Epidemiology of Pediatric Critical Care Admissions in 43 United States Children's Hospitals, 2014-2019.

OBJECTIVES: To identify trends in the population of patients in PICUs over time. DESIGN: Cross-sectional, retrospective cohort study using the Pediatric Health Information System database. SETTING: Forty-three U.S. children's hospitals. PATIENTS: All patients admitted to Pediatric Health Information System-participating hospitals from January 2014 to December 2019. Individuals greater than 65 years old and normal newborns were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PICU care occurred in 13.8% of all pediatric hospital encounters and increased over the study period from 13.3% to 14.3%. Resource intensity, based on average Hospitalization Resource Intensity Scores for Kids score, increased significantly across epochs (6.5 in 2014-2015 vs 6.9 in 2018-2019; p < 0.001), although this was not consistently manifested as additional procedural exposure. Geometric mean PICU cost per patient encounter was stable. The two most common disease categories in PICU patients were respiratory failure and cardiac and circulatory congenital anomalies. Of all PICU encounters, 35.5% involved mechanical ventilation, and 25.9% involved vasoactive infusions. Hospital-level variation in the percentage of days spent in the PICU ranged from 15.1% to 63.5% across the participating sites. Of the total hospital costs for patients admitted to the PICU, 41.7% of costs were accrued during the patients' PICU stay. CONCLUSIONS: The proportional use of PICU beds is increasing over time, although was variable across centers. Case-based resource use and complexity of pediatric patients are also increasing. Despite the higher use of PICU resources, the standardized costs of PICU care per patient encounter have remained stable. These data may help to inform current PICU resource allocation and future PICU capacity planning.

Choosing Wisely For Critical Care: The Next Five.

OBJECTIVES: To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES: Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION: English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION: Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS: Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices. CONCLUSIONS: Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.

Fluid Overload in Pediatric Severe Traumatic Brain Injury.

OBJECTIVE: Pediatric traumatic brain injury is a major public health problem in the United States. Hypertonic saline therapy is a well-established treatment in patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) who have intracranial hypertension. In children, fluid overload is associated with increased mortality, ventilator duration, and length of PICU stay, even when controlling for severity of illness. This study reports prevalence of fluid overload in pediatric patients with severe traumatic brain injury treated with 3% hypertonic saline and effect on clinical outcomes. DESIGN: Single-center retrospective chart review. SETTING: PICUs at two tertiary children's hospitals. PATIENTS: One hundred thirty-eight patients with traumatic brain injury with postresuscitation Glasgow Coma Scale less than or equal to 8 who received hypertonic saline from September 1, 2010, to February 28, 2016, and intracranial pressure monitoring and survived at least 24 hours from admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used fluid balance percentage greater than or equal to 10% as our definition of fluid overload. Ninety-one percent of patients less than 1 year old had fluid overload on day 10 of admission compared with 47% of patients greater than 1 year. Fluid overloaded patients did not have increased mortality, acute kidney injury, PICU length of stay, or ventilator days. Hypertonic saline was not the cause of fluid overload in these patients. CONCLUSIONS: Patients with severe traumatic brain injury do have high rates of fluid overload. However, fluid overload did not contribute to mortality, longer days on the ventilator, increased risk of acute kidney injury, or increased PICU length of stay.

The Fragility of Statistically Significant Findings in Pediatric Critical Care Randomized Controlled Trials.

