Implementation of A Care Process Model for Pediatric Traumatic Stress in Child Advocacy Centers: A Mixed Methods Study.

Child Advocacy Centers (CACs) are well-positioned to identify children with mental health needs and facilitate access to evidence-based treatment. However, use of evidence-based screening tools and referral protocols varies across CACs. Understanding barriers and facilitators can inform efforts to implement mental health screening and referral protocols in CACs. We describe statewide efforts implementing a standardized screening and referral protocol, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), in CACs. Twenty-three CACs were invited to implement the CPM-PTS. We used mixed methods to evaluate the first two years of implementation. We quantitatively assessed adoption, reach, and acceptability; qualitatively assessed facilitators and barriers; and integrated quantitative and qualitative data to understand implementation of mental health screening in CACs. Eighteen CACs adopted the CPM-PTS. Across CACs, screening rates ranged from 10% to 100%. Caregiver ratings indicated high acceptability. Facilitators and barriers were identified within domains of the Consolidated Framework for Implementation Research. Qualitative findings provided insight into adoption, reach, and caregivers' responses. Our findings suggest screening for traumatic stress and suicidality in CACs is valued, acceptable, and feasible. Implementation of mental health screening and referral protocols in CACs may improve identification of children with mental health needs and support treatment engagement.

Influence of Cardiopulmonary Resuscitation Coaching on Interruptions in Chest Compressions During Simulated Pediatric Cardiac Arrest.

OBJECTIVES: To determine the impact of a cardiopulmonary resuscitation coach on the frequency and duration of pauses during simulated pediatric cardiac arrest. DESIGN: This is a secondary analysis of video data collected from a prospective multicenter trial. Forty simulated pediatric cardiac arrest scenarios (20 noncoach and 20 coach teams), each lasting 18 minutes in duration, were reviewed by three clinical experts to document events surrounding each pause in chest compressions. SETTING: Four pediatric academic medical centers from Canada and the United States. SUBJECTS: Two-hundred healthcare providers in five-member interprofessional resuscitation teams that included either a cardiopulmonary resuscitation coach or a noncoach clinical provider. INTERVENTIONS: Teams were randomized to include either a trained cardiopulmonary resuscitation coach or an additional noncoach clinical provider. MEASUREMENTS AND MAIN RESULTS: The frequency, duration, and associated factors with each interruption in chest compressions were recorded and compared between the groups with and without a cardiopulmonary resuscitation coach, using t tests, Wilcoxon rank-sum tests, or chi-squared tests, depending on the distribution and types of outcome variables. Mixed-effect linear models were used to explore the effect of cardiopulmonary resuscitation coaching on pause durations, accounting for multiple measures of pause duration within teams. A total of 655 pauses were identified (noncoach n = 304 and coach n = 351). Cardiopulmonary resuscitation-coached teams had decreased total mean pause duration (98.6 vs 120.85 s, p = 0.04), decreased intubation pause duration (median 4.0 vs 15.5 s, p = 0.002), and similar mean frequency of pauses (17.6 vs 15.2, p = 0.33) when compared with noncoach teams. Teams with cardiopulmonary resuscitation coaches are more likely to verbalize the need for pause (86.5% vs 73.7%, p < 0.001) and coordinate change of the compressors, rhythm check, and pulse check (31.7% vs 23.2%, p = 0.05). Teams with cardiopulmonary resuscitation coach have a shorter pause duration than non-coach teams, adjusting for number and types of tasks performed during the pause. CONCLUSIONS: When compared with teams without a cardiopulmonary resuscitation coach, the inclusion of a trained cardiopulmonary resuscitation coach leads to improved verbalization before pauses, decreased pause duration, shorter pauses during intubation, and better coordination of key tasks during chest compression pauses.

Screening for Trauma in Pediatric Primary Care.

