Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters.

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains. DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017. SETTING: Multicenter study conducted in 33 PICUs across eight countries. SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation. INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions. MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008). CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

OBJECTIVES: To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. DESIGN: Single-center, prospective, observational trial. SETTING: Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. PATIENTS: Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. CONCLUSIONS: On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

Late Rescue Collaborative: Reducing Non-ICU Arrests.

OBJECTIVE: To reduce the frequency of non-ICU arrests through the implementation of an intramural collaborative focused on patient deterioration. DESIGN: Prospective quality improvement project. SETTING: Single-center, free-standing, tertiary children's hospital. PATIENTS: All patients admitted to acute care units. INTERVENTIONS: The Late Rescue Collaborative was formed in 2014 to monitor compliance with hospital escalation protocols and evaluate episodes of patient deterioration. The collaborative is a multidisciplinary team of physicians, nurses, and respiratory care providers. Three monthly meetings occur: 1) individual acute care unit-based meetings to evaluate trends and performance; 2) hospital-wide multidisciplinary whole group meetings to review hospital trends in deterioration and share lessons learned; and 3) steering committee to determine areas of focus. Based on these three meetings, unit- and hospital-based interventions have been put in place to improve recognition of deterioration and promote early rescue. MEASUREMENTS AND MAIN RESULTS: Rates of rapid response team activations, unplanned transfers, and non-ICU arrest are reported. Non-ICU arrest rates fell from a baseline of 0.31 per 1,000 non-ICU patient days to a new centerline of 0.11 and sustained for 36 months. Days between non-ICU arrests increased from a baseline of 15.5 days in year 2014 to a new centerline of 61.5 days and sustained for 37 months. Mortality following non-ICU arrests fell from four in 2014 and 2015 to zero in years 2016-2018. CONCLUSION: The Late Rescue Collaborative is an effective tool to improve patient safety by reducing non-ICU arrests.

Comparison of Pediatric Cardiopulmonary Resuscitation Quality in Classic Cardiopulmonary Resuscitation and Extracorporeal Cardiopulmonary Resuscitation Events Using Video Review.

OBJECTIVES: To assess differences in cardiopulmonary resuscitation quality in classic cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation events using video recordings of actual pediatric cardiac arrest events. DESIGN: Single-center, prospective, observational trial. SETTING: Tertiary-care pediatric teaching hospital, cardiac ICU. PATIENTS: All patients admitted to the pediatric cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventeen events comprising 264.5 minutes of cardiopulmonary resuscitation were included: 11 classic cardiopulmonary resuscitation events (87.5 min) and six extracorporeal cardiopulmonary resuscitation events (177 min). Events were divided into 30-second epochs, and cardiopulmonary resuscitation quality markers were assessed using video and telemetry data review of goal endpoints: end-tidal carbon dioxide greater than or equal to 15 mm Hg, diastolic blood pressure greater than or equal to 30 mm Hg, chest compression fraction greater than 80% per epoch, and chest compression rate between 100 and 120 chest compression per minute. Additionally, each chest compression pause (hands-off event) was recorded and timed. When compared with extracorporeal cardiopulmonary resuscitation, classic cardiopulmonary resuscitation epochs were more likely to have end-tidal carbon dioxide greater than or equal to 15 mm Hg (56% vs 6.2%; p = 0.01) and provide chest compression between 100 and 120 times per minute (112 vs 134 chest compression per minute; p < 0.001). No difference was found between classic cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation in compliance with diastolic blood pressure greater than or equal to 30 mm Hg (38% classic cardiopulmonary resuscitation vs 30% extracorporeal cardiopulmonary resuscitation). There were 135 hands-off events: 52 in classic cardiopulmonary resuscitation and 83 in extracorporeal cardiopulmonary resuscitation (p = 0.12). CONCLUSIONS: Classic cardiopulmonary resuscitation had superior adherence to end-tidal carbon dioxide goals and chest compression rate guidelines than extracorporeal cardiopulmonary resuscitation.

Evaluation of a Pediatric Early Warning Score Across Different Subspecialty Patients.

OBJECTIVE: To evaluate the ability of a Pediatric Early Warning Score to predict deterioration in different subspecialty patient populations. DESIGN: Single center, retrospective cohort study. Patients were classified into five groups: 1) cardiac; 2) hematology/oncology/bone marrow transplant; 3) surgical; 4) neurologic; and 5) general medical. The relationship between the Pediatric Early Warning Score and unplanned ICU transfer requiring initiation of specific ICU therapies (intubation, high-flow nasal cannula, noninvasive ventilation, inotropes, or aggressive fluid hydration within 12 hr of transfer) was evaluated. SETTING: Tertiary care, free-standing, academic children's hospital. PATIENTS: All hospitalized acute care patients admitted over a 6-month time period (September 2012 to March 2013). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study time period, 33,800 patient-days and 136 deteriorations were evaluated. Area under the curve ranged from 0.88 (surgical) to 0.94 (cardiac). Sensitivities for a Pediatric Early Warning Score greater than or equal to 3 ranged from 75% (surgical) to 94% (cardiology) and number needed to evaluate to find one deterioration was 11.5 (neurologic) to 43 patients (surgical). Sensitivities for a Pediatric Early Warning Score greater than or equal to 4 ranged from 54% (general medical) to 79% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 5.5 (neurologic) to 12 patients (general medical). Sensitivities for a Pediatric Early Warning Score of greater than or equal to 5 ranged from 25% (surgical) to 58% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 3.5 (cardiac, hematology/oncology/bone marrow transplant, neurologic) to eight patients (surgical). CONCLUSIONS: An elevated Pediatric Early Warning Score is associated with ICU transfer and receipt of ICU-specific interventions in patients across different pediatric subspecialty patient populations.

