Minimum Supervision Levels Required for Pediatric Cardiology Fellowship Graduation by Pediatric Cardiology Fellowship Program Directors.

Entrustable professional activities (EPAs) are "observable essential tasks expected to be performed by a physician for safe patient care in practice." Six Pediatric Cardiology (PC) EPAs and their level of supervision (LOS) scales were developed by medical educators in PC using a modified Delphi process and reviewed by the Subspecialty Pediatrics Investigator Network (SPIN). However, their general use in assessment for PC fellows for graduation requirements has yet to be studied. The objective of this study was to determine the minimum LOS required for PC fellows to graduate and compare it with the minimum LOS expected for safe and effective practice for the six PC EPAs, from the perspective of the PC Fellowship Program Directors(FPD). All Fellowship Program Directors(FPD) of ACGME-accredited PC fellowships were surveyed through SPIN between April 2017 and August 2017. For each of the PC EPAs, the FPDs were asked to indicate the minimum LOS expected for graduation and whether they would allow a fellow to graduate if this level was not achieved and the minimum LOS expected for a practicing pediatric cardiologist to provide safe and effective patient care. The minimum LOS was defined as the LOS for which no more than 20% of FPDs would want a lower level. The survey response rate was 80% (47/59). The majority of the FPDs did not require a minimum LOS of five corresponding to unsupervised practice in any of the six PC EPAs at graduation. For EPAs related to imaging, arrhythmia management, and management of cardiac problems, the minimum LOS for graduation was 3, corresponding to being "trusted to perform a task with indirect supervision for most simple and a few complex cases." For the EPAs related to interventional cardiology, heart failure pulmonary hypertension, and cardiac intensive care, the minimum LOS for graduation was 2, corresponding to being "trusted to perform a task only with direct supervision and coaching." The minimum LOS considered necessary for safe and effective practice for all but one EPA was 3. For the EPA related to the management of cardiac problems, the minimum LOS for safe practice was 4, corresponding to being "trusted to execute tasks independently except for few complex and critical cases." Most PC FPDs reported they would not require fellows to achieve the highest entrustment level for any of the six PC EPAs for graduation. It is crucial that educational programs evolve to address these essential activities during training better and that stakeholders ensure that graduating PC fellows have adequate resources and infrastructure to continue professional development as early career pediatric cardiologists.

Clinical competency committee perceptions of entrustable professional activities and their value in assessing fellows: A qualitative study of pediatric subspecialty program directors.

OBJECTIVES: To examine the composition and processes of Clinical Competency Committees (CCCs) assigning entrustable professional activity (EPA) levels of supervision for pediatric subspecialty fellows and to examine fellowship program director (FPD) perspectives about using EPAs to determine fellows' graduation readiness. METHODS: A qualitative study was performed using one-on-one interviews with a purposeful sample of pediatric subspecialty FPDs to yield a thematic analysis. Semi-structured interview guides were used for participants who self-identified as EPA users or non-users. Inductive analysis and coding were performed on transcripts until theoretical sufficiency was attained. RESULTS: Twenty-eight FPDs were interviewed. There was significant variability in the composition and processes of CCCs across subspecialties. FPDs felt that CCCs intuitively understand what entrustment means, allowing for ease of application of level of supervision (LOS) scales and consensus. FPDs perceived that EPAs provided a global assessment of fellows and are one tool to determine graduation readiness. CONCLUSIONS: Although there was variability in the makeup and processes of CCCs across subspecialties, FPDs believe EPAs are intuitive and relatively easy to implement. Consensus can be reached easily using EPA-specific LOS scales focusing on entrustment. FPDs desire a better understanding of how EPAs should be used for graduation.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment.

BACKGROUND: Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment. OBJECTIVES: We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME). METHODS: In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale. RESULTS: One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05). CONCLUSIONS: We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

Pediatric Emergency Medicine Fellowship Program Directors' Viewpoint: Minimum Levels of Entrustment for Graduating Fellows and Practicing Physicians to Perform the Subspecialty's Professional Activities.