PURPOSE OF REVIEW: Provided the high prevalence of trauma exposure in childhood as well as the risk for morbidity, this article examines evidence, a recommended approach, and key implementation factors relevant to screening for trauma in pediatric primary care. RECENT FINDINGS: A standardized approach to trauma screening is possible, but previous attempts have relied heavily upon exposure screening and failed to guide an individualized response specific to the impact of trauma on the child and family. Trauma screening tools for pediatric primary care should be brief and inform the care response based on screening for trauma exposure, traumatic stress symptoms, functional impact, and suicidality. Clinicians should use trauma screening to (1) identify if the child has any ongoing risk of harm and report where required; (2) determine risk of suicidality and respond appropriately; (3) assess need for evidence-based trauma treatment based on symptoms and functional impact; and (4) provide a skill or guidance targeting the most severe or pressing traumatic stress symptoms.

Screening for and Responding to Suicidality Among Youth Presenting to a Children's Advocacy Center (CAC).

Youth presenting to a Children's Advocacy Center (CAC) for a forensic interview are at increased risk for suicidality, but no data exist for suicidality or suicide screening and response at the time of the forensic interview. The current study applied a suicide and traumatic stress screening and response protocol, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), with youth (11-18 years) presenting for a forensic interview to one of 16 participating CAC locations, 2018-2020.46.2% of youth screened for traumatic stress and suicidality (N = 1651) endorsed thoughts of suicide or self-harm in the past two weeks, and 13.6% were assessed as high risk for suicide. High symptoms of traumatic stress increased the risk of suicidal thinking as well as of high risk suicidality. CAC workers, both clinicians and non-clinicians, facilitated screening and provided prevention response. Suicide screening and response at the CAC at the time of the forensic interview appears important and feasible.

ILCOR pediatric life support recommendations translation to constituent council guidelines: An emphasis on similarities and differences.

The International Liaison Committee on Resuscitation (ILCOR) performs rigorous scientific evidence evaluation and publishes Consensus on Science with Treatment Recommendations. These evidence-based recommendations are incorporated by ILCOR constituent resuscitation councils to inform regional guidelines, and further translated into training approaches and materials and implemented by laypersons and healthcare providers in- and out-of-hospital. There is variation in council guidelines as a result of the weak strength of evidence and interpretation. In this manuscript, we highlight ten important similarities and differences in regional council pediatric resuscitation guidelines, and further emphasize three differences that identify key knowledge gaps and opportunity for "natural experiments."

Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis.

IMPORTANCE: A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis. OBJECTIVES: We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database. MAIN OUTCOMES AND MEASURES: The primary exposure was NIPPV and the primary outcome was IHCA. MEASUREMENTS AND MAIN RESULTS: Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]). CONCLUSIONS AND RELEVANCE: Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

Traumatic stress symptoms and PTSD risk in children served by Children's Advocacy Centers.

Purpose: Children who experience maltreatment are at high risk for posttraumatic stress disorder (PTSD). Children's Advocacy Centers (CACs) can facilitate access to treatment following maltreatment allegations. We describe PTSD symptoms and intervention decision-making for children served by CACs. Methods: Children served by CACs in a single state were screened for PTSD symptoms using a structured mental health screening/referral protocol. CAC staff used an electronic form that provided guidance for decision-making. We examined descriptive statistics for PTSD symptoms and risk and tested associations between child characteristics and symptoms. We described CAC staff's delivery of brief interventions and referral decisions and tested associations with child characteristics and symptoms. Results: Two thousand and three hundred fifty children completed screening between 2018 and 2020. Almost half (45.5%) exhibited traumatic stress symptoms suggesting high probability of PTSD at the time of their CAC visit. Children who identified as female or transgender male and older children were more likely to be at high risk for PTSD. Brief interventions were delivered to 66% of children, and most were referred to evidence-based trauma treatment (53.1%) or community mental health services (39.0%). Categorization as moderate or high PTSD risk was associated with a higher likelihood of brief intervention delivery and referral to trauma treatment. Conclusion: Many children served by CACs are likely to meet criteria for PTSD at their initial visit. CAC staff demonstrated the ability to deliver brief interventions and make referrals to mental health treatment. Use of structured screening/referral protocols may improve early identification and treatment access for children experiencing PTSD symptoms.

The Concise Assessment of Leader Management Tool: Evaluation of Healthcare Provider Leadership During Real-Life Pediatric Emergencies.

