Infants Admitted to US Intensive Care Units for RSV Infection During the 2022 Seasonal Peak.

Importance: Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections (LRTIs) and infant hospitalization worldwide. Objective: To evaluate the characteristics and outcomes of RSV-related critical illness in US infants during peak 2022 RSV transmission. Design, Setting, and Participants: This cross-sectional study used a public health prospective surveillance registry in 39 pediatric hospitals across 27 US states. Participants were infants admitted for 24 or more hours between October 17 and December 16, 2022, to a unit providing intensive care due to laboratory-confirmed RSV infection. Exposure: Respiratory syncytial virus. Main Outcomes and Measures: Data were captured on demographics, clinical characteristics, signs and symptoms, laboratory values, severity measures, and clinical outcomes, including receipt of noninvasive respiratory support, invasive mechanical ventilation, vasopressors or extracorporeal membrane oxygenation, and death. Mixed-effects multivariable log-binomial regression models were used to assess associations between intubation status and demographic factors, gestational age, and underlying conditions, including hospital as a random effect to account for between-site heterogeneity. Results: The first 15 to 20 consecutive eligible infants from each site were included for a target sample size of 600. Among the 600 infants, the median (IQR) age was 2.6 (1.4-6.0) months; 361 (60.2%) were male, 169 (28.9%) were born prematurely, and 487 (81.2%) had no underlying medical conditions. Primary reasons for admission included LRTI (594 infants [99.0%]) and apnea or bradycardia (77 infants [12.8%]). Overall, 143 infants (23.8%) received invasive mechanical ventilation (median [IQR], 6.0 [4.0-10.0] days). The highest level of respiratory support for nonintubated infants was high-flow nasal cannula (243 infants [40.5%]), followed by bilevel positive airway pressure (150 infants [25.0%]) and continuous positive airway pressure (52 infants [8.7%]). Infants younger than 3 months, those born prematurely (gestational age <37 weeks), or those publicly insured were at higher risk for intubation. Four infants (0.7%) received extracorporeal membrane oxygenation, and 2 died. The median (IQR) length of hospitalization for survivors was 5 (4-10) days. Conclusions and Relevance: In this cross-sectional study, most US infants who required intensive care for RSV LRTIs were young, healthy, and born at term. These findings highlight the need for RSV preventive interventions targeting all infants to reduce the burden of severe RSV illness.

Multisystem Inflammatory Syndrome in Children - Initial Therapy and Outcomes.

BACKGROUND: The assessment of real-world effectiveness of immunomodulatory medications for multisystem inflammatory syndrome in children (MIS-C) may guide therapy. METHODS: We analyzed surveillance data on inpatients younger than 21 years of age who had MIS-C and were admitted to 1 of 58 U.S. hospitals between March 15 and October 31, 2020. The effectiveness of initial immunomodulatory therapy (day 0, indicating the first day any such therapy for MIS-C was given) with intravenous immune globulin (IVIG) plus glucocorticoids, as compared with IVIG alone, was evaluated with propensity-score matching and inverse probability weighting, with adjustment for baseline MIS-C severity and demographic characteristics. The primary outcome was cardiovascular dysfunction (a composite of left ventricular dysfunction or shock resulting in the use of vasopressors) on or after day 2. Secondary outcomes included the components of the primary outcome, the receipt of adjunctive treatment (glucocorticoids in patients not already receiving glucocorticoids on day 0, a biologic, or a second dose of IVIG) on or after day 1, and persistent or recurrent fever on or after day 2. RESULTS: A total of 518 patients with MIS-C (median age, 8.7 years) received at least one immunomodulatory therapy; 75% had been previously healthy, and 9 died. In the propensity-score-matched analysis, initial treatment with IVIG plus glucocorticoids (103 patients) was associated with a lower risk of cardiovascular dysfunction on or after day 2 than IVIG alone (103 patients) (17% vs. 31%; risk ratio, 0.56; 95% confidence interval [CI], 0.34 to 0.94). The risks of the components of the composite outcome were also lower among those who received IVIG plus glucocorticoids: left ventricular dysfunction occurred in 8% and 17% of the patients, respectively (risk ratio, 0.46; 95% CI, 0.19 to 1.15), and shock resulting in vasopressor use in 13% and 24% (risk ratio, 0.54; 95% CI, 0.29 to 1.00). The use of adjunctive therapy was lower among patients who received IVIG plus glucocorticoids than among those who received IVIG alone (34% vs. 70%; risk ratio, 0.49; 95% CI, 0.36 to 0.65), but the risk of fever was unaffected (31% and 40%, respectively; risk ratio, 0.78; 95% CI, 0.53 to 1.13). The inverse-probability-weighted analysis confirmed the results of the propensity-score-matched analysis. CONCLUSIONS: Among children and adolescents with MIS-C, initial treatment with IVIG plus glucocorticoids was associated with a lower risk of new or persistent cardiovascular dysfunction than IVIG alone. (Funded by the Centers for Disease Control and Prevention.).