OBJECTIVES: Entrustable Professional Activities (EPAs) are essential tasks physicians perform within their professions. Entrustment levels that pediatric emergency medicine (PEM) fellowship program directors (FPDs) expect graduating fellows to achieve for PEM-specific and common pediatric subspecialty EPAs remain unreported. This study aims to determine minimum entrustment levels FPDs require fellows to achieve to graduate from fellowship and to compare FPD expectations for fellows versus practicing PEM physicians. METHODS: Secondary analysis of PEM-specific data from a national multispecialty cross-sectional survey of pediatric subspecialty FPDs. For 6 PEM-specific and 7 common pediatric subspecialty EPAs, PEM FPDs indicated (1) minimum entrustment levels fellows should achieve by training completion, (2) whether they would allow a fellow to graduate below these minimum levels, and (3) minimum levels for safe and effective practice by PEM physicians. Minimum levels were defined as the level that more than 80% of FPDs would not drop below. RESULTS: Sixty of 77 PEM FPDs (78%) completed the survey. Most respondents did not require fellows to achieve the highest level (level 5-no supervision) by graduation for any PEM-specific EPAs. The median level FPDs expected for practicing PEM physicians was 5 (trusted to perform without supervision) for EPAs 1 and 4 and level 4 (indirect supervision for complex cases) for the remaining PEM-specific EPAs. Minimum levels expected by FPDs for common subspecialty pediatric EPAs were lower for both groups. CONCLUSIONS: Most PEM FPDs indicated that they would graduate fellows before their achievement of the highest entrustment level for all EPAs. Most also indicated that they do not expect practicing PEM physicians to perform all EPAs without supervision. These findings indicate need for stakeholders to evaluate current structure and outcomes of PEM fellowship programs and for institutions and organizations to ensure adequate support in time and resources for ongoing learning for practicing PEM physicians.

Burnout in Pediatric Critical Care Medicine Fellows.

OBJECTIVES: Assess the overall level of burnout in pediatric critical care medicine fellows and examine factors that may contribute to or protect against its development. DESIGN: Cross-sectional observational study. SETTING: Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine fellowship programs across the United States. SUBJECTS: Pediatric critical care medicine fellows and program directors. INTERVENTIONS: Web-based survey that assessed burnout via the Maslach Burnout Inventory, as well as other measures that elicited demographics, sleepiness, social support, perceptions about prior training, relationships with colleagues, and environmental burnout. MEASUREMENTS AND MAIN RESULTS: One-hundred eighty-seven fellows and 47 program directors participated. Fellows from 30% of programs were excluded due to lack of program director participation. Average values on each burnout domain for fellows were higher than published values for other medical professionals. Personal accomplishment was greater (lower burnout) among fellows more satisfied with their career choice (ß 9.319; p ≤ 0.0001), spiritual fellows (ß 1.651; p = 0.0286), those with a stress outlet (ß 3.981; p = 0.0226), those comfortable discussing educational topics with faculty (ß 3.078; p = 0.0197), and those comfortable seeking support from their co-fellows (ß 3.762; p = 0.0006). Depersonalization was higher for second year fellows (ß 2.034; p = 0.0482), those with less educational debt (ß -2.920; p = 0.0115), those neutral/dissatisfied with their career choice (ß -6.995; p = 0.0031), those with nursing conflict (ß -3.527; p = 0.0067), those who perceived burnout among co-fellows (ß 1.803; p = 0.0352), and those from ICUs with an increased number of patient beds (ß 5.729; p ≤ 0.0001). Emotional exhaustion was higher among women (ß 2.933; p = 0.0237), those neutral/dissatisfied with their career choice (ß -7.986; p = 0.0353), and those who perceived burnout among co-fellows (ß 5.698; p ≤ 0.0001). Greater sleepiness correlated with higher burnout by means of lower personal accomplishment (r = -1.64; p = 0.0255) and higher emotional exhaustion (r = 0.246; p = 0.0007). Except for tangible support, all other forms of social support showed a small to moderate correlation with lower burnout. CONCLUSIONS: Pediatric critical care medicine fellows in the United States are experiencing high levels of burnout, which appears to be influenced by demographics, fellow perceptions of their work environment, and satisfaction with career choice. The exclusion of fellows at 30% of the programs may have over or underestimated the actual level of burnout in these trainees.

