Faculty Decision Making in Ad Hoc Entrustment of Pediatric Critical Care Fellows: A National Case-Based Survey.

Phenomenon: Ad hoc entrustment decisions reflect a clinical supervisor's estimation of the amount of supervision a trainee needs to successfully complete a task in the moment. These decisions have important consequences for patient safety, trainee learning, and preparation for independent practice. Determinants of these decisions have previously been described but have not been well described for acute care contexts such as critical care and emergency medicine. The ad hoc entrustment of trainees caring for vulnerable patient populations is a high-stakes decision that may differ from other contexts. Critically ill patients and children are vulnerable patient populations, making the ad hoc entrustment of a pediatric critical care medicine (PCCM) fellow a particularly high-stakes decision. This study sought to characterize how ad hoc entrustment decisions are made for PCCM fellows through faculty ratings of vignettes. The authors investigated how acuity, relationship, training level, and task interact to influence ad hoc entrustment decisions. Approach: A survey containing 16 vignettes that varied by four traits (acuity, relationship, training level, and task) was distributed to U.S. faculty of pediatric critical care fellowships in 2020. Respondents determined an entrustment level for each case and provided demographic data. Entrustment ratings were dichotomized by "high entrustment" versus "low entrustment" (direct supervision or observation only). The authors used logistic regression to evaluate the individual and interactive effects of the four traits on dichotomized entrustment ratings. Findings: One hundred seventy-eight respondents from 30 institutions completed the survey (44% institutional response rate). Acuity, relationship, and task all significantly influenced the entrustment level selected but did not interact. Faculty most frequently selected "direct supervision" as the entrustment level for vignettes, including for 24% of vignettes describing fellows in their final year of training. Faculty rated the majority of vignettes (61%) as "low entrustment." There was no relationship between faculty or institutional demographics and the entrustment level selected. Insights: As has been found in summative entrustment for pediatrics, internal medicine, and surgery trainees, PCCM fellows often rated at or below the "direct supervision" level of ad hoc entrustment. This may relate to declining opportunities to practice procedures, a culture of low trust propensity among the specialty, and/or variation in interpretation of entrustment scales.

Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory disease in children (MIS-C) is a condition typically seen 3 to 6 weeks after acute infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Believed to be a postinfection hyperinflammatory response, the clinical manifestation of this viral sequelae can vary significantly in severity and symptomatic presentation. Clinical prodrome includes persistent fever and dysfunction of at least two organ systems. Often developing after asymptomatic or mildly symptomatic coronavirus disease 2019 (COVID-19) infection, MIS-C is a diagnosis of exclusion that requires evaluation for other infectious or noninfectious etiology for symptoms. Vital sign instability, including fever, tachycardia, and hypotension; laboratory studies demonstrating elevated inflammatory markers and elevated cardiac markers; and positive SARS-CoV-2 polymerase chain reaction, SARS-CoV-2 antibodies, or exposure to someone with confirmed COVID-19 infection 4 to 6 weeks before clinical presentation are used to diagnose this condition. Skin and mucosal involvement, gastrointestinal symptoms, and neurologic manifestations are also commonly seen. An echocardiogram is indicated to evaluate for cardiac dysfunction, including but not limited to coronary artery enlargement, left ventricular dysfunction, arrythmias, or atrioventricular block. [Pediatr Ann. 2023;52(3):e114-e121.].

Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit.

Introduction: Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the association between critical events (CEs), i.e., MV or VI events, within the first 48 h of PICU transfer from the ward or emergency department (ED) and in-hospital mortality. Methods: We conducted a retrospective study of a cohort of PICU transfers from the ward or the ED at two tertiary-care academic hospitals. We determined the association between mortality and occurrence of CEs within 48 h of PICU transfer after adjusting for age, gender, hospital, and prior comorbidities. Results: Experiencing a CE within 48 h of PICU transfer was associated with an increased risk of mortality [OR 12.40 (95% CI: 8.12-19.23, P < 0.05)]. The increased risk of mortality was highest in the first 12 h [OR 11.32 (95% CI: 7.51-17.15, P < 0.05)] but persisted in the 12-48 h time interval [OR 2.84 (95% CI: 1.40-5.22, P < 0.05)]. Varying levels of risk were observed when considering ED or ward transfers only, when considering different age groups, and when considering individual 12-h time intervals. Discussion: We demonstrate that occurrence of a CE within 48 h of PICU transfer was associated with mortality after adjusting for confounders. Studies focusing on the impact of quality improvement efforts may benefit from using CEs within 48 h of PICU transfer as an additional evaluation metric, provided these events could have been influenced by the initiative.