The Impact of Obesity on Disease Severity and Outcomes Among Hospitalized Children With COVID-19.

OBJECTIVE: To describe the impact of obesity on disease severity and outcomes of coronavirus disease 2019 (COVID-19) among hospitalized children. METHODS: This retrospective cohort study from the Society of Critical Care Medicine Viral Respiratory Illness Universal Study registry included all children hospitalized with COVID-19 from March 2020 to January 2021. Obesity was defined by Centers for Disease Control and Prevention BMI or World Health Organization weight for length criteria. Critical illness definition was adapted from National Institutes of Health criteria of critical COVID. Multivariate mixed logistic and linear regression was performed to calculate the adjusted odds ratio of critical illness and the adjusted impact of obesity on hospital length of stay. RESULTS: Data from 795 patients (96.4% United States) from 45 sites were analyzed, including 251 (31.5%) with obesity and 544 (68.5%) without. A higher proportion of patients with obesity were adolescents, of Hispanic ethnicity, and had other comorbidities. Those with obesity were also more likely to be diagnosed with multisystem inflammatory syndrome in children (35.7% vs 28.1%, P = .04) and had higher ICU admission rates (57% vs 44%, P < .01) with more critical illness (30.3% vs 18.3%, P < .01). Obesity had more impact on acute COVID-19 severity than on multisystem inflammatory syndrome in children presentation. The adjusted odds ratio for critical illness with obesity was 3.11 (95% confidence interval: 1.8-5.3). Patients with obesity had longer adjusted length of stay (exponentiated parameter estimate 1.3; 95% confidence interval: 1.1-1.5) compared with patients without obesity but did not have increased mortality risk due to COVID-19 (2.4% vs 1.5%, P = .38). CONCLUSION: In a large, multicenter cohort, a high proportion of hospitalized children from COVID-19 had obesity as comorbidity. Furthermore, obesity had a significant independent association with critical illness.

Resources and Costs Associated With Repeated Admissions to PICUs.

OBJECTIVE: To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge. DESIGN: Cross-sectional, retrospective cohort study using Pediatric Health Information System. SETTING: Fifty-two tertiary children's hospitals. SUBJECTS: Pediatric patients under 18 years old admitted to the PICU from January 1, 2016, to December 31, 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics and costs of care were compared between those with readmission requiring PICU care and those with only a single PICU admission per annum. In this 2-year cohort, there were 239,157 index PICU patients of which 36,970 (15.5%) were readmitted and required PICU care during the 12 months following index admission. The total hospital cost for all index admissions and readmissions was $17.3 billion, of which 21.5% ($3.71 billion) were incurred during a readmission stay involving care in the PICU; of the 3,459,079 hospital days, 20.3% (702,200) were readmission days including those where PICU care was required. Of the readmitted patients, 11,703 (30.0%) received only PICU care, accounting for $662 million in costs and 110,215 PICU days. Although 43.6% of all costs were associated with patients who required readmission, these patients only accounted for 15.5% of the index patients and 28% of index hospitalization expenditures. More patients in the readmitted group had chronic complex conditions at index discharge compared with those not readmitted (83.9% vs 54.9%; p < 0.001). Compared with those discharged directly to home without home healthcare, patients discharged to a skilled nursing facility had 18% lower odds of readmission (odds ratio 0.82 [95% CI, 0.75-0.89]; p < 0.001) and those discharged home with home healthcare had 43% higher odds of readmission (odds ratio, 1.43 [95% CI, 1.36-1.51]; p < 0.001). CONCLUSIONS: Repeated admissions with PICU care resulted in significant direct medical costs and resource use for U.S. children's hospitals.

Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators.

OBJECTIVES: To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. DESIGN: Multicenter time-series study. SETTING: PICUs in the United States. PATIENTS: All patients received tracheal intubations in ICUs. INTERVENTIONS: We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). CONCLUSIONS: Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

Depression and Anxiety Screening in Adolescents With Diabetes.

Adolescents with diabetes are at increased risk for depression and anxiety, which when untreated negatively affects diabetes control. During a 6-month period, the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) screening tool was utilized. Those with a positive screen then completed the Patient Health Questionnaire for Adolescents (PHQ-A) and the Generalized Anxiety Disorder 7-item (GAD-7) scale. In this article, we report on the correlations in outcomes between the PHQ-4 and the PHQ-A and GAD-7 and its clinical utility for determining the need for standard versus acute behavioral health care. Over 6 months, 77 patients aged 10 to 18 years screened positive on the PHQ-4. Thirty-two patients had positive screening with the PHQ-A and/or the GAD-7. Thoughts of self-harm were reported by 13 (40%), with 1 experiencing current/active symptoms. The PHQ-4 as a screening tool was able to identify adolescents with symptoms of depression and/or anxiety who would benefit from further evaluation by a behavioral health provider.

Impact of Kamishibai Card Process on Compliance With the Central Venous Line Maintenance Bundle.

BACKGROUND: The Kamishibai Card (K-Card) process is a storytelling methodology designed to help identify barriers and remove or redesign them. PURPOSE: The purpose of this study was to evaluate the effectiveness of the K-Card process for central venous line (CVL) maintenance bundle compliance in a pediatric intensive care unit. METHODS: A retrospective evaluation of the implementation of the K-Card process was performed using a pretest and posttest design. RESULTS: A total of 1003 central venous catheter maintenance observations were completed during the study period. A statistically significant change was noted in one element of the CVL maintenance bundle, tubing timed and dated. The most frequent cause for noncompliance with the CVL maintenance bundle was incomplete communication during handoff, followed by device associated factors (failure of device, use of device, and availability of device). CONCLUSIONS: The K-Card process had a positive impact on CVL maintenance bundle compliance in the study setting.

Standardized Implementation of Evidence-based Guidelines to Decrease Blood Transfusions in Pediatric Intensive Care Units.

INTRODUCTION: Despite evidence that red blood cell (RBC) transfusions may be associated with more harm than benefit, current transfusion practices vary significantly. This multicenter, quality improvement study aimed to sustainably decrease the rate of RBC transfusions in pediatric intensive care units (PICUs). METHODS: This 16-month prospective study included 5 PICUs. We implemented a standardized project plan including education, bedside tools, real-time reminders, and email feedback. We collected data from consecutive transfusions during pre-implementation (Phase I), postimplementation (Phase II), and post-stabilization phases (Phase III). RESULTS: Of the 2,064 RBC transfusions, we excluded 35% (N = 729) from analysis in patients undergoing extracorporeal membrane oxygenation. Transfusion/1,000 admissions improved throughout the study periods from a baseline 209.6 -199.8 in Phase II and 195.8 in Phase III (P value < 0.05). There were fewer transfusions outside of the hemoglobin threshold guideline, decreasing from 81% of transfusions outside of guidelines in Phase I to 74% in Phases II and III, P < 0.05. Study phase, site, co-management status, service of requesting provider, admit reason, previous transfusion status, and age were associated with transfusion above guideline threshold. CONCLUSIONS: Multicenter collaboration can successfully deploy a standardized plan that adheres to implementation science principles to sustainably decrease the rate of RBC transfusion outside of guideline thresholds. However, we did not decrease the total number of transfusions in our study. The complexity of multiple specialties co-managing patients is common in the contemporary PICU. Educational initiatives aimed at one specialty may have limited effectiveness in a multifaceted system of care.