Expanding Faculty Development of Teaching Skills: A National Needs Assessment of Pediatric Critical Care Medicine Faculty.

OBJECTIVES: High-quality clinical teaching is an essential element in preparing trainees to become independently competent clinicians. In order to better understand the context-specific faculty development needs of teaching faculty in a specific community, we sought to determine the self-reported teaching skill deficits of pediatric critical care medicine faculty and their preferences and motivations regarding faculty development to enhance their teaching. DESIGN: Modified Delphi technique was used to create an online survey in which respondents rated their need for education on a variety of teaching skills, their preferred learning modalities, and factors that motivate their participation in faculty development. SETTING: Pediatric Critical Care Medicine divisions at the 64 sites in the United States with fellowship programs. SUBJECTS: Five-hundred forty-five Pediatric Critical Care Medicine faculty who teach fellows and other trainees. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Response rate was 40%. Respondents reported a median of 8.5 years (interquartile range, 4-16 yr) as teaching faculty. The median age of faculty was 44.6 years (interquartile range, 38-50 yr). Only 20% of respondents indicated that improving their teaching was a low priority. Thirty-six percent of respondents had not participated in any formal teaching skill development as faculty. The most frequently cited factors motivating engagement in faculty development were education being included as part of regularly attended conferences, resources readily available when needed, and participation promoted by a supervisor. Preferred learning modalities included a brief discussion with a colleague, a 10-minute video, and a regular conference series. CONCLUSIONS: Pediatric Critical Care Medicine faculty reported they experience challenges in teaching and would benefit from faculty development training aimed at improving their knowledge and skills about being an educator. Preferred learning methods and motivating factors highlight the importance of efficiency in content delivery and endorsement by faculty supervisors. Consideration of these needs and preferences may be useful in creating context-focused, community of practice-based faculty development programs.

Assessing Competence in Central Venous Catheter Placement by Pediatric Critical Care Fellows: A National Survey Study.

OBJECTIVES: To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required. DESIGN: Cross-sectional internet-based survey with deliberate sampling. SETTING: United States pediatric critical care medicine fellowship programs. SUBJECTS: Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors (n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important. CONCLUSIONS: Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors' abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.

Magnetic resonance spectroscopy of fiber tracts in children with traumatic brain injury: A combined MRS - Diffusion MRI study.

Traumatic brain injury can cause extensive damage to the white matter (WM) of the brain. These disruptions can be especially damaging in children, whose brains are still maturing. Diffusion magnetic resonance imaging (dMRI) is the most commonly used method to assess WM organization, but it has limited resolution to differentiate causes of WM disruption. Magnetic resonance spectroscopy (MRS) yields spectra showing the levels of neurometabolites that can indicate neuronal/axonal health, inflammation, membrane proliferation/turnover, and other cellular processes that are on-going post-injury. Previous analyses on this dataset revealed a significant division within the msTBI patient group, based on interhemispheric transfer time (IHTT); one subgroup of patients (TBI-normal) showed evidence of recovery over time, while the other showed continuing degeneration (TBI-slow). We combined dMRI with MRS to better understand WM disruptions in children with moderate-severe traumatic brain injury (msTBI). Tracts with poorer WM organization, as shown by lower FA and higher MD and RD, also showed lower N-acetylaspartate (NAA), a marker of neuronal and axonal health and myelination. We did not find lower NAA in tracts with normal WM organization. Choline, a marker of inflammation, membrane turnover, or gliosis, did not show such associations. We further show that multi-modal imaging can improve outcome prediction over a single modality, as well as over earlier cognitive function measures. Our results suggest that demyelination plays an important role in WM disruption post-injury in a subgroup of msTBI children and indicate the utility of multi-modal imaging.

