Implementing adaptive e-learning for newborn care in Tanzania: an observational study of provider engagement and knowledge gains.

INTRODUCTION: To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment. The objectives of this study were to (1) assess implementation success with use of in-person support and nudging strategy and (2) describe baseline provider knowledge and metacognition. METHODS: 6-month observational study at one zonal hospital and three health centres in Mwanza, Tanzania. To assess implementation success, we used the Reach, Efficacy, Adoption, Implementation and Maintenance framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity. RESULTS: aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centres. Median clinical experience was 4 years (IQR 1-9) and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD ±17%). Providers averaged 78% (SD ±31%) completion of initial learning and 7% (SD ±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% (IQR: 38%-63%), unconscious-incompetence 32% (IQR: 23%-42%), conscious-incompetence 7% (IQR: 2%-15%), and unconscious-competence 2% (IQR: 0%-3%). Higher baseline conscious-competence (OR 31.6 (95% CI 5.8 to 183.5)) and being a nursing officer (aOR: 5.6 (95% CI 1.8 to 18.1)), compared with medical officer, were associated with initial learning completion or persistent activity. CONCLUSION: aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalisation is needed.

Delivering bad or difficult news. An innovative simulation-based education approach to prepare interdisciplinary fellowships.

BACKGROUND: There is limited data on the effectiveness of training interventions to improve the delivery of bad news. METHODS: This preliminary research included pre-post assessments and an open-ended survey to evaluate the effectiveness and perceived value of training on delivering bad news for 26 first- and second-year fellows from five adult and pediatric fellowship programs. RESULTS: There was a significant increase in faculty assessment scores (34.5 vs. 41.0, respectively, Z = -3.661, p < 0.001) and Standardized Patient (SP) assessment scores (37.5 vs .44.5, respectively, Z = -2.244, p = 0.025). Fellows valued having a standard framework to aid in the delivery of bad news; receiving targeted feedback and having the opportunity to apply their skills in a subsequent case. CONCLUSIONS: A one-hour, four-phase lesson plan that includes an individualized training approach and simulation do-overs can be effective and valuable for preparing fellows to deliver bad news.

Feasibility of an Adaptive E-Learning Environment to Improve Provider Proficiency in Essential and Sick Newborn Care in Mwanza, Tanzania.

Introduction: To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment (AEE). The objectives of this study were to 1) assess implementation success with use of in-person support and nudging strategy and 2) describe baseline provider knowledge and metacognition. Methods: 6-month observational study at 1 zonal hospital and 3 health centers in Mwanza, Tanzania. To assess implementation success, we used the RE-AIM framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity. Results: aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing, and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centers. Median clinical experience was 4 years [IQR 1,9] and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD±17%). Providers averaged 78% (SD±31%) completion of initial learning and 7%(SD±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% [IQR:38-63%], unconscious-incompetence 32% [IQR:23-42%], conscious-incompetence 7% [IQR:2-15%], and unconscious-competence 2% [IQR:0-3%]. Higher baseline conscious-competence (OR 31.6 [95%CI:5.8, 183.5) and being a nursing officer (aOR: 5.6 [95%CI:1.8, 18.1]), compared to medical officer) were associated with initial learning completion or persistent activity. Conclusion: aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning, and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalization is needed.

Cytokine Release Syndrome in the Pediatric Population and Implications for Intensive Care Management.

Cytokine release syndrome represents a spectrum of disease varying from fever alone to multiorgan system failure. Most commonly seen following treatment with chimeric antigen receptor T cell therapy, it is increasingly being described with other immunotherapies as well as following hematopoietic stem cell transplant. As its symptoms are nonspecific, awareness is key to timely diagnosis and initiation of treatment. Given the high risk of cardiopulmonary involvement, critical care providers must be familiar with the cause, symptoms, and therapeutic options. Current treatment modalities focus on immunosuppression and targeted cytokine therapy.

Emerging Cybersecurity Threats in Radiation Oncology.

