Closing the Loop: The Value of Outcome Letters for Prehospital Pediatric Care.

OBJECTIVES: Providing emergency care to acutely ill or injured children is stressful and requires a high level of training. Paramedics who provide prehospital care are typically not involved in the circle of care and do not receive patient outcome information. The aim of this quality improvement project was to assess paramedics' perceptions of standardized outcome letters pertaining to acute pediatric patients that they had treated and transported to an emergency department. METHODS: Between December 2019 and December 2020, 888 outcome letters were distributed to paramedics who provided care for 370 acute pediatric patients transported to the Children's Hospital of Eastern Ontario in Ottawa, Canada. All paramedics who received a letter (n = 470) were invited to participate in a survey that collected their perceptions and feedback about the letters, as well as their demographic information. RESULTS: The response rate was 37% (172/470). Approximately half of the respondents were Primary Care Paramedics and half Advanced Care Paramedics. The respondents' median age was 36 years, median years of service was 12 years, and 64% identified as male. Most agreed that the outcome letters contained information pertinent to their practice (91%), allowed them to reflect on care they had provided (87%), and confirmed clinical suspicions (93%). Respondents indicated that they found the letters useful for 3 reasons: 1) increases capacity to link differential diagnoses, prehospital care, or patient outcomes; 2) contributes to a culture of continuous learning and improvement; and 3) gives closure, reduces stress, or provides answers for difficult cases. Suggestions for improvement included providing more information, provision of letters on all patients transported, faster turnaround time between call and receipt of letter and inclusion of recommendations or interventions/assessments. CONCLUSIONS: Paramedics appreciated receiving hospital-based patient outcome information after their provision of care and reported that the letters offered opportunities for closure, reflection, and learning.

The care of critically ill adults with COVID-19 in Ontario pediatric intensive care units.

PURPOSE: To describe and review the experience of two pediatric intensive care units (PICUs) in Ontario, Canada, adapting and providing care to critically ill adults during the COVID-19 pandemic. CLINICAL FEATURES: At a time of extreme pressure to adult intensive care unit (ICU) capacity, two PICUs provided care to critically ill adults with COVID-19 pneumonia. Substantial yet rapid planning was required to facilitate safe delivery of critical care to adult patients while maintaining PICU services, including thoughtful development of care pathways and patient selection. To prepare clinical staff, several communication strategies, knowledge translation, skill consolidation, and system-adaptation mechanisms were developed. There was iterative adaptation of operational processes, including staffing models, specialist consultation, and the pharmacy. Care provided by the interprofessional teams was reoriented as appropriate to the needs of critically ill adults in close collaboration with adult ICU teams. Forty-one adults were admitted to the two PICUs over a 12-week period. In total, 36 patients (88%) received invasive ventilation, eight patients (20%) were supported with venovenous extracorporeal membrane oxygenation, and six patients (15%) received continuous renal replacement therapy. Four died in the PICU during this period. Feedback from staff included anxiety around reorienting practice to the care of critically ill adults, physical exhaustion, and psychological distress. Importantly, staff also reported a renewed sense of purpose with participation in the program. CONCLUSION: Though challenging, the experience has provided opportunity to enhance collaboration with partner institutions and improve the care of older children and adolescents in the PICU.

RéSUMé: OBJECTIF: Nous avions pour objectif de décrire et examiner l'expérience de deux unités de soins intensifs pédiatriques (USIP) en Ontario, au Canada, qui se sont adaptées et ont fourni des soins aux adultes gravement malades pendant la pandémie de COVID-19. CARACTéRISTIQUES CLINIQUES: À l'époque où la capacité des unités de soins intensifs (USI) pour adultes était extrêmement sollicitée, deux USIP ont prodigué des soins à des adultes gravement malades souffrant de pneumonie liée à la COVID-19. Une planification substantielle mais rapide a été nécessaire pour faciliter la prestation sécuritaire de soins intensifs à une patientèle adulte tout en maintenant les services de l'USIP, y compris l'élaboration réfléchie des trajectoires de soins et la sélection de la patientèle. Pour préparer le personnel clinique, plusieurs stratégies de communication, d'application des connaissances, de consolidation des compétences et de mécanismes d'adaptation du système ont été élaborées. Il y a eu une adaptation progressive des processus opérationnels, y compris des modèles de dotation, des consultations de spécialistes et de la pharmacie. Les soins fournis par les équipes interprofessionnelles ont été réorientés en fonction des besoins des adultes gravement malades en étroite collaboration avec les équipes adultes de soins intensifs. Quarante et une personnes adultes ont été admises dans les deux unités de soins intensifs pédiatriques sur une période de 12 semaines. Au total, 36 adultes (88 %) ont bénéficié d'une ventilation invasive, huit personnes (20 %) ont reçu une oxygénation par membrane extracorporelle veino-veineuse, et six (15 %) ont reçu un traitement substitutif de l'insuffisance rénale en continu. Quatre personnes sont décédées à l'USIP au cours de cette période. Les commentaires du personnel comprenaient de l'anxiété liée à la réorientation de leur pratique vers des soins à des adultes gravement malades, l'épuisement physique et la détresse psychologique. Fait important, le personnel a également signalé un regain de motivation lié à la participation de leur USIP à ce programme. CONCLUSION: Bien que difficile, l'expérience a permis d'améliorer la collaboration avec les établissements partenaires et d'améliorer les soins aux enfants plus âgé·es et aux adolescent·es de l'USIP.