Timely Hemodynamic Resuscitation and Outcomes in Severe Pediatric Traumatic Brain Injury: Preliminary Findings.

OBJECTIVES: Early resuscitation may improve outcomes in pediatric traumatic brain injury (TBI). We examined the association between timely treatment of hypotension and hypoxia during early care (prehospital or emergency department locations) and discharge outcomes in children with severe TBI. METHODS: Hypotension was defined as systolic blood pressure less than 70 + 2 (age in years), and hypoxia was defined as PaO2 less than 60 mm Hg or oxygen saturation less than 90% in accordance with the 2003 Brain Trauma Foundation guidelines. Timely treatment of hypotension and hypoxia during early care was defined as the treatment within 30 minutes of a documented respective episode. Two hundred thirty-six medical records of children younger than 18 years with severe TBI from 5 regional pediatric trauma centers were examined. Main outcomes were in-hospital mortality and discharge Glasgow Outcome Scale (GOS) score. RESULTS: Hypotension occurred in 26% (60/234) during early care and was associated with in-hospital mortality (23.3% vs 8.6%; P = 0.01). Timely treatment of hypotension during early care occurred in 92% (55/60) by use of intravenous fluids, blood products, or vasopressors and was associated with reduced in-hospital mortality [adjusted relative risk (aRR), 0.46; 95% confidence interval, 0.24-0.90] and less likelihood of poor discharge GOS (aRR, 0.54; 95% confidence interval, 0.39-0.76) when compared to children with hypotension who were not treated in a timely manner. Early hypoxia occurred in 17% (41/236) and all patients received timely oxygen treatment. CONCLUSIONS: Timely resuscitation during early care was common and associated with lower in-hospital mortality and favorable discharge GOS in severe pediatric TBI.

Frequency of and factors associated with emergency department intracranial pressure monitor placement in severe paediatric traumatic brain injury.

OBJECTIVE: To examine the frequency of and factors associated with emergency department (ED) intracranial pressure (ICP) monitor placement in severe paediatric traumatic brain injury (TBI). METHODS: Retrospective, multicentre cohort study of children <18 years admitted to the ED with severe TBI and intubated for >48 hours from 2007 to 2011. RESULTS: Two hundred and twenty-four children had severe TBI and 75% underwent either ED, operating room (OR) or paediatric intensive care unit (PICU) ICP monitor placement. Four out of five centres placed ICP monitors in the ED, mostly (83%) fibreoptic. Nearly 40% of the patients who received ICP monitors get it placed in the ED (29% overall). Factors associated with ED ICP monitor placement were as follows: age 13 to <18 year olds compared to infants (aRR 2.02; 95% CI 1.37, 2.98), longer ED length of stay (LOS) (aRR 1.15; 95% CI 1.08, 1.21), trauma centre designation paediatric only I/II compared to adult/paediatric I/II (aRR 1.71; 95% CI 1.48, 1.98) and higher mean paediatric TBI patient volume (aRR 1.88;95% CI 1.68, 2.11). Adjusted for centre, higher bedside ED staff was associated with longer ED LOS (aRR 2.10; 95% CI 1.06, 4.14). CONCLUSION: ICP monitors are frequently placed in the ED at paediatric trauma centres caring for children with severe TBI. Both patient and organizational level factors are associated with ED ICP monitor placement.

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment.

INTRODUCTION: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion. METHODS: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential. RESULTS: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item ("displays honesty and integrity") was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills. CONCLUSIONS: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

Callosal Function in Pediatric Traumatic Brain Injury Linked to Disrupted White Matter Integrity.