OBJECTIVES: The Fragility Index measures the number of events on which the statistical significance of a result depends and has been suggested as an adjunct statistical assessment for interpretation of trial results. This study aimed to assess the robustness of statistically significant results from pediatric critical care randomized controlled trials with dichotomous outcomes. DATA SOURCES: A previously published scoping review of pediatric critical care randomized controlled trials (www.PICUtrials.net). STUDY SELECTION: A total of 342 trials were screened for inclusion. After applying inclusion/exclusion criteria, 43 fulfilled eligibility criteria and were included in the analysis. DATA EXTRACTION: Calculation of Fragility Index for trials reporting a statistically significant dichotomous outcome, and analysis of the relationship between trial characteristics and Fragility Index. DATA SYNTHESIS: The median Fragility Index was 2 (interquartile range, 1-6). The median sample size was 98 (interquartile range, 50-148) and sample size demonstrated a strong correlation with the Fragility Index (r = 0.729; n = 43; p < 0.001). The median number of outcome events was 8 (interquartile range, 4-15) and the total number of outcome events also showed a strong correlation with the Fragility Index (r = 0.728; n = 43; p < 0.001). CONCLUSIONS: Results from pediatric critical care randomized controlled trials with dichotomous outcomes reporting statistically significant findings often hinge on a small number of outcome events. Clinicians should exercise caution when interpreting results of trials with a low Fragility Index.

Management Options and Outcomes for Neonatal Hypoplastic Left Heart Syndrome in the Early Twenty-First Century.

Without surgical treatment, neonatal hypoplastic left heart syndrome (HLHS) mortality in the first year of life exceeds 90 % and, in spite of improved surgical outcomes, many families still opt for non-surgical management. The purpose of this study was to investigate trends in neonatal HLHS management and to identify characteristics of patients who did not undergo surgical palliation. Neonates with HLHS were identified from a serial cross-sectional analysis using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000 to 2012. The primary analysis compared children undergoing surgical palliation to those discharged alive without surgery using a binary logistic regression model. Multivariate logistic regression was conducted to determine factors associated with treatment choice. A total of 1750 patients underwent analysis. Overall hospital mortality decreased from 35.3 % in 2000 to 22.9 % in 2012. The percentage of patients undergoing comfort care discharge without surgery also decreased from 21.2 to 14.8 %. After controlling for demographics and comorbidities, older patients at presentation were less likely to undergo surgery (OR 0.93, 0.91-0.96), and patients in 2012 were more likely to undergo surgery compared to those in prior years (OR 1.5, 1.1-2.1). Discharge without surgical intervention is decreasing with a 30 % reduction between 2000 and 2012. Given the improvement in surgical outcomes, further dialogue about ethical justification of non-operative comfort or palliative care is warranted. In the meantime, clinicians should present families with surgical outcome data and recommend intervention, while supporting their option to refuse.

Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study.

INTRODUCTION: Consensus criteria for pediatric severe sepsis have standardized enrollment for research studies. However, the extent to which critically ill children identified by consensus criteria reflect physician diagnosis of severe sepsis, which underlies external validity for pediatric sepsis research, is not known. We sought to determine the agreement between physician diagnosis and consensus criteria to identify pediatric patients with severe sepsis across a network of international pediatric intensive care units (PICUs). METHODS: We conducted a point prevalence study involving 128 PICUs in 26 countries across 6 continents. Over the course of 5 study days, 6925 PICU patients <18 years of age were screened, and 706 with severe sepsis defined either by physician diagnosis or on the basis of 2005 International Pediatric Sepsis Consensus Conference consensus criteria were enrolled. The primary endpoint was agreement of pediatric severe sepsis between physician diagnosis and consensus criteria as measured using Cohen's κ. Secondary endpoints included characteristics and clinical outcomes for patients identified using physician diagnosis versus consensus criteria. RESULTS: Of the 706 patients, 301 (42.6%) met both definitions. The inter-rater agreement (κ ± SE) between physician diagnosis and consensus criteria was 0.57 ± 0.02. Of the 438 patients with a physician's diagnosis of severe sepsis, only 69% (301 of 438) would have been eligible to participate in a clinical trial of pediatric severe sepsis that enrolled patients based on consensus criteria. Patients with physician-diagnosed severe sepsis who did not meet consensus criteria were younger and had lower severity of illness and lower PICU mortality than those meeting consensus criteria or both definitions. After controlling for age, severity of illness, number of comorbid conditions, and treatment in developed versus resource-limited regions, patients identified with severe sepsis by physician diagnosis alone or by consensus criteria alone did not have PICU mortality significantly different from that of patients identified by both physician diagnosis and consensus criteria. CONCLUSIONS: Physician diagnosis of pediatric severe sepsis achieved only moderate agreement with consensus criteria, with physicians diagnosing severe sepsis more broadly. Consequently, the results of a research study based on consensus criteria may have limited generalizability to nearly one-third of PICU patients diagnosed with severe sepsis.

