ALS Health care provider wellness.

BACKGROUND: Interest in health care provider (HCP) wellness and burnout is increasing; however, minimal literature explores HCP wellness in the context of Amyotrophic Lateral Sclerosis (ALS) care. OBJECTIVES: We sought to determine rates of burnout and resiliency, as well as challenges and rewards in the provision of ALS care. METHODS: A survey link was sent to physicians at all Canadian ALS centers for distribution to ALS HCPs in their network. The survey included demographics questions, and validated measures for resiliency and burnout; the Brief Resilient Coping Scale (BRCS) and the Single Item Burnout Score (SIBS). Participants were asked to describe challenges and rewards of ALS care, impact of COVID-19 pandemic, and how their workplace could better support them. RESULTS: There were 85 respondents across multiple disciplines. The rate of burnout was 47%. Burnout for female respondents was significantly higher (p = 0.007), but not for age, role, or years in ALS clinic. Most participants were medium resilient copers n = 48 (56.5%), but resiliency was not related to burnout. Challenges included feeling helpless while patients relentlessly progressed to death, and emotionally charged interactions. Participants found fulfillment in providing care, and through relationships with patients and colleagues. There was a strongly expressed desire for increased resources, team building/debriefing, and formal training in emotional exhaustion and burnout. CONCLUSIONS: The high rate of burnout and challenges of ALS care highlight the need for additional resources, team-building, and formal education around wellness.

Canadian Pediatric Intensive Care Adaptations for Critically Ill Adults During the COVID-19 Pandemic: Survey Study.

BACKGROUND: The COVID-19 pandemic overwhelmed Canadian hospitals with adult admissions. A large number of adult patients required critical care therapies, placing significant strain on hospital resources. In order to decompress adult intensive care units, pediatric intensive care units (PICUs) introduced adapted models of traditional care to lessen these burdens. OBJECTIVE: We aimed to evaluate how PICUs across Canada adapted care for the high volumes of critically ill adults. METHODS: A survey containing 40 questions was sent to the medical directors of 14 Canadian PICUs where English was the primary clinical language. The survey was designed to gain perspective on the various adaptations that PICUs instituted during the COVID-19 pandemic. RESULTS: Of the 13 PICUs that returned survey responses (response rate: 13/14, 93%), 10 (77%) participated in at least one adaptation to support the influx of admitted adults with COVID-19. The key challenges included disorganization, loss of autonomy, and compromised patient care. The significant advantages of these adaptations included a sense of learning and comradery. CONCLUSIONS: Our study highlighted an unpreparedness in critical care surge capacity. During the COVID-19 pandemic, adaptations rapidly emerged in Canada that involved PICUs with adult care. In the future, preplanned adaptations for optimizing robust critical care services should be developed based on what has been learned from the COVID-19 pandemic.

Severity of Illness Scoring for Pediatric Interfacility Transport: A North American Survey.

OBJECTIVE: Severity of illness scoring during pediatric critical care transport may provide objective data to determine illness trajectory and disposition and contribute to quality assurance data for pediatric transport programs. The objective of this study was to ascertain the breadth of severity of illness scoring tool application among North American pediatric critical care transport teams. METHODS: A cross-sectional quantitative survey using REDCap was distributed to 137 North American pediatric transport programs. Baseline team characteristics were established along with questions related to severity of illness tool application.Descriptive statistics were used for analysis. RESULTS: There were 55 responses (40%), and of those, 13 (24%) use a severity of illness scoring tool within their practice. A variety of tools were used including: Transport Risk Index of Physiologic Stability, Children's Hospital Medical Center Cincinnati, Canadian Triage and Acuity Score, Transport Risk Assessment in Pediatrics, Pediatric Early Warning Scores, Levels of Acuity, Transport Pediatric Early Warning Scores, and an unspecified tool. The timing of scoring, team personnel who applied the score, and the frequency of analysis varied between transport programs. CONCLUSIONS: Severity of illness scoring is not consistently performed by pediatric interfacility transport programs in North America. Among the programs that use a scoring tool, there is variability in its application. There is no universally accepted or performed severity of illness scoring tool for pediatric interfacility transport.Future research to validate and standardize a pediatric transport severity of illness scoring tool for North America is necessary.

