A Needs Assessment of Brain Death Education in Pediatric Critical Care Medicine Fellowships.

OBJECTIVES: To assess the current training in brain death examination provided during pediatric critical care medicine fellowship. DESIGN: Internet-based survey. SETTING: United States pediatric critical care medicine fellowship programs. SUBJECTS: Sixty-four pediatric critical care medicine fellowship program directors and 230 current pediatric critical care medicine fellows/recent graduates were invited to participate. INTERVENTIONS: Participants were asked demographic questions related to their fellowship programs, training currently provided at their fellowship programs, previous experience with brain death examinations (fellows/graduates), and perceptions regarding the adequacy of current training. MEASUREMENTS AND MAIN RESULTS: Twenty-nine program directors (45%) and 91 current fellows/graduates (40%) responded. Third-year fellows reported having performed a median of five examinations (interquartile range, 3-6). On a five-point Likert scale, 93% of program directors responded they "agree" or "strongly agree" that their fellows receive enough instruction on performing brain death examinations compared with 67% of fellows and graduates (p = 0.007). The responses were similar when asked about opportunity to practice brain death examinations (90% vs 54%; p < 0.001). In a regression tree analysis, number of brain death examinations performed was the strongest predictor of trainee satisfaction. Both fellows and program directors preferred bedside demonstration or simulation as educational modalities to add to the fellowship curriculum. CONCLUSIONS: Pediatric critical care medicine fellows overall perform relatively few brain death examinations during their training. Pediatric critical care medicine fellows and program directors disagree in their perceptions of the current training in brain death examination, with fellows perceiving a need for increased training. Both program directors and fellows prefer additional training using bedside demonstration or simulation. Since clinical exposure to brain death examinations is variable, adding simulated brain death examinations to the pediatric critical care medicine fellowship curriculum could help standardize the experience.

Variations in Alarm Burden, Source, and Cause Across Inpatient Units at a Children's Hospital.

BACKGROUND AND OBJECTIVES: Alarms at hospitals are frequent and can lead to alarm fatigue posing patient safety risks. We aimed to describe alarm burden over a 1-year period and explored variations in alarm rates stratified by unit type, alarm source, and cause. METHODS: A retrospective study of inpatient alarm and patient census data at 1 children's hospital from January 1, 2019, to December 31, 2019, including 8 inpatient units: 6 medical/surgical unit (MSU), 1 PICU, and 1 NICU. Rates of alarms per patient day (appd) were calculated overall and by unit type, alarm source, and cause. Poisson regression was used for comparisons. RESULTS: There were 7 934 997 alarms over 84 077 patient days (94.4 appd). Significant differences in alarm rates existed across inpatient unit types (MSU 81.3 appd, PICU 90.7, NICU 117.5). Pulse oximetry (POx) probes were the alarm source with highest rate, followed by cardiorespiratory leads (54.4 appd versus 31). PICU had lowest rate of POx alarms (33.3 appd, MSU 37.6, NICU 92.6), whereas NICU had lowest rate of cardiorespiratory lead alarms (16.2 appd, MSU 40.1, PICU 31.4). Alarms stratified by cause displayed variation across unit types where "low oxygen saturation" had the highest overall rate, followed by "technical" alarms (43.4 appp versus 16.3). ICUs had higher rates of low oxygenation saturation alarms, but lower rates of technical alarms than MSUs. CONCLUSIONS: Clinical alarms are frequent and vary across unit types, sources, and causes. Unit-level alarm rates and frequent alarm sources (eg, POx) should be considered when implementing alarm reduction strategies.

Reducing the Frequency of Pulse Oximetry Alarms at a Children's Hospital.

BACKGROUND AND OBJECTIVES: Alarm fatigue is exacerbated by frequent, nonactionable physiologic monitor alarms. Overutilization of pulse oximetry (SpO2) compounds this alarm burden. Narrow default alarm limits and overutilization of continuous (CSpO2) rather than intermittent monitoring contribute to nonactionable alarms. There were 1.12 million SpO2 alarms on included units during the baseline period, of which 41.0% were for SpO2 ≥ 88%. We aimed to decrease SpO2 alarms per patient day by 20% within 12 months. METHODS: This quality improvement study included patients admitted January 2019 to June 2022. Intensive care and cardiology units were excluded. Interventions included (1) changing default alarm SpO2 limits on monitors from <90% to <88%, (2) changing SpO2 order default from continuous to intermittent, and (3) adding indication requirements for CSpO2. Outcome measures were total SpO2 alarms and alarms for SpO2 ≥ 88% per patient day. Balancing measures were high acuity transfers and code blues without CSpO2 ordered. Control charts were used for each. RESULTS: Our study included 120 408 patient days with 2.98 million SpO2 alarms. Total SpO2 alarms and alarms for SpO2 ≥ 88% per patient day decreased by 5.48 (30.57 to 25.09; 17.9%) and 4.48 (12.50 to 8.02; 35.8%), respectively. Special cause improvement was associated with changing default monitor alarm parameters. Balancing measures remained stable. CONCLUSIONS: SpO2 monitors alarm frequently at our children's hospital. Widening default alarm limits was associated with decreased SpO2 alarms, particularly nonactionable alarms (≥88%). This high-reliability intervention may be applied, when appropriate, to other monitor alarm parameters to further mitigate alarm burden.

18F-flouro-2-deoxyglucose positron emission tomography/computed tomography imaging of solitary prostatic and pulmonary tuberculosis mimicking metastatic prostate cancer.

Genitourinary tuberculosis (TB) is a common type of extrathoracic TB and can be found in isolation or associated with pulmonary TB. It contributes to 10-14% of extrapulmonary TB. Prostate TB is rare and usually found incidentally following transurethral resection of the prostate for treatment of benign prostatic obstruction as an isolated lesion in immunocompetant patient. The authors report a case of prostatic and pulmonary TB in animmunocompetant patient investigating for the positive positron emission tomography in lung and prostate. To our knowledge, this is the first case reported in the literature presenting with simultaneous hypermetabolic lesions in the prostate and lung.