INTRODUCTION: Resuscitation events in pediatric critical and emergency care are high risk, and strong leadership is an important component of an effective response. The Concise Assessment of Leadership Management (CALM) tool, designed to assess the strength of leadership skills during pediatric crises, has shown promising validity and reliability in simulated settings. The objective of this study was to generate further validity and reliability evidence for the CALM by applying it to real-life emergency events. METHODS: A prospective, video-based study was conducted in an academic pediatric emergency department. Three reviewers independently applied the CALM tool to the assessment of pediatric emergency department physicians as they led both a cardiac arrest and a sepsis event. Time to critical event (epinephrine, fluid, and antibiotic administration) was collected via video review. Based on Kane's framework, we conducted fully crossed, person × event × rater generalizability (G) and decision (D) studies. Interrater reliability was calculated using Gwet AC 2 and intraclass correlation coefficients. Time to critical events was correlated with CALM scores using Spearman coefficient. RESULTS: Nine team leaders were assessed in their leadership of 2 resuscitations each. The G coefficient was 0.68, with 26% subject variance, 20% rater variance, and no case variance. Thirty-three percent of the variance (33%) was attributed to third-order interactions and unknown factors. Gwet AC 2 was 0.3 and intraclass correlation was 0.58. The CALM score and time to epinephrine correlated at -0.79 ( P = 0.01). The CALM score and time to fluid administration correlated at -0.181 ( P = 0.64). CONCLUSIONS: This study provides additional validity evidence for the CALM tool's use in this context if used with multiple raters, aligning with data from the previous simulation-based CALM validity study. Further development may improve reliability. It also serves as an exemplar of the rigors of conducting validity work within medical simulation.

Pediatric in-hospital cardiac arrest: Respiratory failure characteristics and association with outcomes.

AIMS: To characterize respiratory failure prior to pediatric in-hospital cardiac arrest (IHCA) and to associate pre-arrest respiratory failure characteristics with survival outcomes. METHODS: This is a single-center, retrospective cohort study from a prospectively identified cohort of children <18 years in intensive care units (ICUs) who received cardiopulmonary resuscitation (CPR) for ≥1 minute between January 1, 2017 and June 30, 2021, and were receiving invasive mechanical ventilation (IMV) in the hour prior to IHCA. Patient characteristics, ventilatory support and gas exchange immediately pre-arrest were described and their association with the return of spontaneous circulation (ROSC) was measured. RESULTS: In the 187 events among 154 individual patients, the median age was 0.9 [0.2, 2.4] years, and CPR duration was 7.5 [3, 29] minutes. Respiratory failure was acute prior to 106/187 (56.7%) events, and the primary indication for IMV was respiratory in nature in 107/187 (57.2%) events. Immediately pre-arrest, the median positive end-expiratory pressure was 8 [5, 10] cmH2O; mean airway pressure was 13 [10,18] cmH2O; peak inspiratory pressure was 28 [24, 35] cmH2O; and fraction of inhaled oxygen (FiO2) was 0.40 [0.25, 0.80]. Pre-arrest FiO2 was lower in patients with ROSC vs. without ROSC (0.30 vs. 0.99; p < 0.001). Patients without ROSC had greater severity of pre-arrest oxygenation failure (p < 0.001) as defined by oxygenation index, oxygen saturation index, P/F ratio or S/F ratio. CONCLUSIONS: There was substantial heterogeneity in respiratory failure characteristics and ventilatory requirements pre-arrest. Higher pre-arrest oxygen requirement and greater degree of oxygenation failure were associated with worse survival outcomes.

Comparison of paediatric basic life support guidelines endorsed by member councils of Resuscitation Council of Asia.