Family Presence During Pediatric Tracheal Intubations.

IMPORTANCE: Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated. OBJECTIVE: To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs. EXPOSURES: Family presence and no FP during TI in the PICU. MAIN OUTCOMES AND MEASURES: The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level. RESULTS: A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders. CONCLUSIONS AND RELEVANCE: Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.

A Bedside Decision Tree for Use of Saline With Endotracheal Tube Suctioning in Children.

BACKGROUND: Endotracheal tube suctioning is necessary for patients receiving mechanical ventilation. Studies examining saline instillation before suctioning have demonstrated mixed results. METHODS: A prospective study to evaluate whether saline instillation is associated with an increased risk of suctioning-related adverse events in patients 18 years old or younger requiring mechanical ventilation through an endotracheal tube for at least 48 hours when suctioned per protocol using a bedside decision tree. RESULTS: A total of 1986 suctioning episodes (1003 with saline) were recorded in 69 patients. The most common indication for use of saline was thick secretions (87% of episodes). In 586 suctioning episodes, at least 1 adverse event occurred with increased frequency in the saline group (P < .001). Normal saline was more likely to be associated with hemodynamic instability (P = .04), bronchospasm (P < .001), and oxygen desaturation (P < .001). Patient factors associated with adverse events include younger age (P < .001), a cuffed endotracheal tube (P = .001), endotracheal tube diameter of 4.0 mm or less (P < .001), respiratory or hemodynamic indication for intubation (P < .001), underlying respiratory disease (P < .001), and longer duration of mechanical ventilation (P < .001). Saline instillation (P < .001), endotracheal tube size of 4.0 mm or less (P = .03), and comorbid respiratory diseases (P = .03) were associated with an increased risk of adverse events. CONCLUSIONS: Saline instillation before endotracheal tube suctioning is associated with hemodynamic instability, bronchospasm, and transient hypoxemia. Saline should be used cautiously, especially in children with a small endotracheal tube and comorbid respiratory disease.

Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care.

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

Using simulation to investigate the impact of hours worked on task performance in an intensive care unit.

BACKGROUND: Past studies have indicated a positive correlation between shift length and the rate of medical errors. In situ simulation is an innovative way to study issues in quality of care. OBJECTIVES: To explore the use of in situ simulation as an investigative method by using it to examine the effects of work length on completion rate of and accuracy at critical care nursing tasks. METHODS: Participants were drawn from the nursing staff in the pediatric intensive care unit and were assessed by using a high-fidelity pediatric simulator 3 times during a 12-hour shift. Data recorded included demographic information, time to task completion, and number of steps correctly performed per task. RESULTS: Twenty-eight nurses with a mean of 5.5 years of experience participated. Each nurse cared for a mean of 1.4 patients per shift. A significant decrease (P < .001) of 5.5 minutes was noted in mean completion time across assessment intervals (from 17.9 to 13.3, to 12.4 min). No significant changes in accuracy were noted. Some accuracy issues seemed attributable to simulation artifact, whereas the use of simulation enabled greater standardization in other aspects of the study. CONCLUSION: Critical care nurses take significantly less time to complete tasks at the end of their shift than at the beginning. This, coupled with a lack of change in accuracy of task completion over time, suggests that nursing performance of simple tasks may improve over the course of a 12-hour shift. Simulation can be an effective means to address some quality improvement issues.

Integrated in-situ simulation using redirected faculty educational time to minimize costs: a feasibility study.