Evaluation of transport-related outcomes for neonatal transport teams with and without physicians.

OBJECTIVE: The aim of this study was to evaluate if the presence of a physician in the neonatal transport team (NTT) affects transport-related outcomes and procedural success. DESIGN: Retrospective cohort study with propensity score matching. SETTING: Canadian national study. PATIENTS: Neonatal transports from nontertiary centres between January 2014 and December 2017. INTERVENTIONS: Comparison of transports conducted by NTTs with physicians (MD Group) and without physicians (noMD Group). MAIN OUTCOME MEASURES: The primary outcome was the change in patient acuity as measured by the transport risk index of physiologic severity (TRIPS) score. Secondary outcomes included mortality within 24 hours of NICU admission, clinical complications during transport, procedural success, and stabilization time. RESULTS: Among 9,703 eligible cases, 899 neonatal transports attended by NTTs with physicians were compared to 899 neonatal transports without physicians using propensity score matching. No differences were seen in the improvement of TRIPS score or mortality ≤24 hours of NICU admission. The MD Group had more clinical complications (7.7% versus 5.0%, P=0.02). No differences were seen in success rates of invasive procedures. The MD Group had shorter stabilization times. In multivariable analysis, the MD Group was not a significant predictor for the improvement in TRIPS score after adjustment for covariates. CONCLUSIONS: Neonatal transports conducted by teams including physicians compared to teams without physicians, did not have higher improvement in TRIPS scores and had similar success rates for procedures. These results provide insights for the planning of the structure and training of specialized interfacility neonatal transport programs.

Lessons Learned from a Small Pediatric Continuous Renal Replacement Therapy Program.

Continuous renal replacement therapy (CRRT) has become a pillar of care in pediatric intensive care units (PICUs) over the past few decades. Quality indicators (QIs) have been evaluated that reflect safe and accountable CRRT. However, there is a paucity of data on outcomes and QIs in smaller-volume CRRT programming. The purpose of this retrospective study was to evaluate the efficiencies, effectiveness, and outcomes of a small-volume CRRT program. Eighty-two patients received CRRT over a 13-year period, and 79% survived to discharge. Sepsis or nonseptic shock (n = 11 (22%) versus n = 6 (50%); p value = 0.004) and time to CRRT initiation after PICU admission (1.1 versus 5.0 days; p value = 0.005) were independent predictors for mortality. The program also had positive outcomes for QIs related to CRRT efficiency and time of initiation, dosing delivery, and rate of adverse events. This study is important as it illustrates the opportunity that smaller centers have to initiate CRRT programming and provide safe and effective care.

An Inconsistent Canadian Provincial and Territorial Response During the Early COVID-19 Pandemic.

Objectives: According to the World Health Organization (WHO), an early and consistent international and national response is needed to control a pandemic's spread. In this analysis, we evaluate the coordination of Canada's early response to the coronavirus (COVID-19) pandemic in terms of public health interventions and policies implemented in each province and territory. Methods: Retrospective data was obtained from publicly accessible websites maintained by federal, provincial and territorial governmental agencies. Consistent with WHO's spreading of the disease pandemic action, individual and community-based public health interventions and policies were the focus. Time of intervention or policy, and COVID-19 cases per million at time of intervention was recorded for each province and territory. Results: Most public health interventions and policies demonstrated wide time ranges of implementation across individual provinces and territories. At time of implementation, there were also wide variations in the number of positive COVID-19 cases in these jurisdictions. Cases per million per implemented day were also not similar across interventions or policy, suggesting that other factors may have been preferentially considered. Conclusions: Whether an earlier and more structured national approach would have lessened the pandemic's burden is uncertain, calls for greater federal coordination and leadership should to examined.

The World Brain Death Project: The More You Say It Does Not Make It True.

