Measuring continuing medical education conference impact and attendee experience: a scoping review.

Objectives: The aim was to comprehensively identify published research evaluating continuing medical education conferences, to search for validated tools and perform a content analysis to identify the relevant domains for conference evaluation. Methods: We used scoping review methodology and searched MEDLINE® for relevant English or French literature published between 2008 and 2022 (last search June 3, 2022). Original research (including randomized controlled trials, non-randomized studies, cohort, mixed-methods, qualitative studies, and editorial pieces) where investigators described impact, experience, or motivations related to conference attendance were eligible. Citations were assessed in triplicate, and data extracted in duplicate. Results: Eighty-three studies were included, 69 (83%) of which were surveys or interview based, with the majority conducted at the end of or following conference conclusion. Of the 74 tools identified, only one was validated and was narrowly focused on a specific conference component. A total of 620 items were extracted and categorized into 4 a priori suggested domains (engagement-networking, education-learning, impact, scholarship), and an additional 4 identified through content analysis (value-satisfaction, logistics, equity-diversity-inclusivity, career influences). Time trends were evident, including the absence of items related to equity-diversity-inclusivity prior to 2019, and a focus on logistics, particularly technology and virtual conferences, since 2020. Conclusions: This study identified 8 major domains relevant for continuing medical education conference evaluation. This work is of immediate value to individuals and organizations seeking to either design or evaluate a conference and represents a critical step in the development of a standardized tool for conference evaluation.

Resource Utilization in Children who Receive a Pediatric Intensive Care Unit Consult in the Emergency Department: A Retrospective Cohort Study.

OBJECTIVES: To describe the characteristics, critical care resource requirements, and outcomes of children who were hospitalized after a Pediatric Intensive Care Unit (PICU) consult in the Emergency Department (ED). METHODS: In this single-centre retrospective cohort study, we conducted chart reviews for children (<18 years) hospitalized following a PICU consult in the ED to examine patient characteristics, timing of consult, ED length of stay, Medical Emergency Team (MET) utilization, PICU nursing workload, and critical care interventions for children who were and were not admitted to the PICU. RESULTS: During the one-year study period, 247 PICU consults were performed in the ED resulting in 161 (65.2%) direct admissions to PICU and 1 indirect PICU admission via the ward. Of 105 children with complex chronic conditions, 73 (69.5%) were admitted to PICU, including 32 (91.4%) of 35 children with chronic home ventilatory needs, only 2 (6.2%) of whom received a critical care intervention beyond respiratory support. Within 24 h of hospitalization, 112 (69.1%) of 162 PICU admissions received a critical care-specific intervention. Of 86 (34.8%) ward admissions, 16 (18.6%) were reviewed by the MET. Children admitted to the ward had a significantly longer post-consult ED length of stay than children admitted to PICU (median 428 min vs. 130 min; p <0.0001). CONCLUSIONS: Over two-thirds of children admitted to PICU from the ED required early critical care interventions, with the remainder potentially benefitting from closer monitoring or a higher frequency of non-critical care interventions than can be reasonably provided on general inpatient wards. More research is needed to evaluate critical care and hospital resource utilization when children are triaged to the ward following a PICU consult in the ED.

Integrating leadership into interprofessional non-acute care pediatric provider resuscitation training.

Background and Aim: Due to limited clinical exposure, non-acute care pediatric providers often rely on simulated experiences to maintain resuscitation skills. Few training options designed for the non-acute care setting exist, are often difficult to access, and lack incorporation of non-technical skills. The first five minutes (FFM) is a previously published curriculum designed to train non-acute care providers. The goal of this study was to determine the curriculum's effectiveness during a pilot intervention. Methods: A single cohort of multi-professional, non-acute care pediatric providers participated. The primary outcome skill was "establishing leadership," and secondary outcomes included other technical and non-technical skills. Learning of outcome skills was assessed using changes in retrospective pre-post self-assessment Likert scale scores. Differences were compared using paired t-tests and ANOVA. Results: Thirty-seven participants submitted self-assessments. There was improvement in establishing leadership (pre-mean 1.14, post-mean 2.30, P < 0.01), and all other objectives studied. Compared to each other, subgroups of nurses, physicians, and respiratory therapists demonstrated significant differences in learning of technical skills, but similar improvements with non-technical skills. Conclusion: These findings suggest that the FFM curriculum is an effective tool for training non-acute care pediatric providers interprofessional resuscitation skills. Future research should assess provider behavioral changes, retention of training requirements, and patient outcomes. Relevance for Patients: Traditional resuscitation education programs focus largely, or entirely, on performance of technical skills and algorithmic actions. However, non-technical skills, such as leadership, are crucial to the overall success of resuscitation efforts. The FFM program was developed to incorporate leadership principles into the resuscitation education of non-acute care pediatric inpatient providers, and this curricular evaluation suggests that improvements in participant leadership skills occurred due to the program.

