Dynamic Prediction of Mortality Using Longitudinally Measured Pediatric Sequential Organ Failure Assessment Scores: A Joint Modeling Approach.

OBJECTIVES: The pediatric Sequential Organ Failure Assessment (pSOFA) score was designed to track illness severity and predict mortality in critically ill children. Most commonly, pSOFA at a point in time is used to assess a static patient condition. However, this approach has a significant drawback because it fails to consider any changes in a patients' condition during their PICU stay and, especially, their response to initial critical care treatment. We aimed to evaluate the performance of longitudinal pSOFA scores for predicting mortality. DESIGN: Single-center, retrospective cohort study. SETTING: Quaternary 40-bed PICU. PATIENTS: All patients admitted to the PICU between 2015 and 2021 with at least 24 hours of ICU stay. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated daily pSOFA scores up to 30 days, or until death or discharge from the PICU, if earlier. We used the joint longitudinal and time-to-event data model for the dynamic prediction of 30-day in-hospital mortality. The dataset, which included 9146 patients with a 30-day in-hospital mortality of 2.6%, was divided randomly into training (75%) and validation (25%) subsets, and subjected to 40 repeated stratified cross-validations. We used dynamic area under the curve (AUC) to evaluate the discriminative performance of the model. Compared with the admission-day pSOFA score, AUC for predicting mortality between days 5 and 30 was improved on average by 6.4% (95% CI, 6.3-6.6%) using longitudinal pSOFA scores from the first 3 days and 9.2% (95% CI, 9.0-9.5%) using scores from the first 5 days. CONCLUSIONS: Compared with admission-day pSOFA score, longitudinal pSOFA scores improved the accuracy of mortality prediction in PICU patients at a single center. The pSOFA score has the potential to be used dynamically for the evaluation of patient conditions.

Comparing the Quality of Domain-Specific Versus General Language Models for Artificial Intelligence-Generated Differential Diagnoses in PICU Patients.

OBJECTIVES: Generative language models (LMs) are being evaluated in a variety of tasks in healthcare, but pediatric critical care studies are scant. Our objective was to evaluate the utility of generative LMs in the pediatric critical care setting and to determine whether domain-adapted LMs can outperform much larger general-domain LMs in generating a differential diagnosis from the admission notes of PICU patients. DESIGN: Single-center retrospective cohort study. SETTING: Quaternary 40-bed PICU. PATIENTS: Notes from all patients admitted to the PICU between January 2012 and April 2023 were used for model development. One hundred thirty randomly selected admission notes were used for evaluation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five experts in critical care used a 5-point Likert scale to independently evaluate the overall quality of differential diagnoses: 1) written by the clinician in the original notes, 2) generated by two general LMs (BioGPT-Large and LLaMa-65B), and 3) generated by two fine-tuned models (fine-tuned BioGPT-Large and fine-tuned LLaMa-7B). Differences among differential diagnoses were compared using mixed methods regression models. We used 1,916,538 notes from 32,454 unique patients for model development and validation. The mean quality scores of the differential diagnoses generated by the clinicians and fine-tuned LLaMa-7B, the best-performing LM, were 3.43 and 2.88, respectively (absolute difference 0.54 units [95% CI, 0.37-0.72], p < 0.001). Fine-tuned LLaMa-7B performed better than LLaMa-65B (absolute difference 0.23 unit [95% CI, 0.06-0.41], p = 0.009) and BioGPT-Large (absolute difference 0.86 unit [95% CI, 0.69-1.0], p < 0.001). The differential diagnosis generated by clinicians and fine-tuned LLaMa-7B were ranked as the highest quality in 144 (55%) and 74 cases (29%), respectively. CONCLUSIONS: A smaller LM fine-tuned using notes of PICU patients outperformed much larger models trained on general-domain data. Currently, LMs remain inferior but may serve as an adjunct to human clinicians in real-world tasks using real-world data.

Trends in Disease Severity Among Critically Ill Children With Severe Acute Respiratory Syndrome Coronavirus 2: A Retrospective Multicenter Cohort Study in the United States.