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.

Computed Tomography Practice Standards for Severe Pediatric Traumatic Brain Injury in the Emergency Department: a National Survey.

Acute medical management of traumatic brain injury (TBI) can be challenging outside of the resuscitation bay, specifically while obtaining a computed tomography (CT) scan of the brain. We sought out to determine the management practices of Canadian traumatologists for pediatric patients with severe TBI requiring CT in the emergency department (ED). In 2019, surveys were sent to trauma directors in hospitals across Canada to ascertain their clinical practices. Team members present in the CT scan included physicians (89%), registered nurses (100%), and respiratory therapists (38%). The average time to and from the CT scanner was one hour. Over half of respondents (56%) had experienced an adverse event in CT with variable access (11-56%) to necessary resuscitation equipment and medications. Significant hypotension (44%) was the most common adverse event experienced. With the exception of an end tidal CO2 monitoring (56%), heart rate, rhythm, respiratory rate, saturation, and blood pressure were always monitored during a CT scan. Head of bed elevation had an approximately equal distribution of flat (44%) versus elevated (56%). The practice variability of Canadian traumatologists may reflect a lack of evidence to guide patient management. Future research and knowledge translation efforts are needed to optimize patient care during neuroimaging.

Characterization of Ebola Virus Risk to Bedside Providers in an Intensive Care Environment.

BACKGROUND: The 2014-2016 Ebola outbreak in West Africa recapitulated that nosocomial spread of Ebola virus could occur and that health care workers were at particular risk including notable cases in Europe and North America. These instances highlighted the need for centers to better prepare for potential Ebola virus cases; including understanding how the virus spreads and which interventions pose the greatest risk. METHODS: We created a fully equipped intensive care unit (ICU), within a Biosafety Level 4 (BSL4) laboratory, and infected multiple sedated non-human primates (NHPs) with Ebola virus. While providing bedside care, we sampled blood, urine, and gastric residuals; as well as buccal, ocular, nasal, rectal, and skin swabs, to assess the risks associated with routine care. We also assessed the physical environment at end-point. RESULTS: Although viral RNA was detectable in blood as early as three days post-infection, it was not detectable in the urine, gastric fluid, or swabs until late-stage disease. While droplet spread and fomite contamination were present on a few of the surfaces that were routinely touched while providing care in the ICU for the infected animal, these may have been abrogated through good routine hygiene practices. CONCLUSIONS: Overall this study has helped further our understanding of which procedures may pose the highest risk to healthcare providers and provides temporal evidence of this over the clinical course of disease.

Optic Nerve Sheath Diameter in Preterm Infants: Suggested Values.

OBJECTIVE: Timely detection of elevated intracranial pressure (ICP) in highrisk preterm infants may be critical to avoid permanent neurologic sequelae. Size of optic nerve sheath diameter (ONSD) is highly correlated with changes in ICP. Normal ultrasonographic ONSD values for preterm infants have been published. This study sought to compare these data with MRI measured OSND and to propose suggested ultrasonographic ONSD values. METHODS: The ONSD in preterm MRIs were retrospectively measured and related to pre-existing ultrasonographic ONSD. Data were stratified for corrected gestational age. Simple linear regression between ONSD mean values and age was modeled for both eyes, and R2 was calculated. Suggested values for ultrasonographic ONSD were ascertained through linear regression and calculated prediction intervals. RESULTS: ONSD measurements demonstrated R2 values of 0.95 (right ONSD MRI), 0.95 (left ONSD MRI), 0.96 (right ONSD ultrasound), and 0.93 (left ONSD ultrasound). Suggested ONSD values were incremental with corrected gestational age. CONCLUSION: ONSD measurements with MRI and ultrasound are similar. The proposed suggested ONSD values may be helpful in clinical situations where ICPs are suspected or known.

Automated Device for Uncapping Multiple-Size Bioanalytical Sample Tubes Designed to Reduce Technician Strain and Increase Productivity.