Association Between Critical Events in the PICU and Outcomes in Neighboring Patients.

PICU patients who experience critical illness events, such as intubation, are at high risk for morbidity and mortality. Little is known about the impact of these events, which require significant resources, on outcomes in other patients. Therefore, we aimed to assess the association between critical events in PICU patients and the risk of similar events in neighboring patients over the next 6 hours. DESIGN: Retrospective observational cohort study. SETTING: Quaternary care PICU at the University of Chicago. PATIENTS: All children admitted to the PICU between 2012 and 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a critical event defined as the initiation of invasive ventilation, initiating vasoactive medications, cardiac arrest, or death. The exposure was the occurrence of a critical event among other patients in the PICU within the preceding 6 hours. Discrete-time survival analysis using fixed 6-hour blocks beginning at the time of PICU admission was used to model the risk of experiencing a critical event in the PICU when an event occurred in the prior 6 hours. There were 13,628 admissions, of which 1,886 (14%) had a critical event. The initiation of mechanical ventilation was the most frequent event (n = 1585; 59%). In the fully adjusted analysis, there was a decreased risk of critical events (odds ratio, 0.82; 95% CI, 0.70-0.96) in the 6 hours following exposure to a critical event. This association was not present when considering longer intervals and was more pronounced in patients younger than 6 years old when compared with patients 7 years and older. CONCLUSION: Critical events in PICU patients are associated with decreased risk of similar events in neighboring patients. Further studies targeted toward exploring the mechanism behind this effect as well as identification of other nonpatient factors that adversely affect outcomes in children are warranted.

Development and External Validation of a Machine Learning Model for Prediction of Potential Transfer to the PICU.

OBJECTIVES: Unrecognized clinical deterioration during illness requiring hospitalization is associated with high risk of mortality and long-term morbidity among children. Our objective was to develop and externally validate machine learning algorithms using electronic health records for identifying ICU transfer within 12 hours indicative of a child's condition. DESIGN: Observational cohort study. SETTING: Two urban, tertiary-care, academic hospitals (sites 1 and 2). PATIENTS: Pediatric inpatients (age <18 yr). INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Our primary outcome was direct ward to ICU transfer. Using age, vital signs, and laboratory results, we derived logistic regression with regularization, restricted cubic spline regression, random forest, and gradient boosted machine learning models. Among 50,830 admissions at site 1 and 88,970 admissions at site 2, 1,993 (3.92%) and 2,317 (2.60%) experienced the primary outcome, respectively. Site 1 data were split longitudinally into derivation (2009-2017) and validation (2018-2019), whereas site 2 constituted the external test cohort. Across both sites, the gradient boosted machine was the most accurate model and outperformed a modified version of the Bedside Pediatric Early Warning Score that only used physiologic variables in terms of discrimination ( C -statistic site 1: 0.84 vs 0.71, p < 0.001; site 2: 0.80 vs 0.74, p < 0.001), sensitivity, specificity, and number needed to alert. CONCLUSIONS: We developed and externally validated a novel machine learning model that identifies ICU transfers in hospitalized children more accurately than current tools. Our model enables early detection of children at risk for deterioration, thereby creating opportunities for intervention and improvement in outcomes.

Fulminant myocarditis and atrial fibrillation in child with acute COVID-19.

COVID-19 has manifested with ventricular dysfunction and cardiac arrhythmias, most commonly atrial fibrillation (AFib), in adults. However, very few pediatric patients with acute COVID-19 have had cardiac involvement. AFib, an exceedingly rare arrhythmia in otherwise healthy children, has not been reported in children with COVID-19. We report a 15 year-old girl with acute COVID-19, fulminant myocarditis and AFib.

