Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience.

Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiatives, led mostly by Europe and Oceania, have tried to mitigate ICUs' notable environmental impact with varying success. However, there exists a significant gap in the U.S. knowledge and published literature related to sustainability in the ICU. After a narrative review of the literature and related industry standards, we share our experience with a Green ICU initiative at a large hospital system in Texas. Our process has led to a 3-step pathway to inform similar initiatives for sustainable (green) critical care. This pathway involves (1) establishing a baseline by quantifying the status quo carbon footprint of the affected ICU as well as the cumulative footprint of all the ICUs in the healthcare system; (2) forming alliances and partnerships to target each major source of these pollutants and implement specific intervention programs that reduce the ICU-related greenhouse gas emissions and solid waste; and (3) finally to implement a systemwide Green ICU which requires the creation of multiple parallel pathways that marshal the resources at the grass-roots level to engage the ICU staff and institutionalize a mindset that recognizes and respects the impact of ICU functions on our environment. It is expected that such a systems-based multi-stakeholder approach would pave the way for improved sustainability in critical care.

Perspectives on preparedness for pediatric emergencies after residency: A needs assessment.

Background: General emergency physicians provide most pediatric emergency care in the United States yet report more challenges managing emergencies in children than adults. Recommendations for standardized pediatric emergency medicine (PEM) curricula to address educational gaps due to variations in pediatric exposure during emergency medicine (EM) training lack learner input. This study surveyed senior EM residents and recent graduates about their perceived preparedness to manage pediatric emergencies to better inform PEM curricula design. Methods: In 2021, senior EM residents and graduates from the classes of 2020 and 2019 across eight EM programs with PEM rotations at the same children's hospital were recruited and surveyed electronically to assess perceived preparedness for 42 pediatric emergencies and procedures by age: infants under 1 year, toddlers, and children over 4 years. Preparedness was reported on a 5-point Likert scale with 1 or 2 defined as "unprepared." A chi-square test of independence compared the proportion of respondents unprepared to manage each condition across age groups, and a p-value < 0.05 demonstrated significance. Results: The response rate was 53% (129/242), with a higher response rate from senior residents (65%). Respondents reported feeling unprepared to manage more emergency conditions in infants compared to other age groups. Respondents felt least prepared to manage inborn errors of metabolism and congenital heart disease, with 45%-68% unprepared for these conditions across ages. A heat map compared senior residents to recent graduates. More graduates reported feeling unprepared for major trauma, impending respiratory failure, and pediatric advanced life support algorithms. Conclusions: This study, describing the perspective of EM senior residents and recent graduates, offers unique insights into PEM curricular needs during EM training. Future PEM curricula should target infant complaints and conditions with lower preparedness scores across ages. Other centers training EM residents could use our findings and methods to bolster PEM curricula.

Assessment of Machine Learning-Based Medical Directives to Expedite Care in Pediatric Emergency Medicine.

Importance: Increased wait times and long lengths of stay in emergency departments (EDs) are associated with poor patient outcomes. Systems to improve ED efficiency would be useful. Specifically, minimizing the time to diagnosis by developing novel workflows that expedite test ordering can help accelerate clinical decision-making. Objective: To explore the use of machine learning-based medical directives (MLMDs) to automate diagnostic testing at triage for patients with common pediatric ED diagnoses. Design, Setting, and Participants: Machine learning models trained on retrospective electronic health record data were evaluated in a decision analytical model study conducted at the ED of the Hospital for Sick Children Toronto, Canada. Data were collected on all patients aged 0 to 18 years presenting to the ED from July 1, 2018, to June 30, 2019 (77 219 total patient visits). Exposure: Machine learning models were trained to predict the need for urinary dipstick testing, electrocardiogram, abdominal ultrasonography, testicular ultrasonography, bilirubin level testing, and forearm radiographs. Main Outcomes and Measures: Models were evaluated using area under the receiver operator curve, true-positive rate, false-positive rate, and positive predictive values. Model decision thresholds were determined to limit the total number of false-positive results and achieve high positive predictive values. The time difference between patient triage completion and test ordering was assessed for each use of MLMD. Error rates were analyzed to assess model bias. In addition, model explainability was determined using Shapley Additive Explanations values. Results: There was a total of 42 238 boys (54.7%) included in model development; mean (SD) age of the children was 5.4 (4.8) years. Models obtained high area under the receiver operator curve (0.89-0.99) and positive predictive values (0.77-0.94) across each of the use cases. The proposed implementation of MLMDs would streamline care for 22.3% of all patient visits and make test results available earlier by 165 minutes (weighted mean) per affected patient. Model explainability for each MLMD demonstrated clinically relevant features having the most influence on model predictions. Models also performed with minimal to no sex bias. Conclusions and Relevance: The findings of this study suggest the potential for clinical automation using MLMDs. When integrated into clinical workflows, MLMDs may have the potential to autonomously order common ED tests early in a patient's visit with explainability provided to patients and clinicians.

Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children.

Importance: The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective: To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants: This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures: Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results: Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance: This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.

Emergency point-of-care ultrasound in Canadian pediatric emergency fellowship programs: current integration and future directions.

BACKGROUND: Adult and pediatric emergency physicians have been using point-of-care ultrasound (POCUS) for many years. It is a fast, usually painless, noninvasive diagnostic tool that does not expose the patient to radiation. Information about its current implementation in pediatric emergency medicine (PEM) fellowship programs in Canada is lacking. OBJECTIVE: The main goal of our study was to investigate current integration and future direction of POCUS training in Canadian PEM programs. METHODS: The study consisted of two surveys designed for fellows and program directors of all Canadian PEM fellowship programs. The major aspects of the survey were 1) to describe current training in POCUS in fellowship programs, 2) to compare the kind of training that programs offer with what fellows actually receive, and 3) a needs assessment by fellows and program directors for future POCUS training programs. Surveys were sent to program directors and passed on to their fellows. RESULTS: Ninety percent of fellowship program directors as well as 70% (42/60) of fellows responded to the survey. A formal POCUS curriculum exists in five of the nine PEM programs included in this study. Three programs offer specific pediatric POCUS training. The main application is the FAST (focused assessment with sonography for trauma) exam. CONCLUSION: There is a wide variation in POCUS content and delivery across PEM fellowship programs, as well as differences in perceptions of current training and of needs by fellows and program directors. However, given that both groups feel POCUS is very important and essential for PEM training, the opportunity exists to develop a standardized curriculum across Canada.

Emergency Point-of-Care Ultrasound Assessment of Whiteout Lung in the Pediatric Emergency Department.

Point-of-care ultrasound is being used more frequently in pediatric emergency medicine departments. It has become an important adjunct for clinical diagnoses and procedural guidance. We present a case series of 3 patients who presented to a pediatric emergency department and on chest radiographs had whiteout lung. Point-of-care ultrasound was able to differentiate fluid from consolidation, facilitating the appropriate investigations and interventions for these children.

Attention narrows position tuning of population responses in V1.

When attention is directed to a region of space, visual resolution at that location flexibly adapts, becoming sharper to resolve fine-scale details or coarser to reflect large-scale texture and surface properties. By what mechanism does attention improve spatial resolution? An improved signal-to-noise ratio (SNR) at the attended location contributes, because of retinotopically specific signal gain. Additionally, attention could sharpen position tuning at the neural population level, so that adjacent objects activate more distinct regions of the visual cortex. A dual mechanism involving both signal gain and sharpened position tuning would be highly efficient at improving visual resolution, but there is no direct evidence that attention can narrow the position tuning of population responses. Here, we compared the spatial spread of the fMRI BOLD response for attended versus ignored stimuli. The activity produced by adjacent stimuli overlapped less when subjects were attending at their locations versus attending elsewhere, despite a stronger peak response with attention. Our results show that even as early as primary visual cortex (V1), spatially directed attention narrows the tuning of population-coded position representations.