and e-mail communication per applicant was compared to 2015, when traditional scheduling was used. Additionally, 2016 interviewees were surveyed about their experience with the CSP vs. traditional means. Analysis was performed using descriptive statistics and a Student's T-test. RESULTS: We found a significant decrease in mean scheduling time from 14.4 to 1.7h (p<0.001) and in e-mails exchanged from 3.4 to 1.0 (p<0.0001). Survey respondents reported 92% satisfaction with the CSP, and 87% found it easier to schedule interviews. Applicants also reported quicker finalization of interview dates (96%), improved access to interview slots (71%), and easier coordination of additional services and time off (63%). Notably, the mean longest time reported to schedule interviews using traditional methods was 7days (range 1-30). Overall, 84% supported widespread adoption of CSPs. CONCLUSIONS: Using CSPs improved the scheduling process for the significant majority of interviewees, and our program. If widely adopted, this could greatly improve the efficiency of pediatric surgery interview scheduling. LEVEL OF EVIDENCE: N/A.

Development of a Quality Improvement Bundle to Reduce Tracheal Intubation-Associated Events in Pediatric ICUs.

Advanced airway management in the pediatric intensive care unit (PICU) is hazardous, with associated adverse outcomes. This report describes a methodology to develop a bundle to improve quality and safety of tracheal intubations. A prospective observational cohort study was performed with expert consensus opinion of 1715 children undergoing tracheal intubation at 15 PICUs. Baseline process and outcomes data in tracheal intubation were collected using the National Emergency Airway Registry for Children reporting system. Univariate analysis was performed to identify risk factors associated with adverse tracheal intubation-associated events. A multidisciplinary quality improvement committee was formed. Workflow analysis of tracheal intubation and pilot testing were performed to develop the Airway Bundle Checklist with 4 parts: (1) risk factor assessment, (2) plan generation, (3) preprocedure time-out to ensure that providers, equipment, and plans are prepared, (4) postprocedure huddle to identify improvement opportunities. The Airway Bundle Checklist developed may lead to improvement in airway management.

A Quality Assessment of a Collaborative Model of a Pediatric Antimicrobial Stewardship Program.

BACKGROUND: Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship program (ASP) personnel include an infectious disease (ID) physician leader and dedicated ID-trained clinical pharmacist. Limited resources prompted development of an alternative model by using ID physicians and service-based clinical pharmacists at a pediatric hospital. The aim of this study was to analyze the effectiveness and impact of this alternative ASP model. METHODS: The collaborative ASP model incorporated key strategies of education, antimicrobial restriction, day 3 audits, and practice guidelines. High-use and/or high-cost antimicrobial agents were chosen with audits targeting vancomycin, caspofungin, and meropenem. The electronic medical record was used to identify patients requiring day 3 audits and to communicate ASP recommendations. Segmented regression analyses were used to analyze quarterly antimicrobial agent prescription data for the institution and selected services over time. RESULTS: Initiation of ASP and day 3 auditing was associated with blunting of a preexisting increasing trend for caspofungin drug starts and use and a significant downward trend for vancomycin drug starts (relative change -12%) and use (-25%), with the largest reduction in critical care areas. Although meropenem use was already low due to preexisting requirements for preauthorization, a decline in drug use (-31%, P = .021) and a nonsignificant decline in drug starts (-21%, P = .067) were noted. A 3-month review of acceptance of ASP recommendations found rates of 90%, 93%, and 100% for vancomycin, caspofungin, and meropenem, respectively. CONCLUSIONS: This nontraditional ASP model significantly reduced targeted drug usage demonstrating acceptance of integration of service-based clinical pharmacists and ID consultants.

Family Presence During Pediatric Tracheal Intubations.

IMPORTANCE: Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated. OBJECTIVE: To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs. EXPOSURES: Family presence and no FP during TI in the PICU. MAIN OUTCOMES AND MEASURES: The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level. RESULTS: A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders. CONCLUSIONS AND RELEVANCE: Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.

Intraabdominal infections in infants and children: descriptions and definitions.

OBJECTIVE: To define intraabdominal infections in infants and children. DESIGN: Summary of the literature with review and consensus by experts in the field. RESULTS: Intraabdominal infections are common in infants and children and comprise a broad range of disorders of greatly variable severity. In addition to microbiologically mediated processes, other inflammatory disorders frequently present similar clinical syndromes. More aggressive and effective therapy for prematurity, chronic diseases of childhood, malignancies, immunodeficiencies, and organ failure, including transplantation, is likely to increase the frequency with which some of these infections are encountered. Only a limited number of processes have been clearly defined in the pediatric literature. CONCLUSIONS: Criteria defining intraabdominal infection are proposed based on reports in the pediatric literature and expert opinion. Additional study of individual disorders, diagnostic criteria, and approach to management is warranted.

Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS.

PURPOSE: To evaluate the incidence and associated risk factors of difficult tracheal intubations (TI) in pediatric intensive care units (PICUs). METHODS: Using the National Emergency Airway Registry for Children (NEAR4KIDS), TI quality improvement data were prospectively collected for initial TIs in 15 PICUs from July 2010 to December 2011. Difficult pediatric TI was defined as TIs by direct laryngoscopy which failed or required more than two laryngoscopy attempts by fellow/attending-level physician providers. RESULTS: A total of 1,516 oral TIs were reported with a median age of 2 years. A total of 97% of patients were intubated with direct laryngoscopy. The incidence of difficult TI was 9%. In univariate analysis, patients with difficult TI were younger [median 1 year (0-4) vs. 2 (0-8) years, p = 0.046], and had a reported history of difficult TI (22 vs. 8%, p < 0.001). Multivariate analysis showed that history of difficult airway and signs of upper airway obstruction are significantly associated with difficult TI. The advanced airway provider was more involved as a first provider in difficult TI (81 vs. 58%, p < 0.001). The presence of difficult TI was associated with higher incidence of oxygen desaturation below 80% (48 vs. 15%, p < 0.001), adverse TI associated events (53 vs. 20%, p < 0.001), and severe TI associated events (13 vs. 6%, p = 0.003). CONCLUSIONS: Difficult TI was reported in 9% of all TIs and was associated with increased adverse TI events. History of difficult airway and sign of upper airway obstruction were associated with difficult TIs.

Commentary: Those who do not learn from history are doomed to repeat it.

In this commentary, the author asks, can educators learn from being reminded of moments of poor judgment or inappropriate behavior in the history of medical education, or should these incidents not be revived and revisited? The question is posed in relation to the accompanying article in this issue by Halperin, which examines the publication of a medical textbook that featured pin-up style photos of women but not men. Both in the past and now, attitudes and behaviors can be found within medical education that have helped to sustain cultural misunderstanding and bias. It may be difficult to become aware of these attitudes and the ways they can infect teaching, thus detracting from good care of patients. A more recent example from the author's experience is discussed, regarding physician bias toward treating patients with HIV/AIDS. Readers are reminded that medicine not only exists in the context of social mores and customs, but helps create them. Examining the past can help to cultivate awareness of such inappropriate bias and generate strategies for resistance.