Training of Pediatric Critical Care Providers in Developing Countries in Evidence Based Medicine Utilizing Remote Simulation Sessions.

Background. Remote simulation training provides a unique opportunity to captivate providers despite language, distance, and cultural barriers. Previously we developed a novel electronic decision support and rounding tool, the Checklist for Early Recognition and Treatment of Acute Illness in Pediatrics (CERTAINp). This study was conducted to determine the feasibility and impact of remote simulation training of international PICU providers using CERTAINp. Methods. We conducted train-the-trainer sessions in 7 hospitals based in 5 countries (China, Congo, Croatia, India, and Turkey) between 11/2015 and 11/2016. Providers first took part in a base line simulation session to assess their clinical performance. They had structured hands-on training using CERTAINp, which was done remotely using video conference with recording capabilities. Performance in PICU "admission" and "rounding" scenarios was assessed by their adherence to standard of care guidelines using CERTAINp. After this training, the providers were re-evaluated for performance using a validated instrument by 2 independent trained reviewers. Results. A total of 7 hospitals completed both baseline and post simulation sessions. We observed improved critical task (total 14) completion in the admission scenarios where pre training task completion was 8.2 ± 2.6, while after remote training was 11.2 ± 1.8, P = .01. In rounding scenarios, compliance to standard of care guidelines improved overall from 45% to 95% (P < .01). Conclusion. We observed an improvement in compliance for measures determined as best practice guidelines in simulation rounding and overall improvement in critical tasks for simulated admission cases after remote training.

Is Unplanned PICU Readmission a Proper Quality Indicator? A Systematic Review and Meta-analysis.

CONTEXT: Unplanned PICU readmissions within 48 hours of discharge (to home or a different hospital setting) are considered a quality metric of critical care. OBJECTIVE: We sought to determine identifiable risk factors associated with early unplanned PICU readmissions. DATA SOURCES: A comprehensive search of Medline, Embase, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to July 16, 2018. STUDY SELECTION: Observational studies of early unplanned PICU readmissions (<48 hours) in children (<18 years of age) published in any language were included. DATA EXTRACTION: Two reviewers selected and appraised studies independently and abstracted data. A meta-analysis was performed by using the random-effects model. RESULTS: We included 11 observational studies in which 128 974 children (mean age: 5 years) were evaluated. The presence of complex chronic diseases (odds ratio 2.42; 95% confidence interval 1.06 to 5.55; I 2 79.90%) and moderate to severe disability (odds ratio 2.85; 95% confidence interval 2.40 to 3.40; I 2 11.20%) had the highest odds of early unplanned PICU readmission. Other significant risk factors included an unplanned index admission, initial admission to a general medical ward, spring season, respiratory diagnoses, and longer initial PICU stay. Readmission was less likely after trauma- and surgery-related index admissions, after direct admission from home, or during the summer season. Modifiable risk factors, such as evening or weekend discharge, revealed no statistically significant association. Included studies were retrospective, which limited our ability to account for all potential confounders and establish causality. CONCLUSIONS: Many risk factors for early unplanned PICU readmission are not modifiable, which brings into question the usefulness of this quality measure.

Overcoming Barriers to Delirium Screening in the Pediatric Intensive Care Unit.

BACKGROUND: Delirium is associated with poor outcomes in adults but is less extensively studied in children. OBJECTIVES: To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion. METHODS: A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case-control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed. RESULTS: Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and "busy patient." Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9-12] vs 12 [10-13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001). CONCLUSIONS: Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.