Performance of a Provider-Assigned Functional Outcome Score in Critically Ill Children.

OBJECTIVES: Determine agreement between Pediatric Cerebral Performance Category (PCPC) scores integrated into clinical workflow and traditional investigator-assigned scores. DESIGN: Longitudinal study. SETTING: A single-center quaternary-care academic institution. SUBJECTS: Children admitted to the PICU between November 2019 and April 2020. INTERVENTIONS: Providers assigned PCPC scores as part of daily workflow. Investigators assigned scores using retrospective chart review. MEASUREMENTS AND MAIN RESULTS: Of 803 patients admitted to the PICU, 782 survived and were included. Admission and discharge scores were recorded in 95% and 90% of patients, respectively. Agreement between provider- and investigator-assigned scores was excellent, with a weighted kappa of 0.87 (95% CI, 0.84-0.90) and 0.80 (95% CI, 0.76-0.84) for admission and discharge. CONCLUSIONS: Provider-assigned PCPC scores, documented as standard of care, are largely concordant with retrospective investigator-assigned scores. Measurement of cognitive functional status can be successfully integrated into daily provider workflow for use in the clinical, quality improvement, and research arenas.

Laryngeal Ultrasound Detects Vocal Fold Immobility in Adults: A Systematic Review.

Laryngeal ultrasound (US) is becoming widely accepted for assessing true vocal fold immobility (TVFI), a potential complication of laryngeal and thyroid surgery. The objective of this project is to perform a systematic review and meta-analysis of pooled evidence surrounding laryngeal US as a modality for diagnosing TVFI in adults at risk for the condition in comparison to laryngoscopy as a gold standard. Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations from January 1, 2000, to June 30, 2020. Studies were included if they involved patients 16 years and older, where laryngeal US was compared to laryngoscopy for TVFI. Studies were excluded if there were insufficient data to compute a sensitivity/specificity table after attempting to contact the authors. Case reports, and case series were also excluded. The initial search returned 1357 citations. Of these, 109 were selected for review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty citations describing 6033 patients were included in the final meta-analysis. A bivariate random effects meta-analysis was performed, revealing a pooled sensitivity for laryngeal US of 0.95 (95% confidence interval [CI] 0.88-0.98), a specificity of 0.99 (95% CI 0.97-0.99), and a diagnostic odds ratio of 1328.2 (95% CI 294.0-5996.5). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI 0.98-1.00). Laryngeal US demonstrates high sensitivity and specificity for detecting VFI in the hands of clinicians directly providing care to patients.

Frustration With Technology and its Relation to Emotional Exhaustion Among Health Care Workers: Cross-sectional Observational Study.

BACKGROUND: New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout. OBJECTIVE: This study aimed to evaluate and quantify health care workers' frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands. METHODS: This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics. RESULTS: Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P<.001) and each individual item on the Emotional Exhaustion scale (r=0.29-0.36, P<.001 for all). Each 10-point increase in the frustration with technology score was associated with a 1.2-point increase (95% CI 1.1-1.4) in emotional exhaustion (both measured on 100-point scales), after adjustment for other work-life integration items and unit and health care worker characteristics. CONCLUSIONS: This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.

Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis.

Background: Whether health care provider burnout contributes to lower quality of patient care is unclear. Purpose: To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship. Data Sources: MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019. Study Selection: Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care. Data Extraction: 2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests. Data Synthesis: A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout-quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety. Limitation: Studies were primarily observational; neither causality nor directionality could be determined. Conclusion: Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates. Primary Funding Source: Stanford Maternal and Child Health Research Institute.

Association of Blood Pressure Measurements With Peripheral Artery Disease Events.