Pediatic code blue event anaylsis: Performance of non-acute health-care providers.

In-hospital pediatric cardiopulmonary arrest is rare. With more than 50% of patients not surviving to discharge following cardiopulmonary arrest, it is important that health-care providers (HCPs) respond appropriately to deteriorating patients. Our study evaluated the performance of basic life support skills using non-acute HCPs during pediatric inpatient resuscitation events. We conducted a retrospective chart review of all code blue team (CBT) activations in non-acute care areas of a tertiary care children's hospital from 2008 to 2017. The main outcomes were frequency of life support algorithmic assessments and interventions (critical actions) performed by non-acute HCPs prior to the arrival of CBT. CBT activation and outcome data were summarized descriptively. Logistic regression was used to assess for an association of outcomes with the presence of established leadership. A total of 60 CBT activations were retrieved, 48 of which had data available on isolated non-acute HCP performance. Most children (93%) survived to discharge. Critical action performance review revealed that an airway, breathing and pulse assessment was documented to have occurred in 33%, 69% and 29% of cases, respectively. A full primary assessment was documented in 6% of cases. The presence of established leadership was associated with the performance of a partial ABC assessment. Our results suggest that resuscitation performance of pediatric inpatient non-acute HCPs often does not adhere to standard life support guidelines. These results highlight the need to reconsider the current approaches used for non-acute HCP resuscitation training.

Improving Safety Recommendations Before Implementation: A Simulation-Based Event Analysis to Optimize Interventions Designed to Prevent Recurrence of Adverse Events.

INTRODUCTION: Pediatric inpatients are at high risk of adverse events (AE). Traditionally, root cause analysis was used to analyze AEs and identify recommendations for change. Simulation-based event analysis (SBEA) is a protocol that systematically reviews AEs by recreating them using in situ simulated patients, to understand clinician decision making, improve error discovery, and, through guided sequential debriefing, recommend interventions for error prevention. Studies suggest that these interventions are rarely tested before dissemination. This study investigates the use of simulation to optimize recommendations generated from SBEA before implementation. METHODS: Recommendations and interventions developed through SBEA of 2 hospital-based AEs (event A: error of commission; event B: error of detection) were tested using in situ simulation. Each scenario was repeated 8 times. Interventions were modified based on participant feedback until the error stopped occurring and data saturation was reached. RESULTS: Data saturation was reached after 6 simulations for both scenarios. For scenario A, a critical error was repeated during the first 2 scenarios using the initial interventions. After modifications, errors were corrected or mitigated in the remaining 6 scenarios. For scenario B, 1 intervention, the nursing checklist, had the highest impact, decreasing average time to error detection to 6 minutes. Based on feedback from participants, changes were made to all but one of the original proposed interventions. CONCLUSIONS: Even interventions developed through improved analysis techniques, like SBEA, require testing and modification. Simulation optimizes interventions and provides opportunity to assess efficacy in real-life settings with clinicians before widespread implementation.

High Rate of Medical Emergency Team Activation in Children with Tracheostomy.

Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.

A Retrospective Case-Control Study to Identify Predictors of Unplanned Admission to Pediatric Intensive Care Within 24 Hours of Hospitalization.

OBJECTIVES: To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours. DESIGN: A retrospective case-control study. SETTING: A pediatric hospital in Ottawa, ON, Canada. PATIENTS: Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not. INTERVENTIONS: None. MAIN RESULTS: Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6). CONCLUSIONS: We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.

Simulation-Based Event Analysis Improves Error Discovery and Generates Improved Strategies for Error Prevention.