An Evaluation of Family-Centered Rounds in the PICU: Room for Improvement Suggested by Families and Providers.

OBJECTIVE: To identify areas for improvement in family-centered rounds from both the family and provider perspectives. DESIGN: Prospective, cross-sectional mixed-methods study, including an objective measure (direct observation of family-centered rounds) and subjective measures (surveys of English-speaking families and providers) of family-centered rounds. SETTING: PICU in a single, tertiary children's hospital. SUBJECTS: Families of children admitted to the PICU, physicians, and nurses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two hundred thirty-two family-centered round encounters were observed over a 10-week period. Family-centered round encounters averaged 10.5 minutes per child. Multivariable regression analysis revealed that family presence was independently associated with length of family-centered rounds (p < 0.002) despite family talk time accounting for an average of 25 seconds (4%) of the encounter. Non-English-speaking families were less likely to attend family-centered rounds compared with English-speaking families even when physically present at the patient's bedside (p < 0.001). Most commonly families and providers agreed that family-centered rounds keep the family informed and reported positive statements about family presence on family-centered rounds; however, PICU fellows did not agree that families provided pertinent information and nurses reported that family presence limited patient discussions. The primary advice families offered providers to improve family-centered rounds was to be more considerate and courteous, including accommodating family schedules, minimizing distractions, and limiting computer viewing. CONCLUSIONS: Family presence increased the length of family-centered rounds despite a small percentage of time spoken by families, suggesting longer rounds are due to changes in provider behavior when families are present. Also, non-English-speaking families may need more support to be able to attend and benefit from family-centered rounds. Lastly, in an era of full family-centered rounds acceptance, families and most providers, except fellows, report benefit from family presence during family-centered rounds. However, providers should be aware of the perception of their behaviors to optimize the experience for families.

Inpatient nursing care and early warning scores: a workflow mismatch.

Early warning scores calculated by registered nurses (RNs) are used in hospitals to enhance the recognition of and communication about patient deterioration. This study evaluated workflow variables surrounding calculation and documentation of one pediatric hospital's use of an early warning score. Results indicated that there were significant delays in documentation of early warning scores by RNs and inconsistencies between the early warning scores and vital signs collected and documented by non-RN personnel. These findings reflected information obtained from the RNs about how they prioritize tasks and use work-arounds to specific systems issues regarding assessment and documentation in the electronic medical record.

A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19.

BACKGROUND: Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES: To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19. METHODS: A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values. RESULTS: At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked. CONCLUSIONS: Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.

Emissions and energy impacts of the Inflation Reduction Act.

Economy-wide emissions drop 43 to 48% below 2005 levels by 2035 with accelerated clean energy deployment.

A Qualitative Analysis of Observed Behavior of Pediatric Rapid Response Team Performance.

BACKGROUND AND OBJECTIVES: Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs. METHODS: Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs. RESULTS: Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance. CONCLUSIONS: Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs.

We describe the process converting half of our 40-bed PICU into a negative-pressure biocontainment ICU dedicated to adult coronavirus disease 2019 patients within a 1,003-bed academic quaternary hospital. We outline the construction, logistics, supplies, provider education, staffing, and operations. We share lessons learned of working with a predominantly pediatric staff blended with adult expertise staff while maintaining elements of family-centered care typical of pediatric critical care medicine. Critically ill coronavirus disease 2019 adult patients may be cared for in a PICU and care may be augmented by implementing elements of holistic, family-centered PICU practice.

Improving Pediatric Rapid Response Team Performance Through Crew Resource Management Training of Team Leaders.

BACKGROUND: Rapid response teams (RRTs) improve the detection of and response to deteriorating patients. Professional hierarchies and the multidisciplinary nature of RRTs hinder team performance. This study assessed whether an intervention involving crew resource management training of team leaders could improve team performance. METHODS: In situ observations of RRT activations were performed pre- and post-training intervention. Team performance and dynamics were measured by observed adherence to an ideal task list and by the Team Emergency Assessment Measure tool, respectively. Multiple quartile (median) and logistic regression models were developed to evaluate change in performance scores or completion of specific tasks. RESULTS: Team leader and team introductions (40% to 90%, P = .004; 7% to 45%, P = .03), floor team presentations in Situation Background Assessment Recommendation format (20% to 65%, P = .01), and confirmation of the plan (7% to 70%, P = .002) improved after training in patients transferred to the ICU (n = 35). The Team Emergency Assessment Measure metric was improved in all 4 categories: leadership (2.5 to 3.5, P < .001), teamwork (2.7 to 3.7, P < .001), task management (2.9 to 3.8, P < .001), and global scores (6.0 to 9.0, P < .001) for teams caring for patients who required transfer to the ICU. CONCLUSIONS: Targeted crew resource management training of the team leader resulted in improved team performance and dynamics for patients requiring transfer to the ICU. The intervention demonstrated that training the team leader improved behavior in RRT members who were not trained.