BACKGROUND: Current guidelines recommend treating hypertension in patients with peripheral artery disease (PAD) to reduce the risk of cardiac events and stroke, but the effect of reducing blood pressure on lower extremity PAD events is largely unknown. We investigated the association of blood pressure with lower extremity PAD events using data from the ALLHAT trial (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). METHODS: ALLHAT investigated the effect of different antihypertensive medication classes (chlorthalidone, amlodipine, lisinopril, or doxazosin) on cardiovascular events. With the use of these data, the primary outcome in our analysis was time to first lower extremity PAD event, defined as PAD-related hospitalization, procedures, medical treatment, or PAD-related death. Given the availability of longitudinal standardized blood pressure measurements, we analyzed systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure as time-varying categorical variables (reference categories 120-129 mm Hg for SBP, 70-79 mm Hg for DBP, and 45-54 mm Hg for pulse pressure) in separate models. We used extended Cox regression with death as a competing risk to calculate the association of each blood pressure component with PAD events, and report the results as subdistribution hazard ratios and 95% CIs. RESULTS: The present analysis included 33 357 patients with an average age of 67.4 years, 53.1% men, 59.7% white race, and 36.2% with diabetes mellitus. The median baseline blood pressure was 146/84 mm Hg. Participants were followed for a median of 4.3 (interquartile range, 3.6-5.3) years, during which time 1489 (4.5%) had a lower extremity PAD event, and 4148 (12.4%) died. In models adjusted for demographic and clinical characteristics, SBP <120 mm Hg was associated with a 26% (CI, 5%-52%; P=0.015) higher hazard and SBP≥160 mm Hg was associated with a 21% (CI, 0%-48%; P=0.050) higher hazard for a PAD event, in comparison with SBP 120 to 129 mm Hg. In contrast, lower, but not higher, DBP was associated with a higher hazard of PAD events: for DBP <60 mm Hg (hazard ratio, 1.72; CI, 1.38-2.16). Pulse pressure had a U-shaped association with PAD events. CONCLUSIONS: In this reanalysis of data from ALLHAT, we found a higher rate of lower extremity PAD events with higher and lower SBP and pulse pressure and with lower DBP. Given the recent revised blood pressure guidelines advocating lower SBP targets for overall cardiovascular risk reduction, further refinement of optimal blood pressure targets specific to PAD is needed. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00000542.

Safety climate, safety climate strength, and length of stay in the NICU.

BACKGROUND: Safety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs). METHODS: Observational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU's respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (< 1500 g) infants was evaluated using log-linear regression. Secondary outcomes were infections, chronic lung disease, and mortality. RESULTS: NICUs had safety climate PPRs of 66 ± 12%, intra-unit standard deviations 11 (strongest) to 23 (weakest), and median LOS 60 days. NICUs with stronger climates had LOS 4 days shorter than those with weaker climates. In interaction modeling, NICUs with weak climates and low PPR had the longest LOS, NICUs with strong climates and low PPR had the shortest LOS, and NICUs with high PPR (both strong and weak) had intermediate LOS. Stronger climates were associated with lower odds of infections, but not with other secondary outcomes. CONCLUSIONS: Safety climate strength is independently associated with LOS and moderates the association between PPR and LOS among VLBW infants. Strength and PPR together provided better prediction than PPR alone, capturing variance in outcomes missed by PPR. Evaluations of NICU safety climate consider both positivity (PPR) and consistency of responses (strength) across individuals.

Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants.

Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

ALTERED PROFILES OF EXTRACELLULAR MITOCHONDRIAL DNA IN IMMUNOPARALYZED PEDIATRIC PATIENTS AFTER THERMAL INJURY.

ABSTRACT: Background: Thermal injury is a major cause of morbidity and mortality in the pediatric population worldwide with secondary infection being the most common acute complication. Suppression of innate and adaptive immune function is predictive of infection in pediatric burn patients, but little is known about the mechanisms causing these effects. Circulating mitochondrial DNA (mtDNA), which induces a proinflammatory signal, has been described in multiple disease states but has not been studied in pediatric burn injuries. This study examined the quantity of circulating mtDNA and mtDNA mutations in immunocompetent (IC) and immunoparalyzed (IP) pediatric burn patients. Methods: Circulating DNA was isolated from plasma of pediatric burn patients treated at Nationwide Children's Hospital Burn Center at early (1-3 days) and late (4-7 days) time points postinjury. These patients were categorized as IP or IC based on previously established immune function testing and secondary infection. Three mitochondrial genes, D loop, ND1, and ND4, were quantified by multiplexed qPCR to assess both mtDNA quantity and mutation load. Results: At the early time point, there were no differences in plasma mtDNA quantity; however, IC patients had a progressive increase in mtDNA over time when compared with IP patients (change in ND1 copy number over time 3,880 vs. 87 copies/day, P = 0.0004). Conversely, the IP group had an increase in mtDNA mutation burden over time. Conclusion: IC patients experienced a significant increase in circulating mtDNA quantity over time, demonstrating an association between increased mtDNA release and proinflammatory phenotype in the burn patients. IP patients had significant increases in mtDNA mutation load likely representative of degree of oxidative damage. Together, these data provide further insight into the inflammatory and immunological mechanisms after pediatric thermal injury.

Prevalence of burnout and its relation to the neuroendocrine system among pediatric residents during the early Covid-19 pandemic: A pilot feasibility study.