PURPOSE: Modern image guided radiation therapy is dependent on information technology and data storage applications that, like any other digital technology, are at risk from cyberattacks. Owing to a recent escalation in cyberattacks affecting radiation therapy treatments, the American Society for Radiation Oncology's Advances in Radiation Oncology is inaugurating a new special manuscript category devoted to cybersecurity issues. METHODS AND MATERIALS: We conducted a review of emerging cybersecurity threats and a literature review of cyberattacks that affected radiation oncology practices. RESULTS: In the last 10 years, numerous attacks have led to an interruption of radiation therapy for thousands of patients, and some of these catastrophic incidents have been described as being worse than the coronavirus disease of 2019 impact on centers in New Zealand. CONCLUSIONS: Cybersecurity threats continue to evolve, making combatting these attacks more difficult for health care organizations and requiring a change in strategies, tactics, and culture around cyber security in health and radiation oncology. We recommend an assume breach mentality (threat-informed defense posture) and adopting a cloud-first and zero-trust security strategy. A reliance on computer-driven technology makes radiation oncology practices more vulnerable to cyberattacks. Health care providers should increase their resilience and cyber security maturity. The increase in the diversity of these attacks demands improved preparedness and collaboration between oncologic treatment centers both nationwide and internationally to protect patients.

Making a convenient, low-cost phantom with a previously unreported material for practicing ultrasound-guided procedures.

Ultrasound-guided procedures require excellent hand-eye coordination and practice. Trainees should gain this important skill with a phantom prior to performing procedures on patients. Currently available phantoms each have their own unique limitations. We propose an easily made, inexpensive, tissue-like phantom using a previously unreported material. The sonographic appearance of the phantom, with and without a 14-gauge needle, is compared with breast tissue, gelatin phantoms, and commercial phantoms. Target lesions can be produced using readily available materials. The proposed phantom is cheaper than commercial phantoms; performs better than gelatin phantoms, and is ultimately a superior practice tool for residents.

Supporting Frontline Staff During the COVID-19 Pandemic.

ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic that emerged in early 2020 put unprecedented physical, mental, and emotional strain on the staff of health care organizations, who have been caring for a critically ill patient population for more than a year and a half. Amid the ongoing pandemic, health care workers have struggled to keep up with new information about the disease, while also coping with the anxiety associated with caring for affected patients. It has also been a continual challenge for nurse leaders to provide adequate support for staff members and keep them informed about frequently changing practices and protocols. In this article, nursing leaders at an academic medical center in Boston reflect on the initial COVID-19 patient surge, which occurred from March to June 2020, and identify key actions taken to provide clinical and emotional support to frontline staff who cared for these patients. Lessons learned in this period provide insight into the management of redeployed staff, use of emotional support and debriefing, and relationship between access to information and staff morale. The knowledge gained through these initial experiences has been a vital resource as health care workers continue to face challenges associated with the ongoing pandemic.

Rapid Transition of a PICU Space and Staff to Adult Coronavirus Disease 2019 ICU Care.

OBJECTIVES: We describe the process by which a PICU and a PICU care team were incorporated into a hospital-wide ICU care model during the coronavirus disease 2019 pandemic. DESIGN: A descriptive, retrospective report from a single-center PICU. SETTING: Twenty-three bed, quaternary PICU, within an 862-bed hospital. PATIENTS: Critically ill adults, with coronavirus disease 2019-related disease. INTERVENTIONS: ICU care provided by pediatric intensivists with training and support from medical intensivists. MEASUREMENTS AND MAIN RESULTS: Within the context of the institution's comprehensive effort to centralize and systematize care for adults with severe coronavirus disease 2019 disease, the PICU was transitioned to an adult coronavirus disease 2019 critical care unit. Nurses and physicians underwent just-in-time training over 3 days and 2 weeks, respectively. Medical ICU physicians and nurses provided oversight for care and designated hospital-based teams were available for procedures and common adult emergencies. Over a 7-week period, the PICU cared for 60 adults with coronavirus disease 2019-related critical illness. Fifty-three required intubation and mechanical ventilation for a median of 18 days. Eighteen required renal replacement therapy and 17 died. CONCLUSIONS: During the current and potentially in future pandemics, where critical care resources are limited, pediatric intensivists and staff can be readily utilized to meaningfully contribute to the care of critically ill adults.

