Creation of a Rudimentary Electronic Pediatric Intensive Care Unit Model to Explore Resident-Attending Communication.

Background: At-home attending intensivists often must return to the hospital to assist residents. Introduction: To determine if using telemedicine communication between in-house pediatric residents and at-home attending intensivists impacts the rate of attending return to the hospital and improves resident education. Methods: In this single-center prospective study at an academic children's hospital's pediatric intensive care unit (PICU), 40 patients younger than 18 years were randomized into video or telephone arms. Residents and intensivists completed anonymous surveys after each encounter. Video-conferencing encounters between residents and at-home, on-call intensivists were compared with standard telephone calls for admissions to PICU. Results: Video and telephone arms had 21 and 19 patients enrolled, respectively. Data comparison was performed using Mann-Whitney U, chi-square, and Kruskal-Wallis analysis. Clinical illness severity rating for intensivists and residents was not significantly different for video communication compared with telephone (p = 0.63 and p = 0.42, respectively). Intensivists reported no significant difference in ease of use (p = 0.87). There was perceived improvement in resident education with the use of telemedicine (52.6% vs. 76.2%; p = 0.11). Discussion: Video communication was easy to use but did not change the rating of illness severity or need for intensivist to return to the hospital. There was perceived improvement in resident education with the use of telemedicine, and it may serve as a useful tool in demonstrating acute clinical changes to out-of-hospital intensivists. Conclusions: Larger-scale studies in teaching hospitals with out-of-hospital pediatric intensivists need to be conducted to further evaluate the role of telemedicine in patient management and resident education.

Application of Telemedicine Technology to Facilitate Diagnosis of Pediatric Postintensive Care Syndrome.

Background: Postintensive care syndrome (PICS) is well-defined in the adult literature but has not received much attention in pediatrics. Introduction: We sought to use a telemedicine platform for the characterization of PICS by creating a convenient and effective virtual follow-up clinic. Materials and Methods: Prospective single-center study in a pediatric intensive care unit (ICU) of patients aged 4-17 years who underwent any invasive procedures while admitted to the ICU. Parents completed the Weiss Functional Impairment Rating Scale (WFIRS) based on baseline behaviors before ICU admission, with the scale readministered at 1 week, 1 month, and 3 months postdischarge via secure telehealth platform. Patients with a WFIRS baseline raw score of 10 or an interval increase of 2 were referred to psychiatry for evaluation and treatment. Results: Fifty patients were enrolled. Risk factors for PICS included number of procedural interventions, length of pediatric ICU stay, number of specialty consults, sex, race, and duration of sedation/airway instrumentation. In univariate analysis, age appeared to be the only statistically significant factor associated with the development of PICS. Variables associated with a higher change in WFIRS score showed a statistically significant correlation with the number of procedures completed, the number of specialists involved, and the need for a psychiatric referral. Only 34% of total telemedicine follow-ups were completed. Discussion: There is an association between age and the development of PICS and between change in WFIRS score and number of procedures, specialist involved, and psychiatric referral. Conclusions: The use of telemedicine did not result in an improved follow-up rate when compared to outpatient clinic studies.

Real-World Evaluation of the Eko Electronic Teleauscultation System.

Heart murmur evaluation is the most common cause of referral to cardiology, and auscultation of heart sounds with a stethoscope remains a key component of the initial cardiovascular exam. Adoption of telecardiology has been limited by challenges in teleauscultation. We set out to compare in-person auscultatory findings with heart sounds recorded by the Core stethoscope (Eko, Berkeley, CA) in patients with normal heart sounds, innocent heart murmurs, and a variety of pathologic findings. Our study demonstrates that Eko recordings had a high percent of agreement with in-person auscultation findings and echocardiogram findings, with moderate inter-rater reliability. It was useful in identifying patients with pathologic murmurs who would benefit from further assessment. It was able to discern major types of pathological murmurs. Certain qualitative differences in the recorded sounds as compared to in-person auscultation were identified by the reading cardiologists. They were able to acclimate to these subtle differences. The system was felt to be easy to use, and most cardiologists in the study would consider using it in clinical settings. The Eko Core system may be a useful screening tool for murmur evaluation.