INTRODUCTION: An adverse event (AE) is a negative consequence of health care that results in unintended injury or illness. The study investigates whether simulation-based event analysis is different from traditional event analysis in uncovering root causes and generating recommendations when analyzing AEs in hospitalized children. METHODS: Two simulation scenarios were created based on real-life AEs identified through the hospital's Safety Reporting System. Scenario A involved an error of commission (inpatient drug error) and scenario B involved detecting an error that already occurred (drug infusion error). Each scenario was repeated 5 times with different, voluntary clinicians. Content analysis, using deductive and inductive approaches to coding, was used to analyze debriefing data. Causes and recommendations were compiled and compared with the traditional event analysis. RESULTS: Errors were reproduced in 60% (3/5) of scenario A. In scenario B, participants identified the error in 100% (5/5) of simulations (average time to error detection = 15 minutes). Debriefings identified reasons for errors including product labeling, memory aid interpretation, and lack of standard work for patient handover. To prevent error, participants suggested improved drug labeling, specialized drug kits, alert signs, and handoff checklists. Compared with traditional event analysis, simulation-based event analysis revealed unique causes for error and new recommendations. CONCLUSIONS: Using simulation to analyze AEs increased unique error discovery and generated new recommendations. This method is different from traditional event analysis because of the immediate clinician debriefings in the clinical environment. Hospitals should consider simulation-based event analysis as an important addition to the traditional process.

Development and pilot of an interprofessional pediatric resuscitation program for non-acute care inpatient providers.

Multiprofessional ward healthcare providers are generally unprepared to assemble and engage in the initial resuscitation of pediatric inpatients. This is important as the performance of these first-responders, in the several minutes prior to the arrival of acute care support, may have significant effects on overall patient outcome. Accordingly, we aimed to develop and pilot a training program intended for non-acute care inpatient providers, relevant to their working context. Using the latest theory and evidence in medical education, we created an interprofessional, entirely in-situ, simulation-based small-group activity. The activity was then piloted for four months with the goals of assessing perceived usefulness, as well as implementation factors such as participant accessibility and overall resource requirements. A total of 37 interprofessional (physician and nursing) staff were trained in 16 small group sessions over four months. Post-participation questionnaires revealed that the activity was perceived to be highly useful for their practice; especially the rapid cycle deliberate practice instructional method, and the increased focus on crisis resource management. Resource requirements were comparable to, and perhaps less than, existing acute care training programs. This project describes the preliminary steps taken in creating a curriculum intended to improve interprofessional resuscitation performance across an institution.

A case report of full recovery from severe cerebral edema secondary to acetaminophen-induced hepatotoxicity in a 13 year old girl.

BACKGROUND: Acetaminophen is a common cause of acute liver failure in pediatrics. Cerebral edema is a significant complication of acute hepatic failure and is associated with increased mortality. CASE PRESENTATION: We present a case of a 13 -year old girl with severe cerebral edema secondary to acetaminophen toxicity and hepatic failure. Her poor neurological status precluded her from liver transplantation and withdrawal of life sustaining treatment was recommended. However, with supportive care, she remarkably made a full recovery. CONCLUSIONS: This case highlights the difficulties surrounding prognostication in pediatric patients with cerebral edema from acute liver failure secondary to acetaminophen toxicity.

Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study.

OBJECTIVE: Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. DESIGN: Retrospective cohort study. SETTING: Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS: Cohort of 42,308 pediatric admissions to the general inpatient ward. INTERVENTIONS: Data over 7 years were obtained from a prospectively maintained rapid response systems database. MEASUREMENTS AND MAIN RESULTS: From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. CONCLUSIONS: Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.

A Modified Delphi Study to Identify Factors Associated With Clinical Deterioration in Hospitalized Children.

OBJECTIVE: Hospitalized children who are admitted to the inpatient ward can deteriorate and require unplanned transfer to the PICU. Studies designed to validate early warning scoring systems have focused mainly on abnormalities in vital signs in patients admitted to the inpatient ward. The objective of this study was to determine the patient and system factors that experienced clinicians think are associated with progression to critical illness in hospitalized children. METHODS: We conducted a modified Delphi study with 3 iterations, administered electronically. The expert panel consisted of 11 physician and nonphysician health care providers from hospitals in Canada and the United States. RESULTS: Consensus was reached that 21 of the 57 factors presented are associated with clinical deterioration in hospitalized children. The final list of variables includes patient characteristics, signs and symptoms in the emergency department, emergency department management, and system factors. CONCLUSIONS: We generated a list of variables that can be used in future prospective studies to determine if they are predictors of clinical deterioration on the inpatient ward.