Contextual Factors Affecting Implementation of In-hospital Pediatric CPR Quality Improvement Interventions in a Resuscitation Collaborative.

INTRODUCTION: Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative. METHODS: A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide. RESULTS: All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6-124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff. CONCLUSIONS: Using mixed methods, we identified an association between the local QI team's strength and the successful implementation of the QI interventions.

Simulation in Pediatrics: A Learning Lab for Education, Quality Improvement, and Patient Safety.

Simulation-based medical education is an experiential modality that has evolved over the last 60 years, amassing evidence as an efficacious tool for skill acquisition and care improvement. We review the underlying theory, core defining principles, and applications of medical simulation broadly and in pediatrics in hopes that it can be accessible to every pediatric clinician regardless of practice environment and resources. Any situation where there is risk of harm to a patient or clinician can be simulated for practice, reflection, and re-practice. Whether preparing for clinic-based emergencies, new hospital units, or new daily workflows, simulation is valuable to novice and master clinicians for individual and team care enhancement. [Pediatr Ann. 2021;50(1):e13-e18.].

Simulation-Based Curricula for Enhanced Retention of Pediatric Resuscitation Skills: A Randomized Controlled Study.

INTRODUCTION: Resuscitation skills decay as early as 4 months after course acquisition. Gaps in research remain regarding ideal educational modalities, timing, and frequency of curricula required to optimize skills retention. Our objective was to evaluate the impact on retention of resuscitation skills 8 months after the Pediatric Advanced Life Support (PALS) course when reinforced by an adjunct simulation-based curriculum 4 months after PALS certification. We hypothesized there would be improved retention in the intervention group. METHODS: This is a partial, double-blind, randomized controlled study. First-year pediatric residents were randomized to an intervention or control group. The intervention group participated in a simulation-based curriculum grounded in principles of deliberate practice and debriefing. The control group received no intervention. T-tests were used to compare mean percent scores (M) from simulation-based assessments and multiple-choice tests immediately following the PALS course and after 8 months. RESULTS: Intervention group (n = 12) had overall improved retention of resuscitation skills at 8 months when compared with the control group (n = 12) (mean, 0.57 ± 0.05 vs 0.52 ± 0.06; P = 0.037). No significant difference existed between individual skills stations. The intervention group had greater retention of cognitive knowledge (mean, 0.78 ± 0.09 vs 0.68 ± 0.14; P = 0.049). Residents performed 61% of assessment items correctly immediately following the PALS course. CONCLUSIONS: Resuscitation skills acquisition from the PALS course and retention are suboptimal. These findings support the use of simulation-based curricula as course adjuncts to extend retention beyond 4 months.

A Vital Sign-Based Model to Predict Clinical Deterioration in Hospitalized Children.

OBJECTIVES: Clinical deterioration in hospitalized children is associated with increased risk of mortality and morbidity. A prediction model capable of accurate and early identification of pediatric patients at risk of deterioration can facilitate timely assessment and intervention, potentially improving survival and long-term outcomes. The objective of this study was to develop a model utilizing vital signs from electronic health record data for predicting clinical deterioration in pediatric ward patients. DESIGN: Observational cohort study. SETTING: An urban, tertiary-care medical center. PATIENTS: Patients less than 18 years admitted to the general ward during years 2009-2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome of clinical deterioration was defined as a direct ward-to-ICU transfer. A discrete-time logistic regression model utilizing six vital signs along with patient characteristics was developed to predict ICU transfers several hours in advance. Among 31,899 pediatric admissions, 1,375 (3.7%) experienced the outcome. Data were split into independent derivation (yr 2009-2014) and prospective validation (yr 2015-2018) cohorts. In the prospective validation cohort, the vital sign model significantly outperformed a modified version of the Bedside Pediatric Early Warning System score in predicting ICU transfers 12 hours prior to the event (C-statistic 0.78 vs 0.72; p < 0.01). CONCLUSIONS: We developed a model utilizing six commonly used vital signs to predict risk of deterioration in hospitalized children. Our model demonstrated greater accuracy in predicting ICU transfers than the modified Bedside Pediatric Early Warning System. Our model may promote opportunities for timelier intervention and risk mitigation, thereby decreasing preventable death and improving long-term health.