Critical Care for Coronavirus Disease 2019: Perspectives From the PICU to the Medical ICU.

OBJECTIVES: To describe the unique perspective of pediatric intensivists caring for critically ill adults during the coronavirus disease 2019 pandemic. DESIGN: Observational study. SETTING: Academic medical center in New York City. PATIENTS: Coronavirus disease 2019 positive adults requiring admission to an ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In late March 2020, New York Presbyterian Hospital centralized all of its inpatient pediatric units (n = 4) from across the network to a single center, in order to create space to accommodate the increasing number of critically ill adults with coronavirus disease 2019. Within 1 week, the PICU at New York Presbyterian Hospital-Weill Cornell Medicine transferred or discharged all inpatients, underwent a transformation of the physical space, and began admitting adults of all ages with coronavirus disease 2019 related acute respiratory failure. The New York Presbyterian Hospital-Weill Cornell Medicine PICU physician group continued to lead this unit. PICU nurses, respiratory therapists, social workers, and child life specialists joined their PICU physician colleagues to care for these critically ill adults. CONCLUSIONS: In the coronavirus disease 2019 pandemic, PICU physicians are well poised to care for adult patients in a surge capacity, and bring a unique perspective to the experience.

Knowledge acquisition and retention following Saving Children's Lives course for healthcare providers in Botswana: a longitudinal cohort study.

OBJECTIVES: Millions of children die every year from serious childhood illnesses. Most deaths are avertable with access to quality care. Saving Children's Lives (SCL) includes an abbreviated high-intensity training (SCL-aHIT) for providers who treat serious childhood illnesses. The objective of this study was to examine the impact of SCL-aHIT on knowledge acquisition and retention of providers. SETTING: 76 participating centres who provide primary and secondary care in Kweneng District, Botswana. PARTICIPANTS: Doctors and nurses expected by the District Health Management Team to provide initial care to seriously ill children, completed SCL-aHIT between January 2014 and December 2016, submitted demographic data, course characteristics and at least one knowledge assessment. METHODS: Retrospective, cohort study. Planned and actual primary outcome was adjusted acquisition (change in total knowledge score immediately after training) and retention (change in score at 1, 3 and 6 months), secondary outcomes were pneumonia and dehydration subscores. Descriptive statistics and linear mixed models with random intercept and slope were conducted. Relevant institutional review boards approved this study. RESULTS: 211 providers had data for analysis. Cohort was 91% nurses, 61% clinic/health postbased and 45% pretrained in Integrated Management of Childhood Illness (IMCI). A strong effect of SCL-aHIT was seen with knowledge acquisition (+24.56±1.94, p<0.0001), and loss of retention was observed (-1.60±0.67/month, p=0.018). IMCI training demonstrated no significant effect on acquisition (+3.58±2.84, p=0.211 or retention (+0.20±0.91/month, p=0.824) of knowledge. On average, nurses scored lower than physicians (-19.39±3.30, p<0.0001). Lost to follow-up had a significant impact on knowledge retention (-3.03±0.88/month, p=0.0007). CONCLUSIONS: aHIT for care of the seriously ill child significantly increased provider knowledge and loss of knowledge occurred over time. IMCI training did not significantly impact overall knowledge acquisition nor retention, while professional status impacted overall score and lost to follow-up impacted retention.

Provider Beliefs Regarding Early Mobilization in the Pediatric Intensive Care Unit.