Unscheduled Pediatric Intensive Care Unit Admissions in Patients With Cardiovascular Disease: Clinical Features and Outcomes.

BACKGROUND: An unscheduled readmission to the intensive care unit (ICU) is associated with increased morbidity and mortality in children. There is a paucity of data examining the impact of unscheduled admissions on outcomes in children with specific disease processes such as cardiovascular disease. We investigated the impact of scheduled versus unscheduled ICU admission on clinical outcomes and differences in patient characteristics in children with cardiovascular disease. METHODS: This was a retrospective analysis of contemporaneously collected clinical data using the Virtual PICU Systems database. All consecutive admissions at 102 participating pediatric ICUs in patients with cardiovascular disease were collected from October 2010 to September 2012. RESULTS: There were 48,653 admissions included in the analysis (44% scheduled and 56% unscheduled). The median patient age was 31 months. Unscheduled admissions were associated with longer ICU length of stay and increased mortality (both P < .001). Adjusting for age, weight, and primary ICU admission diagnosis (cardiovascular vs noncardiovascular), patients with unscheduled admissions had an increased odds of mortality (odds ratio = 4.8, P < .001). CONCLUSIONS: Unscheduled ICU admissions were associated with worse clinical outcomes including increased mortality. Efforts targeted at reducing unscheduled admissions in at-risk patients are warranted.

Comparison of Pediatric Early Warning Score to Physician Opinion for Deteriorating Patients.

BACKGROUND: This study compares a Pediatric Early Warning Score (PEWS) to physician opinion in identifying patients at risk for deterioration. METHODS: Maximum PEWS recorded during each admission was retrospectively ascertained from electronic medical record data. Physician opinion regarding risk of subsequent deterioration was determined by assignment to an institutional "senior sign-out" (SSO) list that highlights patients whom senior pediatric residents have identified as at risk. Deterioration events were defined as intubation, initiation of high flow nasal cannula, inotropes, noninvasive mechanical ventilation, or aggressive fluid resuscitation within 12 hours of transfer to the PICU. We assessed the relationships of sociodemographic variables, PEWS, and SSO assignment with subsequent deterioration events using multivariate regression analysis to control for a number of covariates. RESULTS: There were 97 patients with nonelective transfers to the PICU who were eligible for placement on the SSO lists before transfer, 51 of whom experienced qualifying deterioration events. Maximum recorded PEWS was significantly higher for patients with a subsequent deterioration event during the first 12 hours after transfer, compared with those who were transferred but did not experience a deterioration event in the first 12 hours (mean [SD]: 3.9 [2.0] vs 2.9 [2.0]; P = .01). This association persisted even after multivariate adjustment. SSO assignment was only marginally associated with risk of deterioration among this patient population, with or without adjustment for covariates. CONCLUSIONS: The PEWS was significantly associated with ICU deterioration, whereas physician opinion was not. Used alone or in conjunction with physician assessment, PEWS is a valuable tool for identifying patients vulnerable to acute deterioration.

Adults with chronic health conditions originating in childhood: inpatient experience in children's hospitals.

OBJECTIVE: To describe the rate of increase of the population of adults seeking care as inpatients in children's hospitals over time. PATIENTS AND METHODS: We analyzed data from January 1, 1999, to December 31, 2008, from patients hospitalized at 30 academic children's hospitals, including growth rates according to age group (pediatric: aged <18 years; transitional: aged 18-21 years; or adult: aged >21 years) and disease. RESULTS: There were 3 343 194 hospital discharges for 2 143 696 patients. Transitional patients represented 2.0%, and adults represented 0.8%, totaling 59 974 patients older than 18 years. The number of unique patients, admissions, patient-days, and charges increased in all age groups over the study period and are projected to continue to increase. Resource use was disproportionately higher in the older ages. The growth of transitional patients exceeded that of others, with 6.9% average annual increase in discharges, 7.6% in patient-days, and 15% in charges. Chronic conditions occurred in 87% of adults compared with 48% of pediatric patients. Compared with pediatric patients, the rates of increase of inpatient-days increased significantly for transitional age patients with cystic fibrosis, malignant neoplasms, and epilepsy, and for adults with cerebral palsy. Annual growth rates of charges increased for transitional and adult patients for all diagnoses except cystic fibrosis and sickle cell disease. CONCLUSIONS: The population of adults with diseases originating in childhood who are hospitalized at children's hospitals is increasing, with varying disease-specific changes over time. Our findings underscore the need for proactive identification of strategies to care for adult survivors of pediatric diseases.