Challenges to well-being in critical care.

BACKGROUND: Paediatric critical care (PCC) is a high-pressure working environment. Staff experience high levels of burnout, symptoms of post-traumatic stress, and moral distress. AIM: To understand challenges to workplace well-being in PCC to help inform the development of staff interventions to improve and maintain well-being. STUDY DESIGN: The Enhanced Critical Incident Technique (ECIT) was used. ECIT encompasses semi-structured interviews and thematic analysis. We identified 'critical incidents', challenges to well-being, categorized them in a meaningful way, and identified factors which helped and hindered in those moments. Fifty-three nurses and doctors from a large UK quaternary PCC unit were consented to take part. RESULTS: Themes generated are: Context of working in PCC, which examined staff's experiences of working in PCC generally and during COVID-19; Patient care and moral distress explored significant challenges to well-being faced by staff caring for increasingly complex and chronically ill patients; Teamwork and leadership demonstrated the importance of team-belonging and clear leadership; Changing workforce explored the impact of staffing shortages and the ageing workforce on well-being; and Satisfying basic human needs, which identified absences in basic requirements of food and rest. CONCLUSIONS: Staff's experiential accounts demonstrated a clear need for psychologically informed environments to enable the sharing of vulnerabilities, foster support, and maintain workplace well-being. Themes resonated with the self-determination theory and Maslow's hierarchy of needs, which outline requirements for fulfilment (self-actualization). RELEVANCE TO CLINICAL PRACTICE: Well-being interventions must be informed by psychological theory and evidence. Recommendations are flexible rostering, advanced communication training, psychologically-informed support, supervision/mentoring training, adequate accommodation and hot food. Investment is required to develop successful interventions to improve workplace well-being.

Critical Care Course of Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 and Response to Immunomodulation.

We describe the critical care course of children with a novel hyperinflammatory syndrome associated with coronavirus disease 2019 (COVID-19) pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with focus on trajectory before and after immunomodulation. Overall, 10 patients who met the U.K. Royal College of Pediatrics and Child Health case definition during a 2-month study period were analyzed. All tested positive for SARS-CoV-2 IgG antibody. Although only 20% were ventilated, 100% required inotropic or vasopressor support. All children had significantly raised inflammatory markers with a median C-reactive protein of 248 (175-263) mg/L, ferritin of 1,561 (726-2,255) µg/L, and troponin-I of 723 (351-2,235) ng/L. Six patients had moderately impaired myocardial function and two had severe impairment. None needed extracorporeal membrane oxygenation. Despite severe illness only a brief period of critical care support of 3 to 5 days was required. Eight received at least one dose of intravenous immunoglobulin. Six received high-dose steroids. Clinical improvement including cardiovascular stability and reduction in inflammatory markers may have occurred with and without immunomodulation.

Wireless monitoring and real-time adaptive predictive indicator of deterioration.

To assist in the early warning of deterioration in hospitalised children we studied the feasibility of collecting continuous wireless physiological data using Lifetouch (ECG-derived heart and respiratory rate) and WristOx2 (pulse-oximetry and derived pulse rate) sensors. We compared our bedside paediatric early warning (PEW) score and a machine learning automated approach: a Real-time Adaptive Predictive Indicator of Deterioration (RAPID) to identify children experiencing significant clinical deterioration. 982 patients contributed 7,073,486 min during 1,263 monitoring sessions. The proportion of intended monitoring time was 93% for Lifetouch and 55% for WristOx2. Valid clinical data was 63% of intended monitoring time for Lifetouch and 50% WristOx2. 29 patients experienced 36 clinically significant deteriorations. The RAPID Index detected significant deterioration more frequently (77% to 97%) and earlier than the PEW score ≥ 9/26. High sensitivity and negative predictive value for the RAPID Index was associated with low specificity and low positive predictive value. We conclude that it is feasible to collect clinically valid physiological data wirelessly for 50% of intended monitoring time. The RAPID Index identified more deterioration, before the PEW score, but has a low specificity. By using the RAPID Index with a PEW system some life-threatening events may be averted.

Implementation and Early Evaluation of a Quantitative Electroencephalography Program for Seizure Detection in the PICU.