Case Volume and Outcomes of Congenital Diaphragmatic Hernia Surgery in Academic Medical Centers.

OBJECTIVE: The outcome of patients with congenital diaphragmatic hernia (CDH) has not improved in the last decade and surgical repair remains the mainstay of treatment. The purpose of the present study was to assess whether a volume-outcome relationship exists in the U.S. academic medical centers performing surgical repair of neonatal CDH. STUDY DESIGN: A retrospective cross-sectional analysis of discharge data for neonates undergoing CDH repair in academic medical center members of the University Health-System Consortium was employed. Unadjusted mortality was compared between lower and higher surgical volume centers. A binary logistic regression model was fit to test the relationship of surgical volume with mortality. RESULTS: A total of 3,738 patients underwent surgical repair in 122 unique academic medical centers in the United States. The overall rate of survival was 75.2%. There was no difference in unadjusted mortality between lower and higher volume centers. After controlling for patient and hospital variables, there was no difference in the odds of mortality between lower and higher volume centers (odds ratio 1.03 [95% confidence interval, 0.86-1.23, p = 0.730]). CONCLUSIONS: Neonates born with congenital diaphragmatic hernia can undergo surgical repair in the U.S. academic medical centers independent of center procedure volume and expect good surgical outcomes.

First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure.

OBJECTIVES: To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV. DESIGN: Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019. SETTING: One hundred thirteen North American PICUs participating in VPS. PATIENTS: Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia. CONCLUSIONS: For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.

Using administrative data for mortality risk adjustment in pediatric congenital cardiac surgery.

OBJECTIVE: To evaluate the performance of risk-adjustment models from the University HealthSystem Consortium and the Agency for Healthcare Research Quality on an administrative dataset for children undergoing congenital cardiac surgery. DESIGN: Retrospective cross-sectional cohort analysis. SETTING: Multi-institutional database of administrative data provided by the University HealthSystem Consortium. PATIENTS: Children whose discharge diagnosis had an associated cardiac surgical procedure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The performance of two risk-adjustment modeling schemata was measured in terms of discrimination and calibration, and receiver operating characteristic curves were compared. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. A total of 19,436 patients were included in the analysis with 816 deaths and an unadjusted overall mortality rate of 4.2%. The University HealthSystem Consortium models applied to the entire population resulted in an area under the curve = 0.73, and by comparison, the Agency for Healthcare Research Quality risk-adjustment model revealed area under the curve = 0.86. The risk-adjustment model of the University HealthSystem Consortium subgroup of Circulatory System Major Diagnostic Category 5 showed better performance with area under the curve = 0.81. Calibration using the Hosmer-Lemeshow test failed to show good agreement between the predicted and actual outcomes across the University HealthSystem Consortium mortality risk groups with an overall standardized mortality ratio of 1.2 (95% CI, 1.1-1.3; p < 0.0001) and poor predictive ability for the highest risk group, with a nearly 1.5-fold overprediction of death. The Agency for Healthcare Research Quality model shared similar calibration results with an overall standardized mortality ratio of 1.6 (95% CI, 1.5-1.7; p < 0.0001) and a nearly two-fold underprediction of death in the highest risk group. CONCLUSIONS: Administrative data can be used to create risk-adjustment models in the congenital cardiac surgery population. Risk-adjustment models generated from administrative data may represent an attractive addition to clinically derived models in pediatric congenital cardiac surgery patients and should be considered for use either alone or in combination with clinical data in future analyses where mortality is a measure of performance and quality.

Machine learning models to predict and benchmark PICU length of stay with application to children with critical bronchiolitis.