PURPOSE: Critically ill patients are at risk for short and long term morbidity. Early mobilization (EM) of critically ill adults is safe and feasible, with improvement in outcomes. There are limited studies evaluating EM in pediatric critical care patients. Provider beliefs and concerns must be evaluated prior to EM implementation in the pediatric intensive care unit (PICU). DESIGN AND METHODS: A survey was distributed to PICU providers assessing beliefs and concerns with regards to EM of PICU patients. RESULTS: Seventy-one providers responded. Most staff believed EM would be beneficial. The largest perceived benefits were decreased length of both stay and mechanical ventilation. The largest perceived concerns were risk of both endotracheal tube and central venous catheter dislodgement. Surveyed clinicians felt significantly more comfortable mobilizing the oldest as compared to the youngest patients (p<0.0001). Clinicians also felt significantly more comfortable mobilizing patients receiving invasive mechanical ventilation in the oldest as compared to the youngest patients (p<0.0001). CONCLUSION: There is clear benefit to the EM of adult ICU patients, with evidence supporting its safety and feasibility. As pediatric patients pose different challenges, it is imperative to understand provider concerns prior to the implementation of EM. Our research demonstrates similar concerns between adult and pediatric programs, with the addition of significant concern surrounding EM in very young children. PRACTICE IMPLICATIONS: Understanding pediatric specific concerns with regards to EM will allow for the proper development and implementation of pediatric EM programs, allowing us to assess safety, feasibility, and ultimately outcomes.

Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium.

OBJECTIVES: Delirium occurs frequently in adults and is an independent predictor of mortality. However, the epidemiology and outcomes of pediatric delirium are not well-characterized. The primary objectives of this study were to describe the frequency of delirium in critically ill children, its duration, associated risk factors, and effect on in-hospital outcomes, including mortality. Secondary objectives included determination of delirium subtype, and effect of delirium on duration of mechanical ventilation, and length of hospital stay. DESIGN: Prospective, longitudinal cohort study. SETTING: Urban academic tertiary care PICU. PATIENTS: All consecutive admissions from September 2014 through August 2015. INTERVENTIONS: Children were screened for delirium twice daily throughout their ICU stay. MEASUREMENTS AND MAIN RESULTS: Of 1,547 consecutive patients, delirium was diagnosed in 267 (17%) and lasted a median of 2 days (interquartile range, 1-5). Seventy-eight percent of children with delirium developed it within the first 3 PICU days. Most cases of delirium were of the hypoactive (46%) and mixed (45%) subtypes; only 8% of delirium episodes were characterized as hyperactive delirium. In multivariable analysis, independent predictors of delirium included age less than or equal to 2 years old, developmental delay, severity of illness, prior coma, mechanical ventilation, and receipt of benzodiazepines and anticholinergics. PICU length of stay was increased in children with delirium (adjusted relative length of stay, 2.3; CI = 2.1-2.5; p < 0.001), as was duration of mechanical ventilation (median, 4 vs 1 d; p < 0.001). Delirium was a strong and independent predictor of mortality (adjusted odds ratio, 4.39; CI = 1.96-9.99; p < 0.001). CONCLUSIONS: Delirium occurs frequently in critically ill children and is independently associated with mortality. Some in-hospital risk factors for delirium development are modifiable. Interventional studies are needed to determine best practices to limit delirium exposure in at-risk children.

Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children.

BACKGROUND: The Richmond Agitation-Sedation Scale (RASS) is a single tool that is intuitive, is easy to use, and includes both agitation and sedation. The RASS has never been formally validated for pediatric populations. The objective of this study was to assess inter-rater agreement and criterion validity of the RASS in critically ill children. METHODS: To evaluate validity, the RASS score was compared to both a visual analog scale (VAS) scored by the patient's nurse, and the University of Michigan Sedation Scale (UMSS), performed by a researcher. The nurse completed the VAS by drawing a single line on a 10-cm scale anchored by "unresponsive" and "combative." The UMSS was used to validate the sedation portion of the RASS only, as it does not include grades of agitation. For inter-rater agreement, one researcher and the patient's nurse simultaneously but independently scored the RASS. RESULTS: One hundred patient encounters were obtained from 50 unique patients, ages 2 months to 21 years. Of these, 27 assessments were on children who were mechanically ventilated and 73 were on children who were spontaneously breathing. In validity testing, the RASS was highly correlated with the nurse's VAS (Spearman correlation coefficient 0.810, p < .0001) and with the UMSS (weighted kappa 0.902, p < .0001). Inter-rater agreement between nurse- and researcher-assessed RASS was excellent, with weighted kappa of 0.825 (p < .0001). CONCLUSIONS: The RASS is a valid responsiveness tool for use in critically ill children. It allows for accurate assessment of awareness in mechanically ventilated and spontaneously breathing patients, and may improve our ability to titrate sedatives and assess for delirium in pediatrics.