Background: Measuring burnout relies on infrequent and subjective surveys, which often do not reflect the underlying factors or biological mechanisms that promote or prevent it. Burnout correlates with cortisol levels and dysregulation of the hypothalamic-pituitary-adrenal axis, but the chronology and strength of this relationship are unknown. Objective: To determine the prevalence and feasibility of studying burnout in pediatric residents using hair cortisol and hair oxytocin concentrations. Design: /Methods: Longitudinal observational cohort study of pediatric residents. We assessed burnout using the Stanford Professional Fulfillment Index and hair cortisol (HCC), and hair oxytocin concentrations (HOC) at four 3-month intervals from January 2020-January 2021. We evaluated test-retest reliability, sensitivity to change using Pearson product-moment correlations, and relationships between burnout and hair biomarkers using hierarchical mixed-effects linear regression. Results: 17 Pediatrics residents provided 78 wellness surveys and 54 hair samples. Burnout symptoms were present in 39 (50%) of the surveys, with 14 (82%) residents reporting burnout in at least one time point. The lowest (41%) and highest (60%) burnout prevalence occurred in 04/2020 and 01/2021, respectively. No significant associations between burnout scores and HCC (ß -0.01, 95%CI: 0.14-0.13), HOC (ß 0.06, 95%CI: 0.06-0.19), or the HCC:HOC ratio (ß -0.04, 95%CI: 0.09-0.02) were noted in separate analyses. Intra-individual changes in hair cortisol concentration were not associated with changes in burnout score. Conclusions: Burnout was prevalent among Pediatrics residents, with highest prevalence noted in January 2021. This pilot longitudinal study demonstrates the feasibility of evaluating burnout with stress and resilience biomarkers in Pediatrics residents.

Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey.

BACKGROUND: Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism. METHODS: In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics. RESULTS: A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness. CONCLUSION: The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Health Care Worker Well-Being.

BACKGROUND: Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey. METHODS: The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics. RESULTS: Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics. CONCLUSION: Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

Exogenous immunoglobulin downregulates T-cell receptor signaling and cytokine production.

Intravenous immune globulin (IVIG), a polyvalent solution of pooled human immunoglobulin, is a potent immunomodulating agent. It is currently approved to treat autoimmune diseases, including idiopathic thrombocytopenia purpura, autoimmune hemolytic anemia, and Kawasaki disease. The basis of IVIG's immunomodulatory properties is not entirely understood. Proposed mechanisms include Fc receptor blockade, interference with cytokine network, and provision of anti-idiotypic antibodies. IVIG has also been shown to affect T-lymphocyte function, although a direct effect has been difficult to reconcile given the lack of immunoglobulin or Fc-receptors on T cells. Experiments were thus carried out to determine whether IVIG was acting on a specific T-cell subset and at the level of the T-cell receptor (TCR), and whether cytokine expression patterns were modulated. T lymphocytes obtained from adult peripheral blood and umbilical cord blood were cultured over a 1-wk time course in the presence of pharmacological IVIG concentrations (Gamunex(®) , 0-2.0 mg/ml). Cells were exposed to various stimulation conditions, and TCR signaling competence was assessed by quantifying activation-induced upregulation of CD25 and CD69, as well as production of specific T-cell cytokines. IVIG was found to significantly decrease T-lymphocyte proliferation, in a dose and time-dependent manner, in both cord and adult blood. IVIG markedly reduced phytohemagglutinin and anti-CD3-induced upregulation of CD25 and CD69 in both CD4 and CD8 T-cell subsets, although phorbol ester-induced responses were intact, suggesting a defect in the CD3/TCR signaling pathway. IVIG also inhibited anti-CD3-induced cytokine production of IL-10, IL-2, and IFN-γ in a dose-dependent manner. These data suggest that IVIG may have direct T-cell immunomodulatory properties by dampening TCR responses. Further studies are needed to more precisely define the molecular targets of IVIG.

Physician Health and Wellness.

Physician health and wellness is a complex topic relevant to all pediatricians. Survey studies have established that pediatricians experience burnout at comparable rates to colleagues across medical specialties. Prevalence of burnout increased for all pediatric disciplines from 2011 to 2014. During that time, general pediatricians experienced a more than 10% increase in burnout, from 35.3% to 46.3%. Pediatric medical subspecialists and pediatric surgical specialists experienced slightly higher baseline rates of burnout in 2011 and similarly increased to just under 50%. Women currently constitute a majority of pediatricians, and surveys report a 20% to 60% higher prevalence of burnout in women physicians compared with their male counterparts. The purpose of this report is to update the reader and explore approaches to pediatrician well-being and reduction of occupational burnout risk throughout the stages of training and practice. Topics covered include burnout prevalence and diagnosis; overview of national progress in physician wellness; update on physician wellness initiatives at the American Academy of Pediatrics; an update on pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); a review of the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual). The development of this clinical report has inevitably been shaped by the social, cultural, public health, and economic factors currently affecting our communities. The coronavirus disease 2019 (COVID-19) pandemic has layered new and significant stressors onto medical practice with physical, mental, and logistical challenges and effects that cannot be ignored.

Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: A randomized clinical trial of WISER.

Importance: Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients. Objective: This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs. Design: We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER. Setting: Web-based intervention for actively employed HCWs across the United States. Participants: Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention. Interventions: Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters). Main outcomes and measures: The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models. Results: In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1-10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [-7.5 (95%CI: -11.0, -4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [-3.7 (95%CI: -8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment. Conclusion and relevance: WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive. Clinical trials number: https://clinicaltrials.gov/ct2/show/, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

Changing safety culture.

Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

Contributions of Systolic and Diastolic Blood Pressures to Cardiovascular Outcomes in the ALLHAT Study.

BACKGROUND: SBP and DBP have important associations with cardiovascular events, but are seldom considered simultaneously. OBJECTIVES: This study sought to simultaneously analyze systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements on the associated risk of a primary composite outcome of all-cause mortality, myocardial infarction (MI), congestive heart failure (CHF), or stroke. METHODS: This study analyzed ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) data, which randomized adults to chlorthalidone, amlodipine, or lisinopril. The authors evaluated the simultaneous association of repeated SBP and DBP measurements on the primary composite outcome, and each outcome using proportional hazards regression. The authors report hazard ratios using a "heat map" to represent high and low risk according to SBP and DBP combinations. RESULTS: During a median follow-up of 4.4 years (interquartile range: 3.6-5.4 years), 33,357 participants experienced 2,636 MIs, 866 CHF events, 936 strokes, and 3,700 deaths; 8,138 patients (24.4%) had at least 1 event. For the composite outcome, all-cause mortality, MI, and CHF, a U-shaped association was observed with SBP and DBP, but the SBP and DBP associated with the lowest hazards differed for each outcome. For example, SBP/DBP of 140-155/70-80 mm Hg was associated with the lowest HR for all-cause mortality, compared with 110-120/85-90 mm Hg for MI and 125-135/70-75 mm Hg for CHF. In contrast, the association of SBP and stroke was linear. CONCLUSIONS: The risk pattern of SBP and DBP differs by clinical outcomes, and the SBP and DBP associated with the lowest risk. Our results suggest individualization of blood pressure targets may depend in part on the cardiovascular event for which the patient is most at risk.

Measuring Electronic Health Record Use in the Pediatric ICU Using Audit-Logs and Screen Recordings.

BACKGROUND: Time spent in the electronic health record (EHR) has been identified as an important unit of measure for health care provider clinical activity. The lack of validation of audit-log based inpatient EHR time may have resulted in underuse of this data in studies focusing on inpatient patient outcomes, provider efficiency, provider satisfaction, etc. This has also led to a dearth of clinically relevant EHR usage metrics consistent with inpatient provider clinical activity. OBJECTIVE: The aim of our study was to validate audit-log based EHR times using observed EHR-times extracted from screen recordings of EHR usage in the inpatient setting. METHODS: This study was conducted in a 36-bed pediatric intensive care unit (PICU) at Lucile Packard Children's Hospital Stanford between June 11 and July 14, 2020. Attending physicians, fellow physicians, hospitalists, and advanced practice providers with ≥0.5 full-time equivalent (FTE) for the prior four consecutive weeks and at least one EHR session recording were included in the study. Citrix session recording player was used to retrospectively review EHR session recordings that were captured as the provider interacted with the EHR. RESULTS: EHR use patterns varied by provider type. Audit-log based total EHR time correlated strongly with both observed total EHR time (r = 0.98, p < 0.001) and observed active EHR time (r = 0.95, p < 0.001). Each minute of audit-log based total EHR time corresponded to 0.95 (0.87-1.02) minutes of observed total EHR time and 0.75 (0.67-0.83) minutes of observed active EHR time. Results were similar when stratified by provider role. CONCLUSION: Our study found inpatient audit-log based EHR time to correlate strongly with observed EHR time among pediatric critical care providers. These findings support the use of audit-log based EHR-time as a surrogate measure for inpatient provider EHR use, providing an opportunity for researchers and other stakeholders to leverage EHR audit-log data in measuring clinical activity and tracking outcomes of workflow improvement efforts longitudinally and across provider groups.

Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic.

OBJECTIVE: To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic. STUDY DESIGN: Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status. RESULT: We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p = 0.027) and difficulty focusing on work (59% vs. 36%, p = 0.013). CONCLUSION: Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.