OBJECTIVES: To describe trends in critical illness from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children over the course of the COVID-19 pandemic. We hypothesized that PICU admission rates were higher in the Omicron period compared with the original outbreak but that fewer patients needed endotracheal intubation. DESIGN: Retrospective cohort study. SETTING: This study took place in nine U.S. PICUs over 3 weeks in January 2022 (Omicron period) compared with 3 weeks in March 2020 (original period). PATIENTS: Patients less than or equal to 21 years old who screened positive for SARS-CoV-2 infection by polymerase chain reaction or hospital-based rapid antigen test and were admitted to a PICU or intermediate care unit were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 267 patients (239 Omicron and 28 original) were reviewed. Forty-five patients in the Omicron cohort had incidental SARS-CoV-2 and were excluded from analysis. The Omicron cohort patients were younger compared with the original cohort patients (median [interquartile range], 6 yr [1.3-13.3 yr] vs 14 yr [8.3-17.3 yr]; p = 0.001). The Omicron period, compared with the original period, was associated with an average increase in COVID-19-related PICU admissions of 13 patients per institution (95% CI, 6-36; p = 0.008), which represents a seven-fold increase in the absolute number admissions. We failed to identify an association between cohort period (Omicron vs original) and odds of intubation (odds ratio, 0.7; 95% CI, 0.3-1.7). However, we cannot exclude the possibility of up to 70% reduction in intubation. CONCLUSIONS: COVID-19-related PICU admissions were seven times higher in the Omicron wave compared with the original outbreak. We could not exclude the possibility of up to 70% reduction in use of intubation in the Omicron versus original epoch, which may represent differences in PICU/hospital admission policy in the later period, or pattern of disease, or possibly the impact of vaccination.

Factors Associated With Mechanical Ventilation Duration in Pediatric Burn Patients in a Regional Burn Center in the United States.

OBJECTIVES: Among burned children who arrive at a burn center and require invasive mechanical ventilation (IMV), some may have prolonged IMV needs. This has implications for patient-centered outcomes as well as triage and resource allocation decisions. Our objective was to identify factors associated with the duration of mechanical ventilation in pediatric patients with acute burn injury in this setting. DESIGN: Single-center, retrospective cohort study. SETTING: Registry data from a regional, pediatric burn center in the United States. PATIENTS: Children less than or equal to 18 years old admitted with acute burn injury who received IMV between January 2005 and December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ventilator days were defined as any full or partial day having received IMV via an endotracheal tube or tracheostomy, not inclusive of time spent ventilated for procedures. Of 5,766 admissions for acute burn care, 4.3% ( n = 249) required IMV with a median duration of 10 days. A multivariable model for freedom from mechanical ventilation showed that the presence of inhalational injury (subhazard ratio [sHR], 0.62; 95% CI, 0.46-0.85) and burns to the head and neck region (sHR, 0.94; 95% CI, 0.90-0.98) were associated with increased risk of remaining mechanically ventilated at any time point. Older (sHR, 1.03; 95% CI, 1.01-1.04) and male children (sHR, 1.39; 95% CI, 1.05-1.84) were more likely to discontinue mechanical ventilation. A majority of children (94.8%) survived to hospital discharge. CONCLUSIONS: The presence of inhalational injury and burns to the head and neck region were associated with a longer duration of mechanical ventilation. Older age and male gender were associated with a shorter duration of mechanical ventilation. These factors should help clinicians better estimate a burned child's expected trajectory and resource-intensive needs upon arrival to a burn center.

Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation.

OBJECTIVES: The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists. DATA SOURCES: An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists. STUDY SELECTION: Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models. DATA EXTRACTION: Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review. DATA SYNTHESIS: Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records. CONCLUSIONS: Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters.

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains. DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017. SETTING: Multicenter study conducted in 33 PICUs across eight countries. SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation. INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions. MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008). CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Pediatric Resident Engagement With an Online Critical Care Curriculum During the Intensive Care Rotation.