Caregiver Characteristics Associated With Quality of Cardiac Compressions on an Adult Mannequin With Real-Time Visual Feedback: A Simulation-Based Multicenter Study.

INTRODUCTION: Chest compression (CC) quality directly impacts cardiac arrest outcomes. Provider body type can influence the quality of cardiopulmonary resuscitation (CPR); however, the magnitude of this impact while using visual feedback is not well described. The aim of the study was to determine the association between provider anthropometric variables on fatigue and CC adherence to 2015 American Heart Association CPR while receiving visual feedback. METHODS: This was a planned secondary analysis of healthcare professionals from multiple hospitals performing continuous CC for 2 minutes on an adult CPR mannequin with dynamic visual feedback. Main outcome measures include compression data (depth, rate, and lean) evaluated in 30-second epochs to explore performance fatigue. Multivariable models examined the relationship of provider anthropometrics to CC quality. Binomial mixed effects models were used to characterize fatigue by examining performance for 4 epochs. RESULTS: Three hundred seventy-seven 2-minute CC episodes were analyzed. Extreme (low and high) BMI and weight are associated with poorer CC. Larger size (height, weight, and BMI) is associated with better depth but worse lean compliance. Performance fatigued for all providers for 2 minutes, but shorter, lighter weight, female participants had the greatest decline. On multivariable analysis, rate compliance did not deteriorate regardless of provider anthropometrics. CONCLUSIONS: Anthropometrics impact provider CC quality. Despite visual feedback, variable effects are seen on compression depth, rate, recoil, and fatigue depending on the provider sex, weight, and BMI. The 2-minute interval for changing chest compressors should be reconsidered based on individual provider characteristics and risk of fatigue's impact on high-quality CPR.

Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study.

BACKGROUND: Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. OBJECTIVE: To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. METHODS: A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. RESULTS: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. CONCLUSIONS: A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.

The effect of an International competitive leaderboard on self-motivated simulation-based CPR practice among healthcare professionals: A randomized control trial.

BACKGROUND: Little is known about how best to motivate healthcare professionals to engage in frequent cardiopulmonary resuscitation (CPR) refresher skills practice. A competitive leaderboard for simulated CPR can encourage self-directed practice on a small scale. The study aimed to determine if a large-scale, multi-center leaderboard improved simulated CPR practice frequency and CPR performance among healthcare professionals. METHODS: This was a multi-national, randomized cross-over study among 17 sites using a competitive online leaderboard to improve simulated practice frequency and CPR performance. All sites placed a Laerdal® ResusciAnne or ResusciBaby QCPR manikin in 1 or more clinical units - emergency department, ICU, etc. - in easy reach for 8 months. These simulators provide visual feedback during 2-minute compressions-only CPR and a performance score. Sites were randomly assigned to the intervention for the first 4-months or the second 4-months. Following any CPR practice by a healthcare professional, participants uploaded scores and an optional 'selfie' photo to the leaderboard. During the intervention phase, the leaderboard displayed ranked scores and high scores earned digital badges. The leaderboard did not display control phase participants. Outcomes included CPR practice frequency and mean compression score, using non-parametric statistics for analyses. RESULTS: Nine-hundred nineteen participants completed 1850 simulated CPR episodes. Exposure to the leaderboard yielded 1.94 episodes per person compared to 2.14 during the control phase (p = 0.99). Mean CPR performance participants did not differ between phases: 90.7 vs. 89.3 (p = 0.19). CONCLUSION: A competitive leaderboard was not associated with an increase in self-directed simulated CPR practice or improved performance.

The Fragility of Statistically Significant Findings in Pediatric Critical Care Randomized Controlled Trials.