Designing a national pediatric critical care database: a Delphi consensus study.

PURPOSE: We sought to describe the processes undertaken for the systematic selection and consensus determination of the common data elements for inclusion in a national pediatric critical care database in Canada. METHODS: We conducted a multicentre Delphi consensus study of Canadian pediatric intensive care units (PICUs) participating in the creation of a national database. Participants were PICU health care professionals, allied health professionals, caregivers, and other stakeholders. A dedicated panel group created a baseline survey of data elements based on literature, current PICU databases, and expertise in the field. The survey was then used for a Delphi iterative consensus process over three rounds, conducted from March to June 2021. RESULTS: Of 86 invited participants, 68 (79%) engaged and agreed to participate as part of an expert panel. Panel participants were sent three rounds of the survey with response rates of 62 (91%), 61 (90%) and 55 (81%), respectively. After three rounds, 72 data elements were included from six domains, mostly reflecting clinical status and complex medical interventions received in the PICU. While race, gender, and home region were included by consensus, variables such as minority status, indigenous status, primary language, and ethnicity were not. CONCLUSION: We present the methodological framework used to select data elements by consensus for a national pediatric critical care database, with participation from a diverse stakeholder group of experts and caregivers from all PICUs in Canada. The selected core data elements will provide standardized and synthesized data for research, benchmarking, and quality improvement initiatives of critically ill children.

RéSUMé: OBJECTIF: Nous avons cherché à décrire les processus entrepris pour la sélection systématique et la détermination consensuelle des éléments de données communs à inclure dans une base de données nationale sur les soins intensifs pédiatriques au Canada. MéTHODE: Nous avons mené une étude multicentrique de consensus selon la méthode Delphi sur les unités de soins intensifs pédiatriques (USIP) canadiennes participant à la création d'une base de données nationale. Les personnes participant à l'étude étaient des professionnel·les de la santé de l'USIP, du personnel paramédical, des soignant·es et d'autres intervenant·es. Un groupe de travail spécialisé a créé une enquête de base des éléments de données sur la littérature, les bases de données actuelles portant sur les USIP et l'expertise dans le domaine. L'enquête a ensuite été utilisée pour créer un processus de consensus itératif Delphi sur trois cycles, mené de mars à juin 2021. RéSULTATS: Sur les 86 personnes invitées à participer, 68 (79 %) se sont engagées et ont accepté de participer à un groupe d'experts. Les membres du panel ont reçu trois rondes du sondage, avec des taux de réponse de 62 (91 %), 61 (90 %) et 55 (81 %), respectivement. Après trois cycles, 72 éléments de données provenant de six domaines ont été inclus, reflétant principalement l'état clinique et les interventions médicales complexes reçues à l'USIP. Alors que la race, le genre et la région d'origine ont été inclus par consensus, des variables telles que le statut de minorité, le statut d'autochtone, la langue principale parlée et l'origine ethnique ne l'ont pas été. CONCLUSION: Nous présentons le cadre méthodologique utilisé pour sélectionner des éléments de données consensuels destinés à une base de données nationale sur les soins intensifs pédiatriques, avec la participation d'un groupe diversifié d'expert·es et de soignant·es de toutes les USIP au Canada. Les éléments de données de base sélectionnés fourniront des données normalisées et synthétisées pour la recherche, l'analyse comparative et les initiatives d'amélioration de la qualité pour les enfants gravement malades.

Noninvasive ventilation of air transported infants with respiratory distress in the Canadian Arctic.