The Effect of Telemedicine on Resource Utilization and Hospital Disposition in Critically Ill Pediatric Transport Patients.

PURPOSE: Pediatric transport teams rely on communication to report patient data to medical command officers, who create care plans and determine disposition. Common destinations are the emergency department (ED), pediatric intensive care unit (PICU), or regular inpatient care area (RIPCA). Telephone report does not result in complete understanding of the patient's condition. Further workup in the ED is often required. Telemedicine allows the patient to be directly seen; parents to be interviewed; and laboratory studies, radiographs, and vital signs to be reviewed. We hypothesized that telemedicine would improve understanding of the patient and result in more accurate disposition. DESIGN: Patients within our hospital from 2012 to 2013 were compared with patients transported using our telemedicine program from April 2014 to April 2015. RESULTS: From 2012 to 2013, a total of 4,662 transports were performed. Of these, 4,067 were inbound transports, 2,302 of these patients were sent to ED (56.6%), 1,062 were sent to RIPCA (26%), and 431 were sent to PICU (10.6%). Over a year-long period of telemedicine implementation, 212 patients used telemedicine and were analyzed. ED utilization decreased to 27% (p < 0.0001), PICU increased to 34.4% (p < 0.0001), and RIPCA rates remained the same at 28% (p = 0.203). Of ED dispositions, 58.6% were admitted to RIPCA for further care, 13.7% to PICU for escalation of care, and 24.1% were discharged. Of RIPCA dispositions, 10% had rapid responses; 0 had code blues. Of PICU dispositions, 90.4% had care escalation; 9.6% were observed in the PICU without escalation. CONCLUSION: Telemedicine use in transported pediatric patients can positively alter disposition patterns.

The Impact of Multiple Viral Respiratory Infections on Outcomes for Critically Ill Children.

OBJECTIVE: Advances in molecular diagnosis have led to increased testing for single and multiviral respiratory infection in routine clinical practice. This study compares outcomes between single and multiviral respiratory infections in children younger than 5 years old admitted to the PICU with respiratory failure. DESIGN: Retrospective, single-center, cohort study. SETTING: Tertiary-care, freestanding children's hospital. PATIENTS: Children younger than 5 years old admitted to the PICU with respiratory failure and positive respiratory molecular panel. Children with comorbidity or history of similar infections were excluded. After exclusions, the children were divided into single or multiviral groups. Their demographics and PICU outcomes were compared and analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred seventy-seven children with respiratory failure tested positive on respiratory panel, out of which 432 had single and 45 had multiple viruses. Children with multiple viruses had a longer PICU stay (4.5 d) compared with the single viral group (3 d; p < 0.002). Multiviral infections were associated with higher utilization of central line (odds ratio, 2.4; 95% CI, 1.3-4.6; p = 0.008) but not with the need of invasive ventilation requirement or cardiovascular dysfunction. Further analysis among invasively ventilated patients showed multiviral infections resulted in higher association of prolonged ventilation (> 7 d) (odds ratio, 3.4; 95% CI, 1.2-9.4; p = 0.01) and bacterial lower respiratory tract infection confirmed by quantitative bronchoalveolar lavage (odds ratio, 2.1; 95% CI, 1.1-11.2; p = 0.03). Infections with human rhinovirus/Enterovirus, Adenovirus, parainfluenza, and influenza formed a significantly larger proportions of cases (p = 0.00089) as multiviral infections compared with individual infections. CONCLUSIONS: Multiviral infections were associated with longer PICU stay, with prolonged mechanical ventilation, with bacterial lower respiratory infections, and with central line requirement. Certain common viruses resulted in higher percentages of PICU admission as multiviral infections.

Use of Telehealth in Pediatric Palliative Care.