Traumatic brain injury (TBI) often results in traumatic axonal injury and white matter (WM) damage, particularly to the corpus callosum (CC). Damage to the CC can lead to impaired performance on neurocognitive tasks, but there is a high degree of heterogeneity in impairment following TBI. Here we examined the relation between CC microstructure and function in pediatric TBI. We used high angular resolution diffusion-weighted imaging (DWI) to evaluate the structural integrity of the CC in humans following brain injury in a sample of 32 children (23 males and 9 females) with moderate-to-severe TBI (msTBI) at 1-5 months postinjury, compared with well matched healthy control children. We assessed CC function through interhemispheric transfer time (IHTT) as measured using event-related potentials (ERPs), and related this to DWI measures of WM integrity. Finally, the relation between DWI and IHTT results was supported by additional results of neurocognitive performance assessed using a single composite performance scale. Half of the msTBI participants (16 participants) had significantly slower IHTTs than the control group. This slow IHTT group demonstrated lower CC integrity (lower fractional anisotropy and higher mean diffusivity) and poorer neurocognitive functioning than both the control group and the msTBI group with normal IHTTs. Lower fractional anisotropy-a common sign of impaired WM-and slower IHTTs also predicted poor neurocognitive function. This study reveals that there is a subset of pediatric msTBI patients during the post-acute phase of injury who have markedly impaired CC functioning and structural integrity that is associated with poor neurocognitive functioning. SIGNIFICANCE STATEMENT: Traumatic brain injury (TBI) is the primary cause of death and disability in children and adolescents. There is considerable heterogeneity in postinjury outcome, which is only partially explained by injury severity. Imaging biomarkers may help explain some of this variance, as diffusion weighted imaging is sensitive to the white matter disruption that is common after injury. The corpus callosum (CC) is one of the most commonly reported areas of disruption. In this multimodal study, we discovered a divergence within our pediatric moderate-to-severe TBI sample 1-5 months postinjury. A subset of the TBI sample showed significant impairment in CC function, which is supported by additional results showing deficits in CC structural integrity. This subset also had poorer neurocognitive functioning. Our research sheds light on postinjury heterogeneity.

The UCLA study of Predictors of Cognitive Functioning Following Moderate/Severe Pediatric Traumatic Brain Injury.

OBJECTIVES: Following pediatric moderate-to-severe traumatic brain injury (msTBI), few predictors have been identified that can reliably identify which individuals are at risk for long-term cognitive difficulties. This study sought to determine the relative contribution of detailed descriptors of injury severity as well as demographic and psychosocial factors to long-term cognitive outcomes after pediatric msTBI. METHODS: Participants included 8- to 19-year-olds, 46 with msTBI and 53 uninjured healthy controls (HC). Assessments were conducted in the post-acute and chronic stages of recovery. Medical record review provided details regarding acute injury severity. Parents also completed a measure of premorbid functioning and behavioral problems. The outcome of interest was four neurocognitive measures sensitive to msTBI combined to create an index of cognitive performance. RESULTS: Results indicated that none of the detailed descriptors of acute injury severity predicted cognitive performance. Only the occurrence of injury, parental education, and premorbid academic competence predicted post-acute cognitive functioning. Long-term cognitive outcomes were best predicted by post-acute cognitive functioning. DISCUSSION: The findings suggest that premorbid factors influence cognitive outcomes nearly as much as the occurrence of a msTBI. Furthermore, of youth with msTBI who initially recover to a level of moderate disability or better, a brief cognitive battery administered within several months after injury can best predict which individuals will experience poor long-term cognitive outcomes and require additional services.

Guideline Adherence and Hospital Costs in Pediatric Severe Traumatic Brain Injury.