OBJECTIVE: To create models for prediction and benchmarking of pediatric intensive care unit (PICU) length of stay (LOS) for patients with critical bronchiolitis. HYPOTHESIS: We hypothesize that machine learning models applied to an administrative database will be able to accurately predict and benchmark the PICU LOS for critical bronchiolitis. DESIGN: Retrospective cohort study. PATIENTS: All patients less than 24-month-old admitted to the PICU with a diagnosis of bronchiolitis in the Pediatric Health Information Systems (PHIS) Database from 2016 to 2019. METHODOLOGY: Two random forest models were developed to predict the PICU LOS. Model 1 was developed for benchmarking using all data available in the PHIS database for the hospitalization. Model 2 was developed for prediction using only data available on hospital admission. Models were evaluated using R2 values, mean standard error (MSE), and the observed to expected ratio (O/E), which is the total observed LOS divided by the total predicted LOS from the model. RESULTS: The models were trained on 13,838 patients admitted from 2016 to 2018 and validated on 5254 patients admitted in 2019. While Model 1 had superior R2 (0.51 vs. 0.10) and (MSE) (0.21 vs. 0.37) values compared to Model 2, the O/E ratios were similar (1.18 vs. 1.20). Institutional median O/E (LOS) ratio was 1.01 (IQR 0.90-1.09) with wide variability present between institutions. CONCLUSIONS: Machine learning models developed using an administrative database were able to predict and benchmark the length of PICU stay for patients with critical bronchiolitis.

Mortality and PICU Hospitalization Among Pediatric Gunshot Wound Victims in Chicago.

Firearm injury accounts for significant morbidity with high mortality among children admitted to the PICU. Understanding risk factors for PICU admission is an important step toward developing prevention and intervention strategies to minimize the burden of pediatric gunshot wound (GSW) injury. OBJECTIVES: The primary objective of this study was to characterize outcomes and the likelihood of PICU admission among children with GSWs. DESIGN SETTING AND PARTICIPANTS: Retrospective cohort study of GSW patients 0-18 years old evaluated at the University of Chicago Comer Children's Hospital Pediatric Trauma Center from 2010 to 2017. MAIN OUTCOMES AND MEASURES: Demographic and injury severity measures were acquired from an institutional database. We describe mortality and hospitalization characteristics for the cohort. We used logistic regression models to test the association between PICU admission and patient characteristics. RESULTS: During the 8-year study period, 294 children experienced GSWs. We did not observe trends in overall mortality over time, but mortality for children with GSWs was higher than all-cause PICU mortality. Children 0-6 years old experienced longer hospitalizations compared with children 13-16 years old (5 vs 3 d; p = 0.04) and greater frequency of PICU admission (83.3% vs 52.9%; p = 0.001). Adjusting for severity of illness, children less than 7 years old were four-fold more likely to be admitted to the PICU than children 13-16 years old (aOR range, 3.9-4.6). CONCLUSIONS AND RELEVANCE: Despite declines in pediatric firearm mortality across the United States, mortality did not decrease over time in our cohort and was higher than all-cause PICU mortality. Younger children with GSWs experience longer hospitalizations and require PICU care more often than older children. Our findings suggest that the youngest victims of firearm-related injury may be particularly at-risk of the long-term sequelae of critical illness and injury.

Correction: Medication Adherence Reminder System for Virtual Home Assistants: Mixed Methods Evaluation Study.

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Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

OBJECTIVES: To determine whether the implementation of a standardized handover protocol could reduce the number of errors occurring during patient transitions from the operating room to the intensive care unit. DESIGN: Prospective, interventional study. SETTING: Pediatric cardiac intensive care unit. SUBJECTS: Seventy-nine patient handovers in patients transitioning from the operating room to the cardiac intensive care unit after congenital cardiac surgery. INTERVENTIONS: A preintervention assessment of patient handovers was obtained by direct observation using a standardized checklist. A teamwork-driven handover process and protocol was developed using traditional and novel quality-improvement techniques. The postimplementation observational assessment of handovers was performed using the same preintervention assessment tool. Preintervention and postintervention data metrics were analyzed and compared. MEASUREMENTS AND MAIN RESULTS: Forty-one and 38 observations were performed in the preintervention and postintervention periods, respectively. Protocol implementation improved key areas of the handover process. Technical errors per handover were reduced from 6.24 to 1.52 (p < .0001), and critical verbal handoff information omissions were reduced from 6.33 to 2.38 (p < .0001) per handover. There was no change in duration of either the verbal handoff briefing or the overall handover process. Caregivers noted improvement in teamwork and handoff content received after the intervention. CONCLUSIONS: A formal, structured handover process for pediatric patients transitioning to the intensive care unit after cardiac surgery can reduce medical errors that occur during the admission process and improve teamwork among caregivers.