OBJECTIVES: Pediatric subspecialty care, including multidisciplinary palliative care, tends to be located in urban academic centers or children's hospitals. Telehealth provides the opportunity to care for patients who would otherwise not be able to access services. We present cases wherein telehealth was used to provide counseling services to patients who would not have been able to receive this service. METHODS: We discuss cases of telehealth use for patient and family counseling in the setting of palliative care and bereavement follow-up. Patients who live a great distance from the hospital with limited access to services were followed by a hospital-based pediatric palliative care team. Patients and families gave feedback after use of telehealth for counseling services. RESULTS: Counseling through telehealth by our hospital-based palliative care social worker was successful for all parties involved: patient, family, and social worker. CONCLUSIONS: Telehealth helps relieve disparity in access to services and care, which is particularly problematic in pediatrics and mental health. For the patients in this case series, it was an effective modality to receive counseling services and meet needs that otherwise would not have been addressed.

A More Rapid, Rapid Response.

OBJECTIVES: Critical care physicians' standard for arrival to a rapid response team activation is 10 minutes or less at this institution. This study proposes that a FaceTime (Apple, Cupertino, CA) video call between the staff at the bedside and the critical care physician will allow the implementation of potentially life-saving therapies earlier than the current average response (4.5 min). DESIGN: Prospective cohort study. SETTING: Freestanding, tertiary-care children's hospital. PATIENTS: Pediatric patients ages 0-17. INTERVENTIONS: Six units were chosen as matched pairs. In the telemedicine units, after notification of an rapid response team, the critical care intensivist established a FaceTime video call with the nurse at the bedside and gathered history, visually assessed the patient, and suggested interventions. Simultaneously, the rapid response nurse, respiratory therapist, and fellow were dispatched to respond to the bedside. After the video call, the intensivist also reported to the bedside. The control units followed the standard rapid response team protocol: the intensivist physically responded to the bedside. Differences in response time, number of interventions, Pediatric Early Warning System scores, and disposition were measured, and the PICU course of those transferred was evaluated. MEASUREMENTS AND MAIN RESULTS: The telemedicine group's average time to establish FaceTime interface was 2.6 minutes and arrival at bedside was 3.7 minutes. The control group average arrival time was 3.6 minutes. The difference between FaceTime interface and physical arrival in the control group was statistically significant (p = 0.012). Physical arrival times between the telemedicine and control groups remained consistent. Fifty-eight percent of the telemedicine patients and 73% of the control patients were admitted to the PICU (p = 0.13). Of patients transferred to the PICU, there was no difference in rate of intubation, initiation of bilevel positive airway pressure, central line placement, or vasopressors. The study group averaged 1.4 interventions and a Pediatric Early Warning Signs score of 3.6. The control group averaged 1.9 interventions and a Pediatric Early Warning Signs score of 3.1 (p = not significant). CONCLUSION: FaceTime allowed the intensivist to become involved earlier and provide immediate guidance to the inpatient care teams. However, it did not clinically alter the patient course. Further study is necessary.

A Prospective Pilot Study of the Use of Telemedicine During Pediatric Transport: A High-Quality, Low-Cost Alternative to Conventional Telemedicine Systems.

OBJECTIVE: Few trials address the use of telemedicine during pediatric transport. We believe that video conferencing has equivalent quality, connectivity, and ease of operation, can be done economically, and will improve evaluation. METHODS: Prospective randomized pilot study was used to examine video versus cellular communication between the medical command officer (MCO) and pediatric transport team (TT) for children with moderate to severe illness undergoing interhospital transport. Twenty-five patients were randomized to cellular communication, and 25 patients were randomized to video. The MCO completed a Likert scale to evaluate connection, quality, and ease of operation. Call durations were recorded. A Likert scale to evaluate the communication mode on patient care was completed. RESULTS: Connection and audio quality were equivalent and there were no dropped calls. Average call duration in the phone group was 186 versus 139 seconds in the video group (P = 0.055). The MCO survey results were the following: 100% found video intuitive, 92% felt that disposition based on phone report was difficult, 80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used for transport. The iPad system offers a significant savings when compared with conventional telemedicine. CONCLUSIONS: Video conferencing seems as easy to complete as phone with equivalent quality and connectivity. Duration of video was equivalent to phone conferencing. Surveyed MCOs believed that video conferencing improved assessment and disposition. The iPad-based conferencing provided significant savings when compared with conventional cart-based or robotic units. Further evaluation of video conferencing during interhospital transport is warranted.