Background: Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is no common RCA algorithm for paediatric life support.We aimed to review published paediatric life support guidelines from different Asian resuscitation councils. Methods: Pubmed and Google Scholar search were performed for published paediatric basic and advanced life support guidelines from January 2015 to June 2023. Paediatric representatives from the Resuscitation Council of Asia were sought and contacted to provide input from September 2022 till June 2023. Results: While most of the components of published paediatric life support algorithms of Asian countries are similar, there are notable variations in terms of age criteria for recommended use of adult basic life support algorithms in the paediatric population less than 18 years old, recommended paediatric chest compression depth targets, ventilation rates post-advanced airway intra-arrest, and first defibrillation dose for shockable rhythms in paediatric cardiac arrest. Conclusion: This was an overview and mapping of published Asian paediatric resuscitation algorithms. It highlights similarities across paediatric life support guidelines in Asian countries. There were some differences in components of paediatric life support which highlight important knowledge gaps in paediatric resuscitation science. The minor differences in the paediatric life support guidelines endorsed by the member councils may provide a framework for prioritising resuscitation research and highlight knowledge gaps in paediatric resuscitation.

From Concept to Publication: Effectiveness of the International Network for Simulation-Based Pediatric Innovation, Research, and Education Project Development Process at Generating Simulation Scholarship.

BACKGROUND: As simulation matures, it is critical to develop pathways for researchers. A recent analysis, however, demonstrates a low conversion rate between abstract and peer-reviewed journal publication in our field. The International Network for Simulation-based Pediatric Innovation, Research, and Education has used the ALERT Presentation process for the past decade as a means of accelerating research. In this study, we analyze the scholarly products attributable to ALERT Presentations. METHODS: Surveys were distributed to all International Network for Simulation-based Pediatric Innovation, Research, and Education Advanced Look Exploratory Research Template (ALERT) Presentation first authors from January 2011 through January 2020. Presenters were asked to provide information on abstracts, grants, journal publications, and book chapters related to their ALERT Presentation, as well as basic demographic information. A structured literature search was conducted for those ALERT Presentations whose authors did not return a survey. The resulting database was descriptively analyzed, and statistical correlations between demographic variables and scholarship were examined. RESULTS: One hundred sixty-five new ALERT presentations were presented over 10 years. We identified 361 associated scholarly works (170 conference abstracts, 125 peer-reviewed journal publications, 65 grants, and 1 book chapter). Sixty-one percent (101 of 165) of ALERT Presentations produced at least 1 item of scholarship, and 59% (34 of 58) of ALERT Presentations that resulted in at least 1 abstract also led to at least 1 peer-reviewed journal article. Presenter gender was associated with likelihood of journal publication. CONCLUSIONS: The ALERT Presentation process is an effective approach for facilitating the development of projects that result in disseminated scholarship. Wider adoption may benefit other simulation and education research networks.

Empty reviews: a description and consideration of Cochrane systematic reviews with no included studies.

BACKGROUND: There is no specific guidance for the reporting of Cochrane systematic reviews that do not have studies eligible for inclusion. As a result, the reporting of these so-called "empty reviews" may vary across reviews. This research explores the incidence of empty systematic reviews in The Cochrane Database of Systematic Reviews (The CDSR) and describes their current characteristics. METHODOLOGY/PRINCIPAL FINDINGS: Empty reviews within The CDSR as of 15 August 2010 were identified, extracted, and coded for analysis. Review group, original publication year, and time since last update, as well as number of studies listed as excluded, awaiting assessment, or on-going within empty reviews were examined. 376 (8.7%) active reviews in The CDSR reported no included studies. At the time of data collection, 45 (84.9%) of the Cochrane Collaboration's 53 Review Groups sustained at least one empty review, with the number of empty reviews for each of these 45 groups ranging from 1 to 35 (2.2-26.9%). Time since original publication of empty reviews ranged from 0 to 15 years with a mean of 4.2 years (SD = 3.4). Time since last assessed as up-to-date ranged from 0 to 12 years with a mean of 2.8 years (SD = 2.2). The number of excluded studies reported in these reviews ranged from 0 to 124, with an average of 9.6 per review (SD = 14.5). Eighty-eight (23.4%) empty reviews reported no excluded studies, studies awaiting assessment, or on-going studies. CONCLUSIONS: There is a substantial number of empty reviews in The CDSR, and there is some variation in the reporting and updating of empty reviews across Cochrane Review Groups. This variation warrants further analysis, and may indicate a need to develop guidance for the reporting of empty systematic reviews in The CDSR.