Technicians in a commercial laboratory manually uncap up to 700 sample tubes daily in preparation for bioanalytical testing. Manually twisting off sample tube caps not only is a time-consuming task, but also poses increased risk for muscle fatigue and repetitive-motion injuries. An automated device capable of uncapping sample tubes at a rate faster than the current workflow would be valuable for minimizing strain on technicians' hands and saving time. Although several commercial sample tube-uncapping products exist, they are not always usable for a workload that uses a mix of tube sizes and specific workflow. A functioning uncapping device was developed that can semi-automatically uncap sample tubes with three different heights and diameters and was compatible with the workflow in a commercial laboratory setting. Under limited testing, the average success rate with uncapping each of the three sample tube sizes or a mix of them was 90% or more, more than three times faster than manual uncapping, and met standard acceptance criteria using mass spectrometry. Our device with its current performance is still a prototype, requiring further development. It showed promise for ergonomic benefit to the laboratory technicians, however, reducing the necessity to manually unscrew caps.

Serial Clinical Scoring to Assess Transported Pediatric Patients.

OBJECTIVES: The objective of this study was to evaluate serial Transport Risk Assessment in Pediatrics (TRAP) scoring during pediatric critical care transport as a potential measure for specialized pediatric transport teams (PTTs). METHODS: This was a retrospective study with a provincial PTT from a tertiary hospital pediatric intensive care unit. All acutely ill children who were transported by the PTT between 2018 and 2019 were included in the study. The TRAP scores were measured at time of transport team arrival (TRAP1), time at arrival to tertiary center (TRAP2), and 4 hours postarrival to tertiary center (TRAP3). RESULTS: A total of 300 transports were included. Patients' mean age was 54 months, with lower respiratory tract infection (40.7%) as the most common diagnosis. There were significant differences between TRAP1-TRAP2 (P < 0.01) and TRAP1-TRAP3 (P < 0.01), but not between TRAP2-TRAP3 (P = 0.67). The most significant improvements of ΔTRAP1-TRAP2 scores were seen in septic shock (mean, 2.0; SD, 1.7). CONCLUSIONS: The TRAP scores improved following the PTTs' arrival to acutely ill children, particularly with sepsis. Serial TRAP scoring may present a system for evaluation of team performance and/or characterize disease states that are positively impacted by PTTs. Future prospective evaluation is needed to validate TRAP for this purpose.

Photovoice as a Participatory Research Tool in Amyotrophic Lateral Sclerosis.

BACKGROUND: Photovoice is a qualitative research tool increasingly utilized in the healthcare field to understand the illness experience from the patient and caregiver perspective. This is the first study to evaluate photovoice in the context of amyotrophic lateral sclerosis (ALS). OBJECTIVE: A patient and caregiver centered research tool was utilized to gain a greater understanding of challenges faced when living with ALS. METHODS: Eight patients and three corresponding caregivers participating by taking photographs, writing descriptive text, and participating in individual and group interviews. Inductive thematic analysis was employed to uncover recurring themes. RESULTS: Five main themes were identified; 1) facing the diagnosis, 2) loss of function, 3) isolation, 4) health system challenges, and 5) hope. Despite the devasting impact of ALS, the majority of participants reported a surprising amount of positivity in the face of receiving this difficult diagnosis, and demonstrated incredible creativity and adaptability to meet the ensuing loss of function. However, patients and caregivers discussed feelings of isolation and health care system challenges. The importance of hope was a strong and recurring theme. CONCLUSIONS: The photovoice research tool demonstrates the profound resilience of these participants, and challenges the medical community to find ways of fostering positivity and hope throughout the ALS disease course. Further clinic and community resources, education, and supports are needed to combat the sense of isolation and health care system challenges experienced by patients and their caregivers.

Canada's Decentralized "Human-Driven" Approach During the Early COVID-19 Pandemic.