A Comparison of Virtual Reality to Traditional Simulation in Health Professions Education: A Systematic Review.

ABSTRACT: With the increasing availability of virtual reality (VR) and its lower overall costs of use, the objective of this review was to compare VR to traditional simulation in terms of learning outcomes. Studies were included if they met the following criteria: ( a ) research study (of any design), ( b ) focused on learners in health professions, and ( c ) compared VR with traditional simulation. Studies were excluded for the following reasons: ( a ) not a research study, ( b ) focused on learners outside health professions, ( c ) used screen-based or computer-based simulation, ( d ) used a task trainer, and ( e ) did not involve a comparison of VR to traditional simulation. The searches were run on November 11 and 12, 2021, in CINAHL via EBSCO, Ovid Embase, ERIC via EBSCO, IEEE Xplore, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science Core Collection. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided the review. A team of researchers applied Kirkpatrick's Levels, Melnyk's Levels of Evidence, and Critical Appraisal Skills Programme guidelines to assess the level of evidence and look for bias. Fifteen studies were reviewed including 11 randomized controlled trials. The lead researcher synthesized the study results into 3 categories: (1) traditional simulation performed better, (2) VR performed better, and (3) comparable outcomes. There is insufficient evidence to endorse one form of simulation (VR or traditional) as more effective at this time. The body of evidence contained too few studies to draw meaningful conclusions to answer the guiding question. The studies covered a large range of modalities, learner groups, and healthcare topics, preventing a meta-analysis. Based on the literature and experience, we recommend that VR experiences be proctored, include debriefing, have a backup plan for cybersickness or myopia, and have time and costs documented. Use of VR is likely to expand; thus, research is needed to inform the best contexts and applications.

Deep Learning Algorithms to Detect Murmurs Associated With Structural Heart Disease.

Background The success of cardiac auscultation varies widely among medical professionals, which can lead to missed treatments for structural heart disease. Applying machine learning to cardiac auscultation could address this problem, but despite recent interest, few algorithms have been brought to clinical practice. We evaluated a novel suite of Food and Drug Administration-cleared algorithms trained via deep learning on >15 000 heart sound recordings. Methods and Results We validated the algorithms on a data set of 2375 recordings from 615 unique subjects. This data set was collected in real clinical environments using commercially available digital stethoscopes, annotated by board-certified cardiologists, and paired with echocardiograms as the gold standard. To model the algorithm in clinical practice, we compared its performance against 10 clinicians on a subset of the validation database. Our algorithm reliably detected structural murmurs with a sensitivity of 85.6% and specificity of 84.4%. When limiting the analysis to clearly audible murmurs in adults, performance improved to a sensitivity of 97.9% and specificity of 90.6%. The algorithm also reported timing within the cardiac cycle, differentiating between systolic and diastolic murmurs. Despite optimizing acoustics for the clinicians, the algorithm substantially outperformed the clinicians (average clinician accuracy, 77.9%; algorithm accuracy, 84.7%.) Conclusions The algorithms accurately identified murmurs associated with structural heart disease. Our results illustrate a marked contrast between the consistency of the algorithm and the substantial interobserver variability of clinicians. Our results suggest that adopting machine learning algorithms into clinical practice could improve the detection of structural heart disease to facilitate patient care.

Recipe for Disaster: Homemade Formula Leading to Severe Complications in 2 Infants.