OBJECTIVES: The Fragility Index measures the number of events on which the statistical significance of a result depends and has been suggested as an adjunct statistical assessment for interpretation of trial results. This study aimed to assess the robustness of statistically significant results from pediatric critical care randomized controlled trials with dichotomous outcomes. DATA SOURCES: A previously published scoping review of pediatric critical care randomized controlled trials (www.PICUtrials.net). STUDY SELECTION: A total of 342 trials were screened for inclusion. After applying inclusion/exclusion criteria, 43 fulfilled eligibility criteria and were included in the analysis. DATA EXTRACTION: Calculation of Fragility Index for trials reporting a statistically significant dichotomous outcome, and analysis of the relationship between trial characteristics and Fragility Index. DATA SYNTHESIS: The median Fragility Index was 2 (interquartile range, 1-6). The median sample size was 98 (interquartile range, 50-148) and sample size demonstrated a strong correlation with the Fragility Index (r = 0.729; n = 43; p < 0.001). The median number of outcome events was 8 (interquartile range, 4-15) and the total number of outcome events also showed a strong correlation with the Fragility Index (r = 0.728; n = 43; p < 0.001). CONCLUSIONS: Results from pediatric critical care randomized controlled trials with dichotomous outcomes reporting statistically significant findings often hinge on a small number of outcome events. Clinicians should exercise caution when interpreting results of trials with a low Fragility Index.

Leveraging Quick Response Code Technology to Facilitate Simulation-Based Leaderboard Competition.

INTRODUCTION: Leaderboards provide feedback on relative performance and a competitive atmosphere for both self-guided improvement and social comparison. Because simulation can provide substantial quantitative participant feedback, leaderboards can be used, not only locally but also in a multidepartment, multicenter fashion. Quick Response (QR) codes can be integrated to allow participants to access and upload data. We present the development, implementation, and initial evaluation of an online leaderboard employing principles of gamification using points, badges, and leaderboards designed to enhance competition among healthcare providers. METHOD: This article details the fundamentals behind the development and implementation of a user-friendly, online, multinational leaderboard that employs principles of gamification to enhance competition and integrates a QR code system to promote both self-reporting of performance data and data integrity. An open-ended survey was administered to capture perceptions of leaderboard implementation. RESULTS: Conceptual step-by-step instructions detailing how to apply the QR code system to any leaderboard using simulated or real performance metrics are outlined using an illustrative example of a leaderboard that employed simulated cardiopulmonary resuscitation performance scores to compare participants across 17 hospitals in 4 countries for 16 months. The following three major descriptive categories that captured perceptions of leaderboard implementation emerged from initial evaluation data from 10 sites: (1) competition, (2) longevity, and (3) perceived deficits. CONCLUSIONS: A well-designed leaderboard should be user-friendly and encompass best practices in gamification principles while collecting and storing data for research analyses. Easy storage and export of data allow for longitudinal record keeping that can be leveraged both to track compliance and to enable social competition.

The Fragility Index in a Cohort of Pediatric Randomized Controlled Trials.

Data suggest inadequacy of common statistical techniques for reporting outcomes in clinical trials. The Fragility Index can measure how many events the statistical significance hinges on, and may facilitate better interpretation of trial results. This study aimed to assess the Fragility Index in pediatric randomized controlled trials (RCTs) with statistically significant findings published in high-quality medical journals. A Fragility Index was calculated on included trials with dichotomous positive outcomes. Analysis of the relationship between trial characteristics and the Fragility Index was performed. Of the 429 abstracts screened, 17 met the inclusion criteria and underwent analysis. The median Fragility Index was 7 with an interquartile range of 2-11. In 41% of the studies, the number of patients lost to follow-up or withdrawn prior to analysis was equal to or greater than the Fragility Index. There was no correlation between the RCT sample size and the Fragility Index (r = 0.249, p = 0.335) nor the event group size and the Fragility Index (r = 0.250, p = 0.334). There was a strong negative correlation between the original p-value and the Fragility Index (r = -0.700, p = 0.002). The Fragility Index is a calculated metric that may assist in applying clinical relevance to statistically significant outcomes in pediatric randomized controlled trials with dichotomous outcomes.