Education and Visual Reminders Fail to Reduce Overuse and Waste in Interhospital Transfers to a Pediatric Intensive Care Unit.

INTRODUCTION: As healthcare costs continue to rise, initiatives to reduce costs while maintaining high-quality care become a priority. Nonclinically indicated studies add to this cost, especially during interfacility transfers when studies are often repeated. Also, unnecessary evaluations add to nonmonetary costs such as pain, radiation exposure, and iatrogenic anemia. This study aimed to establish the frequency of redundant testing on interfacility transfers to the pediatric intensive care unit (PICU) and then implement an education-based quality improvement strategy for waste reduction. METHODS: In the preintervention period (September 2018-February 2019), we collected data on patients transferred to the PICU from any outside facility. Investigators evaluated studies repeated within 6 hours and deemed them redundant or indicated. We then determined a rate of patients with redundant studies as the first aim. This result prompted an educational intervention focused on testing stewardship. Investigators then collected data in the postintervention period (July-December 2019) and compared the rate of redundant studies. RESULTS: Study efforts identified 150 patients in the preintervention period and 131 in the postintervention period, establishing a 21%-25% frequency of redundant testing. Education and visual reminders failed to reduce this testing. CONCLUSION: This study established a baseline rate of redundant testing on transferred patients to the PICU. An educational intervention alone did not produce significant change.

Resources and Costs Associated With Repeated Admissions to PICUs.

OBJECTIVE: To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge. DESIGN: Cross-sectional, retrospective cohort study using Pediatric Health Information System. SETTING: Fifty-two tertiary children's hospitals. SUBJECTS: Pediatric patients under 18 years old admitted to the PICU from January 1, 2016, to December 31, 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics and costs of care were compared between those with readmission requiring PICU care and those with only a single PICU admission per annum. In this 2-year cohort, there were 239,157 index PICU patients of which 36,970 (15.5%) were readmitted and required PICU care during the 12 months following index admission. The total hospital cost for all index admissions and readmissions was $17.3 billion, of which 21.5% ($3.71 billion) were incurred during a readmission stay involving care in the PICU; of the 3,459,079 hospital days, 20.3% (702,200) were readmission days including those where PICU care was required. Of the readmitted patients, 11,703 (30.0%) received only PICU care, accounting for $662 million in costs and 110,215 PICU days. Although 43.6% of all costs were associated with patients who required readmission, these patients only accounted for 15.5% of the index patients and 28% of index hospitalization expenditures. More patients in the readmitted group had chronic complex conditions at index discharge compared with those not readmitted (83.9% vs 54.9%; p < 0.001). Compared with those discharged directly to home without home healthcare, patients discharged to a skilled nursing facility had 18% lower odds of readmission (odds ratio 0.82 [95% CI, 0.75-0.89]; p < 0.001) and those discharged home with home healthcare had 43% higher odds of readmission (odds ratio, 1.43 [95% CI, 1.36-1.51]; p < 0.001). CONCLUSIONS: Repeated admissions with PICU care resulted in significant direct medical costs and resource use for U.S. children's hospitals.

Medication Adherence Reminder System for Virtual Home Assistants: Mixed Methods Evaluation Study.