Objectives: Since 2016, use of nasal continuous positive airway pressure (nCPAP) in Nunavut for air transport in select patients has become common practice. This study examines the outcomes of patients transferred by air from the Qikiqtaaluk Region during air transport. We examined intubation rates, adverse events during transfer, and respiratory parameters at departure and upon arrival. Methods: This was a retrospective review from September 2016 to December 2019 including patients under 2 years of age transferred by air on nCPAP from the Qikiqtaaluk Region of Nunavut. Results: Data were collected for 40 transfers involving 34 unique patients. Six transfers were from remote communities in Nunavut to Iqaluit, and 33 transfers were from Iqaluit to CHEO. The primary outcome measure was whether the patient required intubation during transport, or urgent intubation upon arrival to CHEO. The median nCPAP setting during transport was 6 cm H2O (5-7 cm H2O) and at arrival to CHEO was 6 cm H2O (6-7 cm H2O). Six of the 33 (18.2%) patients required intubation during their hospital stay and five (15.2%) in a controlled ICU setting. There were no discernible adverse events that occurred during transport for 28 patients (84.5%). Four patients (12.1%) required a brief period of bag-mask ventilation and one patient had an episode of bradycardia. Conclusions: nCPAP on air transport is a safe and useful method for providing ventilatory support to infants and young children with respiratory distress.

Household transmission of SARS-CoV-2 from unvaccinated asymptomatic and symptomatic household members with confirmed SARS-CoV-2 infection: an antibody-surveillance study.

BACKGROUND: Household transmission contributes to SARS-CoV-2 spread, but the role of children in transmission is unclear. We conducted a study that included symptomatic and asymptomatic children and adults exposed to SARS-CoV-2 in their households with the objective of determining how SARS-CoV-2 is transmitted within households. METHODS: In this case-ascertained antibody-surveillance study, we enrolled households in Ottawa, Ontario, in which at least 1 household member had tested positive for SARS-CoV-2 on reverse transcription polymerase chain reaction testing. The enrolment period was September 2020 to March 2021. Potentially eligible participants were identified if they had tested positive for SARS-CoV-2 at an academic emergency department or affiliated testing centre; people who learned about the study through the media could also self-identify for participation. At least 2 participants were required for a household to be eligible for study participation, and at least 1 enrolled participant per household had to be a child (age < 18 yr). Enzyme-linked immunosorbent assays were used to evaluate SARS-CoV-2-specific IgA, IgM and IgG against the spike-trimer and nucleocapsid protein. The primary outcome was household secondary attack rate, defined as the proportion of household contacts positive for SARS-CoV-2 antibody among the total number of household contacts participating in the study. We performed descriptive statistics at both the individual and household levels. To estimate and compare outcomes between patient subgroups, and to examine predictors of household transmission, we fitted a series of multivariable logistic regression with robust standard errors to account for clustering of individuals within households. RESULTS: We enrolled 695 participants from 180 households: 180 index participants (74 children, 106 adults) and 515 of their household contacts (266 children, 249 adults). A total of 487 household contacts (94.6%) (246 children, 241 adults) had SARS-CoV-2 antibody testing, of whom 239 had a positive result (secondary attack rate 49.1%, 95% confidence interval [CI] 42.9%-55.3%). Eighty-eight (36.8%, 95% CI 29.3%-43.2%) of the 239 were asymptomatic; asymptomatic rates were similar for children (51/130 [39.2%, 95% CI 30.7%-48.5%]) and adults (37/115 [32.2%, 95% CI 24.2%-41.4%]) (odds ratio [OR] 1.3, 95% CI 0.8-2.1). Adults were more likely than children to transmit SARS-CoV-2 (OR 2.2, 95% CI 1.3-3.6). The odds of transmission from asymptomatic (OR 0.6, 95% CI 0.2-1.4) versus symptomatic (OR 0.9, 95% CI 0.6-1.4) index participants to household contacts was uncertain. Predictors of household transmission included household density (number of people per bedroom), relationship to index participant and number of cases in the household. INTERPRETATION: The rate of SARS-CoV-2 transmission within households was nearly 50% during the study period, and children were an important source of spread. The findings suggest that children are an important driver of the COVID-19 pandemic; this should inform public health policy.

Continuous EEG in a Pediatric Intensive Care Unit: Adherence to Monitoring Criteria and Barriers to Adequate Implementation.