Lumbar puncture simulation in pediatric residency training: improving procedural competence and decreasing anxiety.

BACKGROUND: Pediatric residents must become proficient with performing a lumbar puncture (LP) during training. Residents have traditionally acquired LP skills by observing the procedure performed by a more senior resident or staff physician and then attempting the procedure themselves. This process can result in variable procedural skill acquisition and trainee discomfort. This study assessed changes in resident procedural skill and self-reported anxiety when residents were provided with an opportunity to participate in an interactive training session and practice LPs using a simulator. METHODS: All pediatric residents at our institution were invited to participate. Residents were asked to report their post-graduate year (PGY), prior LP attempts and self-reported anxiety scores as measured by the standardized State-Trait Anxiety Inventory - State Anxiety Scale (STAI-S) prior to completing an observed pre-test using an infant-sized LP simulator. Staff physicians observed and scored each resident's procedural skill using a previously published 21-point scoring system. Residents then participated in an interactive lecture on LP technique and were given an opportunity for staff-supervised, small group simulator-based practice within 1 month of the pre-test. Repeat post-test was performed within 4 months. RESULTS: Of the pediatric residents who completed the pre-test (N = 20), 16/20 (80 %) completed both the training session and post-test. Their PGY training level was: PGY1 (38 %), PGY2 (25 %), PGY3 (25 %) or PGY4 (12 %). Procedural skill improved in 15/16 residents (paired t-test; p < 0.001), driven by a significant improvement in skill for residents in PGY1 (P = 0.015) and PGY2 (p = 0.003) but not PGY3 or PGY4. Overall anxiety scores were higher at baseline than at post testing (mean ± SD; 44.8 ± 12.1 vs 39.7 ± 9.4; NS) however only PGY1 residents experienced a significant reduction in anxiety (paired t-test, p = 0.04). CONCLUSION: LP simulation training combined with an interactive training session may be a useful tool for improving procedural competence and decreasing anxiety levels, particularly among those at an earlier stage of residency training.

Routine Medical Emergency Team Assessments of Patients Discharged From the PICU: Description of a Medical Emergency Team Follow-Up Program.

OBJECTIVE: This study describes one follow-up program in the Ontario Rapid-Response System project consisting of routine medical emergency team visits of patients discharged from the PICU consisting of two planned visits within 48 hours following discharge. Study purpose was to describe interventions provided and the patient characteristics associated with medical emergency team utilization. DESIGN: Retrospective cohort study. SETTING: Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS: Discharged pediatric patients from PICU. INTERVENTIONS: Data over 41 months were obtained from a prospectively maintained rapid-response system database. Major medical emergency team support was defined as an early unplanned visit, intervention, or readmission during the follow-up period. MEASUREMENTS AND MAIN RESULTS: Interrupted time-series analysis comparing the 2 years preceding rapid-response system implementation with the subsequent 4 years demonstrated a statistically significant immediate change in PICU readmission rate (-5.5%, p = 0.0001). There were 1,805 patients followed after PICU discharge. During the 48-hour planned follow-up period, 4% of patients received an unplanned medical emergency team visit and 13% received an active intervention. Analysis of the first medical emergency team visit identified that 10% received major medical emergency team support. After the initial visit, 6% of patients received major medical emergency team support with predictive characteristics being an unplanned first visit (odds ratio, 3.7; 95% CI, 1.6-8.5) or an intervention during the first visit (odds ratio, 3.5; 95% CI, 2.1-5.8). Multiple diseased organs were associated with major medical emergency team support after the initial visit for recent surgical patients (odds ratio, 3.0 vs 1.2; p = 0.03). CONCLUSIONS: Routine medical emergency team visits following PICU discharge reduced the risk of early readmission. Our results suggest that one in seven patients in the follow-up program receive major medical emergency team support. We suggest a follow-up program with at least one routine medical emergency team visit within the first 24 hours of discharge with a second planned visit reserved for complex postsurgical patients.

Patient characteristics and disposition after pediatric medical emergency team (MET) activation: disposition depends on who activates the team.