OBJECTIVES: To describe implementation and early evaluation of using quantitative electroencephalography for electrographic seizure detection by PICU clinician staff. DESIGN: Prospective observational study of electrographic seizure detection by PICU clinicians in patients monitored with quantitative electroencephalography. Quantitative electroencephalography program implementation included a continuous education and training package. Continuous quantitative electroencephalography monitoring consisted of two-channel amplitude-integrated electroencephalography, color density spectral array, and raw-electroencephalography. SETTING: PICU. PATIENTS: Children less than 18 years old admitted to the PICU during the 14-month study period and deemed at risk of electrographic seizure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Real time electrographic seizure detection by a PICU team was analyzed for diagnostic accuracy and promptness, against electrographic seizure identification by a trained neurophysiologist, retrospectively reading the same quantitative electroencephalography and blinded to patient details. One-hundred one of 1,510 consecutive admissions (6.7%) during the study period underwent quantitative electroencephalography monitoring. Status epilepticus (35%) and suspected hypoxic-ischemic injury (32%) were the most common indications for quantitative electroencephalography. Electrographic seizure was diagnosed by the neurophysiologist in 12% (n = 12) of the cohort. PICU clinicians correctly diagnosed all 12 patients (100% sensitivity and negative predictive value). An additional eleven patients had a false-positive diagnosis of electrographic seizure (false-positive rate = 52% [31-73%]) leading to a specificity of 88% (79-94%). Median time to detect seizures was 25 minutes (5-218 min). Delayed recognition of electrographic seizure (> 1 hr from onset) occurred in five patients (5/12, 42%). CONCLUSIONS: Early evaluation of quantitative electroencephalography program to detect electrographic seizure by PICU clinicians suggested good sensitivity for electrographic seizure detection. However, the high false-positive rate is a challenge. Ongoing work is needed to reduce the false positive diagnoses and avoid electrographic seizure detection delays. A comprehensive training program and regular refresher updates for clinical staff are key components of the program.

Evolution, safety and efficacy of targeted temperature management after pediatric cardiac arrest.

BACKGROUND: It is unknown whether targeted temperature management (TTM) improves survival after pediatric out-of-hospital cardiac arrest (OHCA). The aim of this study was to assess the evolution, safety and efficacy of TTM (32-34 °C) compared to standard temperature management (STM) (<38 °C). METHODS: Retrospective, single center cohort study. Patients aged >one day up to 16 years, admitted to a UK Paediatric Intensive Care Unit (PICU) after OHCA (January 2004-December 2010). Primary outcome was survival to hospital discharge; efficacy and safety outcomes included: application of TTM, physiological, hematological and biochemical side effects. RESULTS: Seventy-three patients were included. Thirty-eight patients (52%) received TTM (32-34 °C). Prior to ILCOR guidance adoption in January 2007, TTM was used infrequently (4/25; 16%). Following adoption, TTM (32-34 °C) use increased significantly (34/48; 71% Chi(2); p < 0.0001). TTM (32-34 °C) and STM (<38 °C) groups were similar at baseline. TTM (32-34 °C) was associated with bradycardia and hypotension compared to STM (<38 °C). TTM (32-34 °C) reduced episodes of hyperthermia (>38 °C) in the 1st 24h; however, excessive hypothermia (<32 °C) and hyperthermia (>38 °C) occurred in both groups up to 72 h, and all patients (n = 11) experiencing temperature <32 °C died. The study was underpowered to determine a difference in hospital survival (34% (TTM (32-34 °C)) versus 23% (STM (<38 °C)); p = 0.284). However, the TTM (32-34 °C) group had a significantly longer PICU length of stay. CONCLUSIONS: TTM (32-34 °C) was feasible but associated with bradycardia, hypotension, and increased length of stay in PICU. Temperature <32 °C had a universally grave prognosis. Larger studies are required to assess effect on survival.

Developing an intervention to equip nurses for acute life threatening events (ALTEs) in hospital: a phenomenological approach to healthcare research.

OBJECTIVES: To understand staff's experiences of acute life threatening events (ALTEs) in a pediatric hospital setting. These data will inform an intervention to equip nurses with clinical and emotional skills for dealing with ALTEs. METHOD: A mixed design was used in the broader research program; this paper focuses on phenomenon-focused interviews analyzed using interpretative phenomenological analysis (IPA). RESULTS: Emerging themes included staff's relationships with patients and the impact of personhood on their ability to perform competently in an emergency. More experienced nurses described "automatic" competence generated through increased exposure to ALTEs and were able to recognize "fumbling and shaking" as a normal stress response. Designating a role was significant to staff experience of effectiveness. Key to nurses' learning experience was reflection and identifying experiences as "teachable moments." Findings were considered alongside existing theories of self-efficacy, reflective thought, and advocacy inquiry to create an experiential learning intervention involving a series of clinical and role-related scenarios. CONCLUSION: The phenomenological work facilitated an in-depth reading of experience. It accentuated the importance of exposure to ALTEs giving nurses experiential knowledge to prepare them for the impact of these events. Challenges included bracketing the personhood of child patients, shifting focus to clinical tasks during the pressured demands of managing an ALTE, normalizing the physiological stress response, and the need for a forum and structure for reflection and learning. An intervention will be designed to provide experiential learning and encourage nurses to realize and benefit from their embodied knowledge.

Survey of the use of therapeutic hypothermia after cardiac arrest in UK paediatric emergency departments.