Cost Associated With Pediatric Delirium in the ICU.

OBJECTIVE: To determine the costs associated with delirium in critically ill children. DESIGN: Prospective observational study. SETTING: An urban, academic, tertiary-care PICU in New York city. PATIENTS: Four-hundred and sixty-four consecutive PICU admissions between September 2, 2014, and December 12, 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All children were assessed for delirium daily throughout their PICU stay. Hospital costs were analyzed using cost-to-charge ratios, in 2014 dollars. Median total PICU costs were higher in patients with delirium than in patients who were never delirious ($18,832 vs $4,803; p < 0.0001). Costs increased incrementally with number of days spent delirious (median cost of $9,173 for 1 d with delirium, $19,682 for 2-3 d with delirium, and $75,833 for > 3 d with delirium; p < 0.0001); this remained highly significant even after adjusting for PICU length of stay (p < 0.0001). After controlling for age, gender, severity of illness, and PICU length of stay, delirium was associated with an 85% increase in PICU costs (p < 0.0001). CONCLUSIONS: Pediatric delirium is associated with a major increase in PICU costs. Further research directed at prevention and treatment of pediatric delirium is essential to improve outcomes in this population and could lead to substantial healthcare savings.

Bilateral Dilated Nonreactive Pupils in a Neonate After Surgery.

Fixed and dilated pupils are disturbing when encountered during a physical examination in the pediatric intensive care unit, particularly when sedation or neuromuscular blockade confounds the neurologic examination. Rocuronium, a nondepolarizing neuromuscular drug, does not cross the blood-brain barrier and is not considered a causative agent for fixed mydriasis. We report a case of bilateral fixed and dilated pupils in a 1-week-old low-birth-weight neonate, which we contend was secondary to centrally mediated neuromuscular blockade.

Effects of health information technology on patient outcomes: a systematic review.

OBJECTIVE: To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes. MATERIALS AND METHODS: The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes. RESULTS: Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry. DISCUSSION AND CONCLUSION: Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

Evaluation of the Safety of Quetiapine in Treating Delirium in Critically Ill Children: A Retrospective Review.

OBJECTIVE: Quetiapine is an atypical antipsychotic that has been used off-label for the treatment of intensive care unit (ICU) delirium in the adult population, with studies demonstrating both efficacy and a favorable safety profile. Although there is a potential role for quetiapine in the treatment of pediatric ICU delirium, there has been no systematic reporting to date of safety in this patient population. METHODS: Pharmacy records were used to identify 55 consecutive pediatric ICU patients who were diagnosed with delirium and received quetiapine. A comprehensive retrospective medical chart review was performed to collect data on demographics, dosing, and side effects. RESULTS: Fifty patients treated between January 2013 and November 2014 were included, and five patients were excluded from the study. Subjects ranged in age from 2 months to 20 years. Median daily dose was 1.3 mg/kg/day, and median duration of treatment was 12 days. There were three episodes of QTc prolongation that were clinically nonsignificant with no associated dysrhythmia: Two resolved over time without intervention, and one resolved with decrease in quetiapine dosage. There were no episodes of extrapyramidal symptoms or neuroleptic malignant syndrome. CONCLUSIONS: In this population of critically ill youth, short-term use of quetiapine as treatment for delirium appears to be safe, without serious adverse events. Further research is required to assess efficacy and evaluate for long-term effects. A prospective, randomized, placebo-controlled study of quetiapine in managing pediatric delirium is necessary.

An 11p;17p telomeric translocation in two families associated with recurrent miscarriages and Miller-Dieker syndrome.

Translocations occur in a proportion of couples affected by recurrent miscarriages. We describe two such families in which the underlying cause was a cryptic subtelomeric 11p;17p translocation detected only after the birth of an affected child carrying an unbalanced form of the rearrangement. Unbalanced subtelomeric rearrangements are now recognised as a significant cause of mental impairment and we believe that these rearrangements may also be an important cause of recurrent miscarriages. In these two families the translocation is most likely to have arisen from a single ancestral event because all translocation carriers shared almost identical haplotypes around the breakpoints on both chromosomes.