OBJECTIVES: This study focused on health care staff (HCS) responsible for activating the medical emergency team (MET) at a pediatric tertiary hospital using a well-established rapid response system. Our goals were to report the patient characteristics, MET interventions, and disposition by activating HCS. METHODS: This is a retrospective cohort study of pediatric patients who received MET activation at the Children's Hospital of Eastern Ontario in Ottawa, Canada. Data were obtained from a prospectively maintained rapid response system database. The primary outcome was PICU admission, with the number and type of interventions performed as secondary outcomes. RESULTS: The most common MET activators were physicians (410, 53.3%) with nurses generating a comparable number (367, 47.7%). Significant differences in PICU admission rates were observed between activator groups, with physicians having statistically higher PICU admission rates when compared with nurses (25.2% vs 15.0%, P = .001). Compared with physicians, nursing-led activations on surgical patients had significantly lower odds of PICU admission relative to medical patients (odds ratio 0.19 vs 0.67; P = .03). No significant difference was observed in the type or number of interventions between any subgroup based on patient (surgery vs medical) or activator type. CONCLUSIONS: This study suggests that when nurses activate MET, patients are less likely to be transferred to the PICU despite receiving similar type and number of interventions. Our study results may help direct education initiatives aimed at enhancing the effectiveness of the afferent limb through informing specific HCS as to the importance of their role in using the MET.

Clinical profile of children requiring early unplanned admission to the PICU.

OBJECTIVE: The goal of this study was to describe the frequency, characteristics, and outcomes of children who require early unplanned admission to the PICU within 24 hours of hospitalization from the emergency department. METHODS: This study was a retrospective audit of 24 months of prospectively collected medical emergency team records at a tertiary pediatric hospital in Canada. Our review identified 39 hospitalized children who had an activation that resulted in unplanned admission to the PICU within 24 hours of admission from the ED. RESULTS: Forty-six percent of the study subjects were infants aged < 1 year, and 64% were male. Respiratory complaints were the most common reason for hospitalization (59%). Preexisting medical conditions (51%), abnormal respiratory rates (46%), abnormal heart rates (33%), abnormal blood gas values (49%), high supplemental oxygen requirement (23%), and treatment with nebulized medications (46%), intravenous fluids (33%), and antibiotics (33%) were common. The median time to medical emergency team activation was 9.4 hours (interquartile range: 4.4-14.5). Nearly one-half (49%) of the patients required a significant intervention after admission to the PICU, with a mean length of stay of 3.4 days and a mortality rate of 50/%. CONCLUSIONS: Male subjects, infants aged < 1 year, and children with respiratory complaints accounted for a large proportion of children requiring early unplanned admission to the PICU within 24 hours of hospitalization from the ED. Further studies are required to determine which factors are associated with deterioration after hospitalization.

Capillary refill time and cardiac output in children undergoing cardiac catheterization.

OBJECTIVE: Many pediatric healthcare providers believe that capillary refill time is a measure of perfusion and cardiac output in children. Despite its widespread use, there are no studies examining the relationship of capillary refill time to cardiac output in noncritically ill children. This study examined the inter-rater reliability of capillary refill time and its relationship to hemoglobin and with cardiac output in pediatric patients undergoing cardiac catheterization. DESIGN: Prospective observational study. SETTING: Tertiary care pediatric hospital. PATIENTS: A total of 58 children, ages 0.3-17 yrs, with congenital heart disease undergoing cardiac catheterization. INTERVENTIONS: Two clinicians performed two measurements of capillary refill time in a standardized fashion on 58 children undergoing cardiac catheterization. Cardiac output was determined by the Fick method within 15 mins of the first assessment of capillary refill time (time 1). MEASUREMENTS AND MAIN RESULTS: Capillary refill time and cardiac output measurements were obtained in 44 children, and 108 paired measurements of capillary refill time were obtained to assess inter-rater reliability. The mean capillary refill time was 1.2 secs (±0.5 secs), and the mean cardiac output was 3.6 L/min/m (2.2-5.7 L/min/m). The inter-rater intraclass correlation coefficient was 0.12 (time 1) (95% confidence interval -0.15 to +0.37) and was 0.32 (95% confidence interval 0.058-0.54) at the end of the catheterization (time 2). A significant association was noted between average capillary refill time at time 1 and hemoglobin, with higher hemoglobin correlating with longer capillary refill time (p = .015). There was no significant correlation between the average capillary refill time taken at the time of cardiac output measurement (time 1) and measured cardiac output (r = .331, 95% confidence interval for r, .066-.552). CONCLUSIONS: We found that the inter-rater reliability of capillary refill time was poor and variable under controlled conditions and capillary refill time was not correlated with cardiac output in anesthetized nonacutely ill pediatric patients undergoing cardiac catheterization. Caution should be used in inferring cardiac output from capillary refill time measurements alone.