INTRODUCTION: Simulation is an effective teaching tool, but many hospitals do not possess the space or finances to support traditional simulation centers. Our objective is to describe the feasibility of an in situ simulation program model that uses minimal permanent space and "redirected" cost-neutral faculty educational time to address these issues. METHODS: Two pediatric simulators and audiovisual equipment were purchased. Course faculty were derived from a group of physicians and nurses with a percentage work assignment apportioned to education. A portion of this was subsequently redirected toward simulation. After 2 years of operation, faculty were surveyed regarding time devoted to the program. Program growth and quality statistics were examined descriptively. RESULTS: The program supported 786 learner encounters in 166 sessions over 2 years. Simulation hours per month increased over sixfold during that period (P < 0.001). Program initiation cost was $128920.89, with subsequent yearly costs of $11,695. Mean program ratings ranged between 4.5/5 for Crisis Resource Management and 4.4/5 for communication skills training. Resident (2.6 h/y increase, P value <0.001) and nursing (2.2 h/y increase, P < 0.001) simulation hours increased significantly. Faculty involvement averaged between 3% and 32% of total work hours. CONCLUSION: This report demonstrates the feasibility of implementing an in situ simulation program using minimal permanent institutional space and cost-neutral redirected faculty time. This type of programmatic structure is conducive to short- and medium-term growth, is well received by participants, and allows for substantial cost savings. Future work will be needed to determine what growth limitations are inherent in this staffing and structural model.

Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations.

OBJECTIVE: To review and revise the 1987 pediatric brain death guidelines. METHODS: Relevant literature was reviewed. Recommendations were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. CONCLUSIONS AND RECOMMENDATIONS: 1) Determination of brain death in term newborns, infants, and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants <37 wks gestational age are not included in this guideline. 2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. 3) Two examinations, including apnea testing with each examination separated by an observation period, are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hrs for term newborns (37 wks gestational age) to 30 days of age and 12 hrs for infants and children (>30 days to 18 yrs) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for ≥24 hrs if there are concerns or inconsistencies in the examination. 4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco2 20 mm Hg above the baseline and ≥60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. 5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be used to assist the clinician in making the diagnosis of brain death a) when components of the examination or apnea testing cannot be completed safely as a result of the underlying medical condition of the patient; b) if there is uncertainty about the results of the neurologic examination; c) if a medication effect may be present; or d) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed and components that can be completed must remain consistent with brain death. In this instance, the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. 6) Death is declared when these criteria are fulfilled.

A multirater instrument for the assessment of simulated pediatric crises.

BACKGROUND: Few validated instruments exist to measure pediatric code team skills. The goal of this study was to develop an instrument for the assessment of resuscitation competency and self-appraisal using multirater and gap analysis methodologies. METHODS: Multirater assessment with gap analysis is a robust methodology that enables the measurement of self-appraisal as well as competency, offering faculty the ability to provide enhanced feedback. The Team Performance during Simulated Crises Instrument (TPDSCI) was grounded in the Accreditation Council for Graduate Medical Education competencies. The instrument contains 5 competencies, each assessed by a series of descriptive rubrics. It was piloted during a series of simulation-based interdisciplinary pediatric crisis resource management education sessions. Course faculty assessed participants, who also did self-assessments. Internal consistency and interrater reliability were analyzed using Cronbach α and intraclass correlation (ICC) statistics. Gap analysis results were examined descriptively. RESULTS: Cronbach α for the instrument was between 0.72 and 0.69. The overall ICC was 0.82. ICC values for the medical knowledge, clinical skills, communication skills, and systems-based practice were between 0.87 and 0.72. The ICC for the professionalism domain was 0.22. Further examination of the professionalism competency revealed a positive skew, 43 simulated sessions (98%) had significant gaps for at least one of the competencies, 38 sessions (86%) had gaps indicating self-overappraisal, and 15 sessions (34%) had gaps indicating self-underappraisal. CONCLUSIONS: The TPDSCI possesses good measures of internal consistency and interrater reliability with respect to medical knowledge, clinical skills, communication skills, systems-based practice, and overall competence in the context of simulated interdisciplinary pediatric medical crises. Professionalism remains difficult to assess. These results provide an encouraging first step toward instrument validation. Gap analysis reveals disparities between faculty and self-assessments that indicate inadequate participant self-reflection. Identifying self-overappraisal can facilitate focused interventions.