BACKGROUND: Medication nonadherence is a global public health challenge that results in suboptimal health outcomes and increases health care costs. Forgetting to take medicines is one of the most common reasons for unintentional medication nonadherence. Research findings indicate that voice-activated virtual home assistants, such as Amazon Echo and Google Home devices, may be useful in promoting medication adherence. OBJECTIVE: This study aims to create a medication adherence app (skill), MedBuddy, for Amazon Echo devices and measure the use, usability, and usefulness of this medication-taking reminder skill. METHODS: A single-group, mixed methods, cohort feasibility study was conducted with women who took oral contraceptives (N=25). Participants were undergraduate students (age: mean 21.8 years, SD 6.2) at an urban university in the Southeast United States. Participants were given an Amazon Echo Dot with MedBuddy-a new medication reminder skill for Echo devices created by our team-attached to their study account, which they used for 60 days. Participants self-reported their baseline and poststudy medication adherence. MedBuddy use was objectively evaluated by tracking participants' interactions with MedBuddy through Amazon Alexa. The usability and usefulness of MedBuddy were evaluated through a poststudy interview in which participants responded to both quantitative and qualitative questions. RESULTS: Participants' interactions with MedBuddy, as tracked through Amazon Alexa, only occurred on half of the study days (mean 50.97, SD 29.5). At study end, participants reported missing their medication less in the past 1 and 6 months compared with baseline (χ21=0.9 and χ21=0.4, respectively; McNemar test: P<.001 for both). However, there was no significant difference in participants' reported adherence to consistently taking medication within the same 2-hour time frame every day in the past 1 or 6 months at the end of the study compared with baseline (χ21=3.5 and χ21=0.4, respectively; McNemar test: P=.63 and P=.07, respectively). Overall feedback about usability was positive, and participants provided constructive feedback about the skill's features that could be improved. Participants' evaluation of MedBuddy's usefulness was overwhelmingly positive-most (15/23, 65%) said that they would continue using MedBuddy as a medication reminder if provided with the opportunity and that they would recommend it to others. MedBuddy features that participants enjoyed were an external prompt separate from their phone, the ability to hear the reminder prompt from a separate room, multiple reminders, and verbal responses to prompts. CONCLUSIONS: The findings of this feasibility study indicate that the MedBuddy medication reminder skill may be useful in promoting medication adherence. However, the skill could benefit from further usability enhancements.

Terbutaline and aminophylline as second-line therapies for status asthmaticus in the pediatric intensive care unit.

OBJECTIVE: Asthma is the most common chronic disease of childhood. Although asthma admissions to the pediatric intensive care unit (PICU) are increasing, there are no evidence-based guidelines on preferred escalation of therapies for patients with status asthmaticus who fail to respond to inhaled bronchodilators and systemic corticosteroids. The purpose of this study was to assess outcomes of PICU patients receiving aminophylline versus terbutaline as second-tier therapies for status asthmaticus. DESIGN: Retrospective cohort study using Pediatric Health Information System from 2016-2019. SETTING: Fifty-three tertiary children's hospitals. SUBJECTS: Children aged 2 to 18 years admitted to the PICU in children's hospitals contributing data to the Pediatric Health Information System with a primary diagnosis of status asthmaticus. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 11 133 pediatric patients treated for status asthmaticus in the PICU during the study period, 1144 received either terbutaline or aminophylline. There was no difference in intubation and mechanical ventilation between patients who received aminophylline and those who received terbutaline. However, in African American patients, those who received terbutaline had a significantly higher odds of intubation and mechanical ventilation compared to those who received aminophylline (OR, 12.41; 95%CI, 1.61,95). CONCLUSIONS: The use of aminophylline is associated with lower odds of intubation and mechanical ventilation in African American patients with status asthmaticus as compared to terbutaline.

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications.

This study assessed the perceptions of nurses about the creation and staffing of a dedicated cardiac intensive care unit. Nurses perceived a clinical benefit to cohorting cardiac surgery patients; however, they reported more knowledge deficits in cardiac patient care than other intensive care unit disease categories. More than 25% of nurses reported a patient assignment in which they identified suboptimal skills to provide safe patient care. Years of clinical experience did not reduce concerns for quality of care or safe practice.