Implementation of a multicenter rapid response system in pediatric academic hospitals is effective.

OBJECTIVES: This is the first large multicenter study to examine the effectiveness of a pediatric rapid response system (PRRS). The primary objective was to determine the effect of a PRRS using a physician-led team on the rate of actual cardiopulmonary arrests, defined as an event requiring chest compressions, epinephrine, or positive pressure ventilation. The secondary objectives were to determine the effect of PRRSs on the rate of PICU readmission within 48 hours of discharge and PICU mortality after readmission and urgent PICU admission. METHODS: A PRRS was developed, implemented, and evaluated in a standardized manner across 4 pediatric academic centers in Ontario, Canada. The team responded to activations for inpatients and followed patients discharged from the PICU for 48 hours. A 2-year, prospective, observational study was conducted after implementation, and outcomes were compared with data collected 2 years before implementation. RESULTS: After PRRS implementation, there were 55 963 hospital admissions and a team activation rate of 44 per 1000 hospital admissions. There were 7302 patients followed after PICU discharge. Implementation of the PRRS was not associated with a reduction in the rate of actual cardiopulmonary arrests (1.9 vs 1.8 per 1000 hospital admissions; P=.68) or PICU mortality after urgent admission (1.3 vs 1.1 per 1000 hospital admissions; P=.25). There was a reduction in the PICU mortality rate after readmission (0.3 vs 0.1 death per 1000 hospital admissions; P=.05). CONCLUSION: The standardized implementation of a multicenter PRRS was associated with a decrease in the rate of PICU mortality after readmission but not actual cardiopulmonary arrests.

An implementation strategy for a multicenter pediatric rapid response system in Ontario.

A rapid response system using a medical emergency team was implemented across four pediatric hospitals in Ontario, Canada, in a social marketing approach.

A multidisciplinary survey on capillary refill time: Inconsistent performance and interpretation of a common clinical test.

OBJECTIVE: Capillary refill time is a common clinical test used in pediatric critical care and emergency medicine. Despite this, we hypothesize that capillary refill time is performed inconsistently and its interpretation by healthcare providers in the acute care setting is variable. DESIGN: Multidisciplinary survey. SETTING: Canadian tertiary care pediatric hospital. SUBJECTS: Subjects were 198 pediatric healthcare providers. INTERVENTIONS: A self-administered questionnaire survey was sent to healthcare providers in pediatric and neonatal critical care, emergency medicine, and cardiology. MEASUREMENTS AND MAIN RESULTS: Seventy-eight surveys were returned: 23 of 33 pediatric trainees (70%), 22 of 38 staff physicians (58%), and 33 of 125 nurses (26%). Ninety-five percent of pediatric healthcare providers reported performing capillary refill time on most patients. However, while 90% of nurses and 70% of trainees described performing capillary refill time on every patient, only 18% of staff physicians reported performing capillary refill time routinely on every patient. Although all participants responded that a capillary refill time of >3 secs was abnormal, responders were divided on the definition of normal capillary refill time. While other sites were described, responders most commonly reported performing capillary refill time on a patient's chest. Ninety-six percent of responders agreed that prolonged capillary refill time indicates abnormal perfusion. CONCLUSIONS: The results of this single-institution survey show that while most nurses and pediatric trainees reported using capillary refill time on every patient as a test for perfusion, only a few staff physicians reported using capillary refill time on every patient. In addition, although this study shows that the majority of survey responders stated that they used capillary refill time frequently, we observed no consistent response in how they performed and interpreted capillary refill time. Given that the use of this simple, noninvasive clinical test is supported by many pediatric organizations and pediatricians, the results of this study emphasize the need to examine why this test is inconsistently performed by healthcare providers so as to ensure its reliable performance in the future.