A country's early response to a pandemic is critical for controlling the disease outbreak. During the COVID-19 pandemic, a number of southeast Asian countries adopted centralized, coordinated, rapid, and comprehensive approaches that involved smart technology (the "techno-driven" approach). In comparison, Canada's approach appeared to be decentralized, uncoordinated, and slow, and it focused on educating citizens and enhancing social and human capital (the "human-driven" approach). We propose that in future pandemics, early and coordinated "techno-driven" approaches should receive more careful consideration to curtail outbreaks; however, these approaches must be balanced with protecting individuals' freedoms.

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study.

BACKGROUND: Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics. OBJECTIVES: To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care. METHODS: A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews. RESULTS: The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities. CONCLUSIONS: Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.

Noninvasive ventilation for pediatric interfacility transports: a retrospective study.

BACKGROUND: To characterize pediatric patients supported with continuous positive airway pressure and bilevel positive airway pressure (CPAP/BiPAP) or high-flow nasal cannula (HFNC) during interfacility transport (IFT). METHODS: A retrospective study with a provincial pediatric transport team from a tertiary hospital pediatric intensive care unit. Pediatric patients aged 28 days to < 17 years, who required IFT between January 2017 and December 2018, were identified through a transport registry and were included in the study. RESULTS: A total of 118 (26.7%) patients received CPAP/BIPAP or HFNC support for IFT. The most common respiratory diagnosis was bronchiolitis (46%). These patients were placed on respiratory support, 31.4 minutes after the transport team's arrival. None required intubation during their IFT, despite mean transport times of 163 minutes. CONCLUSIONS: This study may provide important information for programs with large catchment areas, in which large distances and transport times should not be barriers to NIV implementation.

Rare cause of emergency in the first week of life: congenital hepatoblastoma (case report).

During the first week of life, a sudden deterioration in a newborn commonly includes investigations to rule out infections, lung pathologies, cardiac lesions, neurological insults, metabolic disorders or gastrointestinal emergencies. It is unusual, however, to consider malignancy as the primary causative factor. In this case report, we describe a rare and unusual presentation of congenital hepatoblastoma, its complications and management in a neonate with multi-organ dysfunction. A term infant presented with sudden deterioration, hemodynamic instability and an acute abdomen on his 4th day of life. Surgical exploration revealed a ruptured neoplasm that pathology diagnosed as a congenital hepatoblastoma. After the patient was stabilized, chemotherapy was initiated. At present, the patient is 8 months old and under continuous follow-up of oncology service. This case highlights the importance of considering rare diagnoses including congenital malignancy when investigating and managing a sick newborn with multi-organ dysfunction.

Rural Residence and Diagnostic Delay for Amyotrophic Lateral Sclerosis in Saskatchewan.

BACKGROUND: Diagnostic delay in amyotrophic lateral sclerosis (ALS) is common. In a recent Canadian study evaluating provincial differences in care, Saskatchewan had the longest delay at 27 months. Since Saskatchewan has a large rural population, this study sought to determine whether geographically determined access to a neurologist at tertiary centers could be contributing to this lengthy delay. METHODS: A retrospective chart review of 171 patients seen in the ALS clinic in Saskatoon, Saskatchewan was performed. Urban or rural location, distance from nearest tertiary center, and clinically relevant data were collected. RESULTS: There was no difference between urban and rural populations for delay in symptom onset to diagnosis. For rural patients, linear regression modeling did not uncover a significant relationship between distance from tertiary center and time to diagnosis. Additionally, there were no differences between urban and rural dwellers either for referral or utilization of feeding tube, noninvasive ventilation, riluzole, or communication devices. Contrary to the previous data showing a 27-month diagnostic delay in Saskatchewan, our study which included a larger provincial population found the mean diagnostic delay was 16.6 months. CONCLUSIONS: This study did not uncover differences in diagnostic delay or ALS care between urban and rural dwellers. Further study is required to determine reproducibility of results.

Correction to: Impact of intensive care unit supportive care on the physiology of Ebola virus disease in a universally lethal non-human primate model.

Please note that four authors (Logan Banadyga, Alixandra Albietz, Brad Pickering, and Gary Wong) have been erroneously omitted from the author list in the published original article [1].