OBJECTIVES: Residents are often assigned online learning materials as part of blended learning models, superimposed on other patient care and learning demands. Data that describe the time patterns of when residents interact with online learning materials during the ICU rotation are lacking. We describe resident engagement with assigned online curricula related to time of day and ICU clinical schedules, using website activity data. DESIGN: Prospective cohort study examining curriculum completion data and cross-referencing timestamps for pre- and posttest attempts with resident schedules to determine the hours that they accessed the curriculum and whether or not they were scheduled for clinical duty. Residents at each site were cohorted based on two differing clinical schedules-extended duration (>24 hr) versus shorter (maximum 16 hr) shifts. SETTING: Two large academic children's hospitals. SUBJECTS: Pediatric residents rotating in the PICU from July 2013 to June 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One-hundred and fifty-seven pediatric residents participated in the study. The majority of residents (106/157; 68%) completed the curriculum, with no statistically significant association between overall curriculum completion and schedule cohort at either site. Residents made more test attempts at nighttime between 6 PM and 6 AM (1,824/2,828; 64%) regardless of whether they were scheduled for clinical duty. Approximately two thirds of test attempts (1,785/2,828; 63%) occurred when residents were not scheduled to work, regardless of time of day. Forty-two percent of all test attempts (1,199/2,828) occurred between 6 PM and 6 AM while off-duty, with 12% (342/2,828) occurring between midnight and 6 AM. CONCLUSIONS: Residents rotating in the ICU completed online learning materials mainly during nighttime and off-duty hours, including usage between midnight and 6 AM while off-duty. Increasing nighttime and off-duty workload may have implications for educational design and trainee wellness, particularly during busy, acute clinical rotations, and warrants further examination.

Growth and Changing Characteristics of Pediatric Intensive Care 2001-2016.

OBJECTIVES: We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016. DESIGN: Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey. SETTING: PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU. SUBJECTS: Physician medical directors and nurse managers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital. CONCLUSIONS: U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.

The Top Ten Websites in Critical Care Medicine Education Today.

INTRODUCTION:: The number of websites for the critical care provider is rapidly growing, including websites that are part of the Free Open Access Med(ical ed)ucation (FOAM) movement. With this rapidly expanding number of websites, critical appraisal is needed to identify quality websites. The last major review of critical care websites was published in 2011, and thus a new review of the websites relevant to the critical care clinician is necessary. METHODS:: A new assessment tool for evaluating critical care medicine education websites, the Critical Care Medical Education Website Quality Evaluation Tool (CCMEWQET), was modified from existing tools. A PubMed and Startpage search from 2007 to 2017 was conducted to identify websites relevant to critical care medicine education. These websites were scored based on the CCMEWQET. RESULTS:: Ninety-seven websites relevant for critical care medicine education were identified and scored, and the top ten websites were described in detail. Common types of resources available on these websites included blog posts, podcasts, videos, online journal clubs, and interactive components such as quizzes. Almost one quarter of websites (n = 22) classified themselves as FOAM websites. The top ten websites most often included an editorial process, high-quality and appropriately attributed graphics and multimedia, scored much higher for comprehensiveness and ease of access, and included opportunities for interactive learning. CONCLUSION:: Many excellent online resources for critical care medicine education currently exist, and the number is likely to continue to increase. Opportunities for improvement in many websites include more active engagement of learners, upgrading navigation abilities, incorporating an editorial process, and providing appropriate attribution for graphics and media.

Pediatric Critical Care Medicine Training: 2004-2016.

OBJECTIVES: To describe growth trends in the number of programs, positions, and applicants in pediatric critical care medicine fellowship training as part of the Pediatric Critical Care Medicine Training Study. DESIGN: Descriptive study. SETTINGS: Available archived Match data through the National Resident Matching Program and training data from the Accreditation Council for Graduate Medical Education. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed all data on programs, positions, and applicants through the National Resident Matching Program Specialties Matching Service during the study period of 2004 to 2016. We also analyzed available training data available through the Accreditation Council for Graduate Medical Education for the corresponding study period. During the 12-year study period, there was a statistically significant expansion in programs (38%), positions (82%), and applicants (151%). Correspondingly, the percentage of pediatric critical care medicine programs participating in the Match as a percentage of all Accreditation Council for Graduate Medical Education-accredited programs for that academic year increased 24%. As of 2015, 94% of total first year positions offered for pediatric critical care medicine were through the Match. CONCLUSIONS: For the period 2004 to 2016, there was a substantial increase in positions and applicants applying for training in pediatric critical care medicine. We document an increase in demand (i.e., applicants) that has been matched by an increase in supply (i.e., positions) for pediatric critical care medicine fellowship training. The nearly complete use of the National Resident Matching Program for placing applicants in training positions in pediatric critical care medicine suggests that these data can be used to inform workforce analysis in pediatric critical care medicine.