Families and physicians alike benefit from the advances and ease of the Internet. Similarly, both can be unaware of harmful misinformation circulating the Web. In this article, we describe the presentation of 2 unrelated infants, within 1 week of each other, with vitamin D deficiency rickets and severe extraskeletal manifestations of hypocalcemia, including seizures and cardiac arrest, from homemade, vegan formula found through Pinterest (San Francisco, CA). Despite good parental intentions this formula did not meet macronutrient and micronutrient standards, particularly regarding vitamin D, phosphorus, and calcium content, and led to rare, life-threatening complications in both cases. Before presentation, both patients followed appropriately with their pediatrician and discussed feeding in detail, although neither family disclosed the use of homemade formula. Pediatricians must be aware of these dangerous homemade alternative formulas, consider the manner and depth of their feeding history questioning, and continue to counsel against homemade formula to prevent further harm to children.

Virtual Reality Simulation for Pediatric Airway Intubation Readiness Education.

Background The objective of this study was to provide education to inexperienced trainees regarding preparation for airway intubation using virtual reality (VR) tutorial and comparison of performance with that of experienced trainees without VR training. We hypothesized that after the VR tutorial, junior fellows and residents will have comparable recall of the proper steps as experienced trainees. Methods This project was initiated in the pediatric intensive care unit from July 1, 2019, to July 30, 2019. Volunteer residents and pediatric critical care medicine fellows participated. The VR group completed a 19-minute immersive tutorial and then demonstrated learned skills with a traditional manikin. Non-VR group fellows listed steps to prepare for airway intubation from memory with scoring on a 24-point timed checklist. Results Seventeen subjects participated; two residents were excluded. The VR group had seven trainees (47%) and scored similarly to the other group based on checklist items (50.5% vs 50.8%, P=1). Conclusion VR technologies can be used for education in preparation for pediatric airway intubation. There was no difference in the performance accuracy between the two groups. Larger studies are essential to study benefits of VR in preparation and performance of airway intubation.

Legacy Building in Pediatric End-of-Life Care through Innovative Use of a Digital Stethoscope.

Background: Legacy making has been the focus of recent literature; however, few studies examine how legacy making affects bereaved parents. Objective: To better understand legacy making's effect on bereaved parents, this study examined (1) the presentation of legacy making to parents, (2) parent satisfaction, and (3) parent utilization of the project. Design: Eko CORE (Eko Devices, Inc., Berkeley, CA), a digital stethoscope that generates a phonocardiogram, a graphical representation of S1 and S2 heart sounds, was used to record children's heartbeats as they approached end of life. The heartbeat was then overlaid to a song or voice recording or kept as a stand-alone file. An artistic embellishment of the phonocardiogram was also created. Parents were surveyed about their experience with the Music Therapy Heart Sounds (MTHS) program. Twelve parents completed the survey. Setting/subjects: Tertiary care children's hospital. The subjects were bereaved parents. Measurements: Five-question survey. Institutional Review Board review exempt. Results: All respondents would recommend the MTHS program to other families experiencing end-of-life decision making. Forty-two percent (N = 5) heard about the program from pediatric palliative physicians, and 50% (N = 6) heard about it from therapists such as music or child life. The respondents varied in how often they utilized their child's heartbeat recordings: 25% (N = 3) viewed or listened monthly, 33% (N = 4) not at all, 17% (N = 2) almost weekly, 17% less than monthly, and 8% (N = 1) daily. Conclusion: The MTHS program is an easy-to-implement and cost-effective way to perform legacy making that bereaved parents recommend for other families.

Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence.

We report a fatal tracheoinnominate artery fistula (TIF) in a 13-year-old female patient with long-term tracheostomy tube dependence due to chronic respiratory failure. Thirteen years after placement of her tracheostomy tube, the patient experienced two separate episodes of sentinel bleeding prior to a fatal hemorrhagic event. Diagnostic evaluation after the sentinel events was mostly nonconclusive. This case highlights the risk of TIF in pediatric age group, even years after initial tracheostomy tube placement, and the need for a high index of suspicion for TIF when children present with unexplained tracheal bleeding.

A retrospective study of the factors associated with hypercoagulability in the pediatric patients at a tertiary care children's hospital.