Effect of fatigue, workload, and environment on patient safety in the pediatric intensive care unit.

INTRODUCTION: Pediatric intensive care unit patient care occurs in an unpredictable, technology-rich environment that is dependent on highly skilled providers who need constant communication-all features providing the setting for potential error. This review examines basic principles of human error and sleep physiology and evaluates the evidence for potential effects of fatigued healthcare workers and workload on medical error. BODY: The pediatric intensive care unit setting, examined from a human factors engineering standpoint, is a highly complex environment in which fatigue and excessive workload can provide potential "holes" that may allow errors to occur. A large body of evidence is examined that suggests sleep deprivation can impair medical and surgical performance and can be improved with scheduling intervention. Nursing fatigue and workload have documented effects on increasing intensive care unit error, infections, and cost. Specific environmental factors such as distractions and communication barriers are also associated with greater error. CONCLUSION: Fatigue, excessive workload, and the pediatric intensive care unit environment can adversely affect the performance of physicians and nurses working in the pediatric intensive care unit. The weight of the evidence suggests that these factors have the potential to contribute to medical error in the pediatric intensive care unit.

Comparison of end-tidal CO2 and Paco2 in children receiving mechanical ventilation.

OBJECTIVE: To determine whether end-tidal CO(2) (Petco(2)) measurement provides a reliable estimate of ventilation in critically ill children who are mechanically ventilated. DESIGN: Prospective, nonrandomized, consecutive enrollment study. SETTING: A university-affiliated children's hospital pediatric intensive care unit. PATIENTS: All intubated, mechanically ventilated pediatric patients. INTERVENTIONS: All Petco(2)-Paco(2) pairs were from patients ventilated with a Servo 300 Ventilator (Siemens-Elema AB, Stockholm, Sweden). When a blood gas sample was obtained, Petco(2) as measured by a continuous mainstream Petco(2) capnograph was recorded. Measurements: The results of blood gas measurements and corresponding Petco(2) measurements were recorded. Demographic data and primary diagnosis were noted. Petco(2)-Paco(2) pairs obtained from patients with intracardiac shunts or obtained during high-frequency oscillation or extracorporeal membrane oxygenation at the time of measurement were excluded from analysis. Linear regression was used to analyze Petco(2)-Paco(2) pairs. Repeated measure analysis of variance with the mixed-model algorithm in SAS software (SAS Institute, Carey, NC) was used to analyze the trend in the Petco(2) and Paco(2) relationship. Chi-square was used to analyze categorical data. Statistical significance was considered p <.05. RESULTS: A total of 129 children were enrolled, and 1708 paired Paco(2) and Petco(2) measurements were recorded. The mean age +/- sd was 4.1 +/- 5.6 yrs. Paco(2) positively correlated with Petco(2). The linear equation for the regression analysis was y = 0.71x (95% confidence interval, 0.69-0.73) + 8.93 (95% confidence interval, 7.89-9.97), with r (2) =.716 and p <.001. The Petco(2)-Paco(2) difference was 10 mm Hg (1.33 kPa) difference between the Petco(2) and Paco(2). However, only 111 of 1068 (10%) Petco(2)-Paco(2) pairs had a difference of >10 mm Hg (1.33 kPa) in patients with a Pao(2)/Fio(2) ratio >200. Trend analysis showed the Petco(2)-Paco(2) difference increased with increasing duration of mechanical ventilation. CONCLUSION: In most intubated, mechanically ventilated infants and children, Petco(2) reliably estimates ventilation.