OBJECTIVES: To ascertain current use of therapeutic hypothermia (TH) after paediatric cardiac arrest in UK emergency departments (EDs), and views on participating in a UK randomised controlled trial (RCT) incorporating early induction of TH in ED. DESIGN: Anonymous web-based survey of 77 UK Emergency Medicine (EM) consultants from 28 UK EDs that see children during the period April-June 2010. RESULTS: 62% (48/77) of surveyed consultants responded from 21/28 (75%) EDs. All managed children post cardiac arrest. 90% (43/48) were aware of the literature concerning TH after cardiac arrest in adults. However, 63% (30/48) had never used TH in paediatric practice. All departments had at least one method of inducing TH (surface cooling; air/water blankets; intravenous cold fluid or catheters). Reasons stated for not inducing TH included no equipment available (26%; 11/42), TH not advocated by the local PICU (24%; 10/42) and not enough evidence for its use (24%; 10/42). TH was considered based on advice from the local Paediatric Intensive Care Units (68%; 17/25) or likelihood of recovery after arrest (32%; 8/25). There was strong support for a UK RCT of TH versus normothermia (85%; 40/47). The proposed RCT was felt to be ethical (87%; 40/48) with use of deferred consent acceptable (74%; 34/46). CONCLUSION: UK EM consultants are aware of TH but infrequently initiate the therapy in children for a number of reasons. Their involvement would enable early induction of TH in EDs after paediatric cardiac arrest during a UK RCT. The authors have demonstrated the availability of suitable equipment and EM consultant support for participation in such a RCT.

Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children.

INTRODUCTION: The timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals. METHODS: We performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients. RESULTS: A total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001). CONCLUSIONS: The Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.

Survey of the use of therapeutic hypothermia post cardiac arrest.

OBJECTIVES: Therapeutic hypothermia improves neurological outcome in adults after ventricular fibrillation cardiac arrest and neonates with hypoxic ischaemic encephalopathy. There is currently no clinical research to support its use in the paediatric population. This survey aims to ascertain current practice in the UK, and attitudes and opinions to guide the feasibility of a UK multicentre, randomised, controlled trial of therapeutic hypothermia after cardiac arrest in children (The Cold-PACK Post Arrest Cooling in Kids study). METHODS: Anonymous survey of UK paediatric intensive care consultants (n=149). RESULTS: A total of 113 (76%) of 149 surveys were returned; 65% responded that they do not know if therapeutic hypothermia improves survival after cardiac arrest. Despite this, 48% 'always' or 'often' use therapeutic hypothermia after return of spontaneous circulation following cardiac arrest in children. Among those who never use therapeutic hypothermia (33%) the commonest explanation given was 'not enough research evidence' (91%). With respect to the dose of therapeutic hypothermia the median duration of cooling used is 24-48 h (range 4-72 h) and median target temperature 34°C to 35°C (range 32°C to 37°C); 68% target a temperature range higher than that applied in the published adult and neonatal studies (33±1°C). There was strong support for a trial of therapeutic hypothermia being ethical (89%) and using deferred consent (85%). CONCLUSIONS: Wide variation in UK practice in the use of therapeutic hypothermia and a state of clinical equipoise is demonstrated by this survey, which shows important support for UK multicentre collaboration in a future trial of therapeutic hypothermia after cardiac arrest.

Increased airway mucins after cardiopulmonary bypass associated with postoperative respiratory complications in children.

OBJECTIVE: Airway mucins may play an important role in the mechanism of respiratory complications after cardiopulmonary bypass in infants and children. Our aim was to measure airway mucin levels before and after cardiopulmonary bypass and to determine whether changes in mucin levels were associated with the development of respiratory complications. METHODS: Airway glycoprotein and mucins (MUC5AC, MUC5B, and MUC2) in serial small-volume airway lavage samples from 39 young children who underwent cardiac operations with cardiopulmonary bypass were measured by slot-blot assay with specific antimucin peptide antibodies. The relationship between mucin changes and post-cardiopulmonary bypass respiratory complications was investigated. Airway lavage samples were also collected from 11 children before and after operation without cardiopulmonary bypass, and changes in mucin levels were compared with those in subjects who underwent cardiopulmonary bypass. Airway lavage sample DNA was also measured to investigate the relationship between mucin changes and lung injury. RESULTS: Glycoprotein, MUC5AC, and MUC5B levels were significantly increased after cardiopulmonary bypass (P <.001) whereas MUC2 level was not. Children with respiratory complications showed significantly higher glycoprotein and MUC5AC levels than did children without respiratory complications before and after cardiopulmonary bypass (P <.05). Increase of total mucin (MUC5AC, MUC5B, and MUC2) during cardiopulmonary bypass showed positive correlation with DNA increase during cardiopulmonary bypass (r = 0.73), PaCO(2) (r = 0.62) and alveolar-arterial oxygen difference (r = 0.55) immediately after cardiopulmonary bypass. Increase of total mucin was associated with postoperative respiratory complications and their severity. There were no significant changes detected in airway mucin during operations without cardiopulmonary bypass. CONCLUSIONS: Airway mucins were increased during cardiopulmonary bypass, and this increase was associated with markers of lung injury after cardiopulmonary bypass and with the development of postoperative respiratory complications.