OBJECTIVE: The objective of this study was to determine the risk factors of hypercoagulability in children. We explored the interaction of multiple risk factors with the incidence of thrombosis. Our hypothesis was that as the number of risk factors for thrombosis increased the actual incidence of thrombosis would also increase. DESIGN: Retrospective review from 2003 through 2006 based on a search using two electronic medical record databases. SETTING: Pediatric Tertiary Care Children's Hospital. PATIENTS: Two hundred twenty-six patients were identified and analyzed. MEASUREMENTS: Search terms included factor V Leiden polymerase chain reaction, prothrombin gene 20210A mutation, methylene tetrahydrofolate reductase mutation, antithrombin III, and protein C and S levels. Clinical data were compiled for regression analysis. MAIN RESULTS: The presence of one risk factor was not significant. Two risk factors increased the risk of thrombosis (p = 0.005; OR 3.128). Three or more risk factors further increased the risk of thrombosis (p = 0.003; OR 4.861). Older age (>11 yrs) was protective against thrombosis (p = 0.007; OR 0.995), and the presence of a central venous catheter when analyzed against accumulating risk factors showed a higher risk than that found during the regression analysis (p = 0.001; OR 3.638). CONCLUSIONS: The population at our institution is reflective of the previously reported standards for the genetic predispositions toward thrombosis. Although older age is associated with a lower incidence of thrombosis, the presence of a central venous access device is detrimental. Accumulation of factors results in an increased risk of thrombosis. This article suggests that when inserting a central venous access device, consideration of a hypercoagulation workup should occur. Those with any two or more risk factors, genetic or acquired, and the comorbidity of a CVL may warrant consideration for the institution of anticoagulation with an agent like low molecular weight heparin.

An unusual case of button battery-induced traumatic tracheoesophageal fistula.

BACKGROUND: Much of pediatric medicine is focused on prevention of disease and injury. Although accidental ingestions of various household chemicals and medicines are well described and the treatment is supported by local poison control hotlines, the ingestion of button batteries by children is less publicized, and the dangers are less understood by both parents and health care providers. METHODS: We describe a case report of a 17-month-old girl with no significant medical history who presented with respiratory distress, cough, and fever and subsequently was discovered to have ingested a button battery. RESULTS: The formation of a traumatic tracheoesophageal fistula required intensive management that escalated to cardiopulmonary bypass and eventual pericardial patch closure of the tracheal defect after the failure of conventional mechanical ventilation. CONCLUSIONS: Esophageal button battery impaction places the patient at high risk for full-thickness damage to the esophagus and tracheal structures with fistula formation in as little as a few hours. The key to successful therapy is prompt diagnosis and removal, but in nonverbal pediatric patients, this often is not achievable. Because of the complications associated with this disease (tracheoesophageal fistula) and subsequent difficulties associated with oxygenation and ventilation, these patients should be managed at an institution with the skilled capability of providing cardiopulmonary bypass quickly as a potentially lifesaving therapy.

Intussusception in a child with respiratory syncytial virus: a new association.

Intussusception is known to be associated with childhood viral illnesses. Respiratory syncytial virus (RSV) has not, to our knowledge, been previously reported in association with intussusception. We report a case of a 4-month-old boy admitted with RSV bronchiolitis, who subsequently developed an intussusception during the hospital course, necessitating laparotomy and resection.

Projectile embolization to the left femoral artery with stroke following gunshot wound to the chest.

Missile embolization is a rare phenomenon with most cases reported in the literature as a consequence of direct or indirect vascular trauma. Despite their characterization as toys, traumatic injuries from pellet guns are associated with significant rates of morbidity related to their vascular and neurological complications. We present a 9-year-old boy who was shot in the chest with a pellet gun and suffered a femoral arterial occlusion and a delayed stroke in the middle cerebral arterial distribution.

Empyema necessitatis in an infant: a rare surgical disease.

Empyema necessitatis is a rare complication of empyema and is more commonly reported in adults. It is characterized by purulence in the pleural space extending into the overlying soft tissues. We report a rare case in an otherwise healthy 3-month-old girl who presented with right chest wall swelling and was subsequently found to have methicillin-resistant Staphylococcus aureus empyema necessitatis requiring thoracotomy with decortication.