Test-Enhanced E-Learning Strategies in Postgraduate Medical Education: A Randomized Cohort Study.

BACKGROUND: The optimal design of pedagogical strategies for e-learning in graduate and postgraduate medical education remains to be determined. Video-based e-learning use is increasing, with initial research suggesting that taking short breaks while watching videos (independent of answering test questions) may improve learning by focusing attention on the content presented. Interspersed test questions may also improve knowledge acquisition and retention. OBJECTIVE: To examine the effect of interspersed test questions and periodic breaks on immediate knowledge acquisition and retention at 6 months by pediatric residents engaged in video-based e-learning. METHODS: First- and second-year pediatric residents were randomized to 1 of the following 3 groups: viewing the complete video uninterrupted (full video), viewing the video interrupted with unrelated logic puzzles (logic puzzles), or viewing the video interrupted with brief comprehension test questions (short answer questions). Residents answered pre- and post-tests before and after video viewing, followed by a retention test at 6 months. Primary outcome included comparison of the change in test scores between groups. RESULTS: A total of 49 residents completed the initial testing session. All 3 learning groups had comparable mean increases in immediate knowledge gain, but with no significant differences between groups (F2,46=0.35, P=.71). Thirty-five residents completed retention testing with comparable degrees of knowledge retention in the full video and short answer test questions groups (P<.001), but no significant change in the logic puzzles group (F1,32=2.44, P=.13). CONCLUSIONS: Improved knowledge gain was not demonstrated among residents answering interspersed questions or completing logic puzzles during interrupted online video viewing when compared with residents viewing uninterrupted video content. However, residents who either participated in uninterrupted video viewing or answered interspersed questions during interrupted video viewing demonstrated significant knowledge retention at 6 months.

Epidemiology of death in the PICU at five U.S. teaching hospitals*.

OBJECTIVE: To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States. DESIGN: Prospective case series. SETTING: Five U.S. teaching hospitals. SUBJECTS: We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall mortality rate was 2.39% (range, 1.85-3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death. CONCLUSIONS: The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

The development of an internet-based knowledge exchange platform for pediatric critical care clinicians worldwide*.

OBJECTIVES: Advances in Internet technology now enable unprecedented global collaboration and collective knowledge exchange. Up to this time, there have been limited efforts to use these technologies to actively promote knowledge exchange across the global pediatric critical care community. To develop an open-access, peer-reviewed, not-for-profit Internet-based learning application, OPENPediatrics, a collaborative effort with the World Federation of Pediatric Intensive and Critical Care Societies, was designed to promote postgraduate educational knowledge exchange for physicians, nurses, and others caring for critically ill children worldwide. DESIGN: Description of program development. SETTING: International multicenter tertiary pediatric critical care units across six continents. SUBJECTS: Multidisciplinary pediatric critical care providers. INTERVENTIONS: A software application, providing information on demand, curricular pathways, and videoconferencing, downloaded to a local computer. MEASUREMENTS AND MAIN RESULTS: In 2010, a survey assessing postgraduate educational needs was distributed through World Federation of Pediatric Intensive and Critical Care Societies to constituent societies. Four hundred and twenty-nine critical care providers from 49 countries responded to the single e-mail survey request. Respondents included 68% physicians and 28% nurses who care for critically ill children. Fifty-two percent of respondents reported accessing the Internet at least weekly to obtain professional educational information. The five highest requests were for educational content on respiratory care [mechanical ventilation] (48% [38%]), sepsis (28%), neurology (25%), cardiology (14%), extracorporeal membrane oxygenation (10%), and ethics (8%). Based on these findings, and in collaboration with researchers in adult learning and online courseware, an application was developed and is currently being used by 770 registered users in 60 countries. CONCLUSIONS: We describe here the development and implementation of an Internet-based application which is among the first efforts designed to promote global knowledge exchange for physicians and nurses caring for critically ill children. This application has the potential to evolve new methods in postgraduate education. Ongoing assessment of the efficacy of Internet-based learning platforms will be necessary.