BACKGROUND: Subclinical seizures are common in critically ill children and are best detected by continuous EEG (cEEG) monitoring. Timely detection of seizures requires pediatric intensive care unit (PICU) physicians to identify patients at risk of seizures and request cEEG monitoring. A recent consensus statement from the American Clinical Neurophysiology Society (ACNS) outlines the indications for cEEG monitoring in critically ill patients. However, adherence to these cEEG monitoring criteria among PICU physicians is unknown. Our project had two goals: 1. To assess adherence to cEEG monitoring indications and barriers toward their implementation; 2. To improve compliance with the ACNS cEEG monitoring criteria in our PICU. METHODS: This is a single-institution study. A total of 234 PICU admissions (183 unique patients) were studied. A 6-month retrospective chart review identified PICU patients meeting ACNS criteria for cEEG monitoring, and patients for whom monitoring was requested. This was followed by an 8-week quality improvement project. During this mentorship period, a didactic 15-min lecture and summary handouts regarding the ACNS indications for cEEG monitoring were provided to all PICU physicians. Requests for cEEG monitoring during the mentorship period were compared to baseline adherence to cEEG monitoring recommendations, and barriers toward timely cEEG monitoring were assessed. RESULTS: Nearly every fifth PICU patient met cEEG monitoring indications, and prevalences of patients meeting those indications were similar in the retrospective and the prospective mentorship period (18% vs. 19%). Almost all patients (98%) requiring cEEG as per ACNS criteria met the indication for monitoring already at the time of their PICU admission. During the retrospective period, 23% of patients meeting ACNS criteria had a request for cEEG monitoring, which increased to 83% during the mentorship period. The median delay to cEEG initiation was 16.7 h during the mentorship period, largely due to limited hours of EEG technician availability. Electrographic seizures were identified in 36% of patients monitored, all within the first 120 min of cEEG recording. The majority (79%) of cEEGs informed clinical management. CONCLUSIONS: A brief teaching intervention supplemented by pictographic handouts significantly increased adherence to cEEG monitoring recommendations, and cEEGs guided clinical management. However, there were long delays to cEEG initiation. In order to promptly recognize subclinical seizures in critically ill children, we strongly advocate for a routine screening for cEEG monitoring indications as part of the PICU admission process, and a care model allowing for cEEG initiation around-the-clock.

Paediatric health care access in community health centres is associated with survival for critically ill children who undergo inter-facility transport: A province-wide observational study.

BACKGROUND: Diverse settlement makes inter-facility transport of critically ill children a necessary part of regionalized health care. There are few studies of outcomes and health care services use of this growing population. METHODS: A retrospective study evaluated the frequency of transports, health care services use, and outcomes of all critically ill children who underwent inter-facility transport to a paediatric intensive care unit (PICU) in Ontario from 2004 to 2012. The primary outcome was PICU mortality. Secondary outcomes were 24-hour and 6-month mortality, PICU and hospital lengths of stay, and use of therapies in the PICU. RESULTS: The 4,074 inter-facility transports were for children aged median (IQR) 1.6 (0.1 to 8.3) years. The rate of transports increased from 15 to 23 per 100,000 children. There were 233 (5.7%) deaths in PICU and an additional 78 deaths (1.9%) by 6 months. Length of stay was median (IQR) 2 (1 to 5) days in PICU and 7 (3 to 14) days in the receiving hospital. Lower PICU mortality was independently associated with prior acute care contact (odds ratio [OR]=0.3, 95% confidence interval [CI]: 0.2 to 0.6) and availability of paediatric expertise at the referral hospital (OR=0.7, 95% CI: 0.5 to 1.0). CONCLUSIONS: We found that in Ontario, children undergoing inter-facility transport to PICUs are increasing in number, consume significant acute care resources, and have a high PICU mortality. Access to paediatric expertise is a potentially modifiable factor that can impact mortality and warrants further evaluation.

Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults.

BACKGROUND: Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms. METHODS: We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. RESULTS: From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine. CONCLUSIONS: Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

PRAM score as predictor of pediatric asthma hospitalization.

OBJECTIVES: The objective was to determine the association between asthma severity as measured by the Pediatric Respiratory Assessment Measure (PRAM) score and the likelihood of admission for pediatric patients who present to the emergency department (ED) with moderate-to-severe asthma exacerbations and who receive intensive asthma therapy. METHODS: This was a secondary analysis of a prospective study of triage nurse-initiated steroid therapy in pediatric asthma. Children aged 2 to 17 years inclusive, presenting with moderate-to-severe acute asthma exacerbations (defined as PRAM ≥ 4), were included. To be eligible for inclusion in the study, children must have received "intensive asthma therapy," defined as nurse-initiated initial bronchodilator and oral steroid therapy at arrival to triage. PRAM scores were measured hourly as per ED protocol. The primary outcome was inpatient hospitalization; secondary outcome was ED stay greater than 8 hours. Logistic regression models were used to predict admission based on PRAM score at triage and then hourly thereafter. The area under the receiver operating characteristic curve (AUC) was calculated for each hour. RESULTS: A total of 297 patients were included in the analysis, with an admission rate of 11.4% for patients receiving intensive therapy. The 3-hour PRAM (AUC = 0.85) significantly improved prediction of admission compared to PRAM at triage (p = 0.04). CONCLUSIONS: The 3-hour PRAM scores best predicts the need for hospitalization. These results may be applied in clinical settings to facilitate the decision to admit or initiate more aggressive adjunctive therapy to decrease the need for hospitalization.