OBJECTIVES: Adherence to pediatric traumatic brain injury guidelines has been associated with improved survival and better functional outcome. However, the relationship between guideline adherence and hospitalization costs has not been examined. To evaluate the relationship between adherence to pediatric severe traumatic brain injury guidelines, measured by acute care clinical indicators, and the total costs of hospitalization associated with severe traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS: Demographic, injury, treatment, and charge data were included for pediatric patients (17 yr) with severe traumatic brain injury. INTERVENTIONS: Percent adherence to clinical indicators was determined for each patient. Cost-to-charge ratios were used to estimate ICU and total hospital costs for each patient. Generalized linear models evaluated the association between healthcare costs and adherence rate. MEASUREMENTS AND MAIN RESULTS: Cost data for 235 patients were examined. Estimated mean adjusted hospital costs were $103,485 (95% CI, 98,553-108,416); adjusted ICU costs were $82,071 (95% CI, 78,559-85,582). No association was found between adherence to guidelines and total hospital or ICU costs, after adjusting for patient and injury characteristics. Adjusted regression model results provided cost ratio equal to 1.01 for hospital and ICU costs (95% CI, 0.99-1.03 and 0.99-1.02, respectively). CONCLUSIONS: Adherence to severe pediatric traumatic brain injury guidelines at these five leading pediatric trauma centers was not associated with increased hospitalization and ICU costs. Therefore, cost should not be a factor as institutions and providers strive to provide evidence-based guideline driven care of children with severe traumatic brain injury.

Developing a Family-Centered Care Model for Critical Care After Pediatric Traumatic Brain Injury.

OBJECTIVES: This study examined the family experience of critical care after pediatric traumatic brain injury in order to develop a model of specific factors associated with family-centered care. DESIGN: Qualitative methods with semi-structured interviews were used. SETTING: Two level 1 trauma centers. PARTICIPANTS: Fifteen mothers of children who had an acute hospital stay after traumatic brain injury within the last 5 years were interviewed about their experience of critical care and discharge planning. Participants who were primarily English, Spanish, or Cantonese speaking were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Content analysis was used to code the transcribed interviews and develop the family-centered care model. Three major themes emerged: 1) thorough, timely, compassionate communication, 2) capacity building for families, providers, and facilities, and 3) coordination of care transitions. Participants reported valuing detailed, frequent communication that set realistic expectations and prepared them for decision making and outcomes. Areas for capacity building included strategies to increase provider cultural humility, parent participation in care, and institutional flexibility. Coordinated care transitions, including continuity of information and maintenance of partnerships with families and care teams, were highlighted. Participants who were not primarily English speaking reported particular difficulty with communication, cultural understanding, and coordinated transitions. CONCLUSIONS: This study presents a family-centered traumatic brain injury care model based on family perspectives. In addition to communication and coordination strategies, the model offers methods to address cultural and structural barriers to meeting the needs of non-English-speaking families. Given the stress experienced by families of children with traumatic brain injury, careful consideration of the model themes identified here may assist in improving overall quality of care to families of hospitalized children with traumatic brain injury.

Practice Patterns in Pediatric Critical Care Medicine: Results of a Workforce Survey.

OBJECTIVE: To obtain current data on practice patterns of the U.S. pediatric critical care medicine workforce. DATA SOURCES: Membership of the American Academy of Pediatrics Section on Critical Care and individuals certified by the American Board of Pediatrics in pediatric critical care medicine. STUDY SELECTION: All active members of the American Academy of Pediatrics Section on Critical Care, and nonduplicative individuals certified by the American Board of Pediatrics in pediatric critical care medicine, were classified as eligible to participate in this electronically administered workforce survey. DATA EXTRACTION: Data were extracted by a doctorate-level research professional. Extracted data included demographic information, work environment, number of hours worked, training, clinical responsibilities, work satisfaction and burnout, and plans to leave the practice of pediatric critical care medicine. DATA SYNTHESIS: Of 1,857 individuals contacted, 923 completed the survey (49.7%). The majority of respondents were white, male, non-Hispanic, university-employed, and taught residents. Respondents who worked full time were on clinical intensive care service for a median of 15 wk/yr and responsible for a median of 13 ICU beds, working a median of 60 hr/wk. Total night call responsibility was a median of 60 nights/yr; about half of respondents indicated night call was in-hospital. Fewer than half were engaged in basic science or clinical research. Compared with earlier data, there was minimal change in work hours and proportion of time devoted to research, but there was an increase in the proportion of female pediatric critical care medicine physicians. CONCLUSIONS: These data provide a description of the typical intensivist and a snapshot of the current pediatric critical care medicine workforce, which may be experiencing a mild-to-moderate undersupply. The results are useful for assessing the current workforce and valuable for future planning.

Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.

OBJECTIVE: The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. DESIGN: Retrospective multicenter cohort study. SETTING: Five regional pediatric trauma centers affiliated with academic medical centers. PATIENTS: Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86). CONCLUSIONS: Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.

Development of learning objectives and a validated testing tool for management of pediatric mechanical ventilation*.

OBJECTIVES: Graduate medical education is shifting toward an outcome-based paradigm, where physicians are evaluated for competency using well-defined criteria. Our aim was to learning objectives and a testing tool to assess competency in the management of mechanical ventilation for infants, children, and adolescents and to verify that the test was reliable and valid. DESIGN: Prospective reliability and validity study. SETTING: Large, university-affiliated academic hospital. SUBJECTS: Sixty-one total subjects from five different academic centers divided into three groups of varying experience. The groups were second- and third-year pediatric residents (Novice), second- and third-year pediatric critical care fellows (Advanced), and pediatric critical care faculty (Expert). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ten learning objectives considered important for the management of pediatric mechanical ventilation were developed from expert opinion and current evidence. Based on these objectives, a 35-question multiple choice, knowledge- and case-based test was created. Content validity was achieved by consensus of three experts in pediatric critical care medicine evaluating whether the questions reflected the learning objectives and the responses were consistent with current practice and evidence-based medicine. The test was then administered to the three groups to establish construct validity. The "Novice" group scored a mean of 34.6% (95% CI, 28-41%), the "Advanced" group a mean of 59.4% (95% CI, 53-65%), and the "Expert" group a mean of 74.8% (95% CI, 69-80%), with p less than 0.01 for all comparisons. As determined by Hoyt's analysis, the reliability coefficient was 0.89, reflecting excellent reliability. CONCLUSIONS: This is the first description of specific learning objectives for management of pediatric mechanical ventilation and the first validated and reliable testing tool for assessing knowledge. This tool could be used by fellowship programs to assess fellow competency and identify knowledge gaps in this area prior to completion of training. Further work must be done to determine the criteria for determination of competency.

Child Health Needs and the Pediatric Emergency Medicine Workforce: 2020-2040.

Approximately 30 million ill and injured children annually visit emergency departments (EDs) in the United States. Data suggest that patients seen in pediatric EDs by board-certified pediatric emergency medicine (PEM) physicians receive higher-quality care than those cared for by non-PEM physicians. These benefits, coupled with the continued growth in PEM since its inception in the early 1990s, have impacted child health broadly. This article is part of a Pediatrics supplement focused on predicting the future pediatric subspecialty workforce supply by drawing on the American Board of Pediatrics workforce data and a microsimulation model of the future pediatric subspecialty workforce. The article discusses the utilization of acute care services in EDs, reviews the current state of the PEM subspecialty workforce, and presents projected numbers of PEM subspecialists at the national, census region, and census division on the basis of this pediatric subspecialty workforce supply model through 2040. Implications of this model on education and training, clinical practice, policy, and future workforce research are discussed. Findings suggest that, if the current growth in the field of PEM continues on the basis of the increasing number and size of fellowship programs, even with a potential reduction in percentage of clinical time and attrition of senior physicians, the PEM workforce is anticipated to increase nationally. However, the maldistribution of PEM physicians is likely to be perpetuated with the highest concentration in New England and Mid-Atlantic regions and "PEM deserts" in less populated areas.