[Using descriptors during the implementation of Mini-CEX at pediatric residency]. / Uso de descriptores durante la implementación de Mini-CEX en la residencia de pediatría.

UNLABELLED: The Mini Clinical Evaluation Exercise (Mini-CEX) is an assessment tool, which emphasizes the educational value and is based on direct performance observation. The objective was to evaluate the reliability and feasibility of Mini-CEX using pediatric descriptors during its implementation in two pediatric residency programs. The design was observational, exploratory and feasibility in the use of this evaluation tool. Based on the original format, descriptors related to the pediatric consult for each Mini-CEX dimension's were agreed. Operators were trained in the use of this tool by means of descriptors as well as in debriefing strategies. Finally, there were two simultaneous and independent evaluations for each observation. ANALYSIS: a) Mini-CEX global and dimension score; b) Concordance between operators scores (mean differences and 95% CI); c) Non evaluable descriptors frequency; d) Duration and satisfaction in use. There were 80 observations in 40 pediatric consults. Overall score 7.5±0.9 (6.4±2 to 8.3±1.1 depending on dimension), with no significant differences between the two institutions. There was high agreement between observers (Mean, difference between 0.1 and 0.3, 95% CI -0.8 to 0.3). The frequency of non evaluable descriptors ranged 5-28 (9% to 51%) and it was not associated with the implementation stage. The average implementation time was 20 minutes, and satisfaction in use was high among both operators and residents. Mini-CEX tool using pediatric descriptors showed high reliability. The joint experience was satisfactory and simultaneously confirmed the value of debriefing.

Epidemiology and outcomes of pediatric cardiac arrest in a cardiovascular unit at a public hospital in Argentina.

BACKGROUND: Children with congenital heart disease present a higher frequency of cardiorespiratory arrest (CRA) than the general pediatric population. The epidemiology of CRA is not exactly known in our setting, nor are the mortality risk or the neurological evolution factors. OBJECTIVE: To describe the epidemiology and outcomes associated with pediatric cardiopulmonary resuscitation in a cardiovascular recovery unit. The primary endpoint was the survival to discharge and the secondary endpoints were the return to spontaneous circulation, the survival at 24 hours and the remote neurological condition. METHODS: Descriptive, prospective, longitudinal cohort study in children under 18 years of age who required cardiopulmonary resuscitation between 2016 and 2019. Demographic variables, characteristics of cardiopulmonary arrest, resuscitation and outcome were analyzed. An uni- and multivariate analysis was performed comparing survivors and deceased. RESULTS: Out of 1,842 hospitalized patients, 4.1% presented CRA. Fifty patients with complete records were analyzed. Seventy-eight percent (39) returned to spontaneous circulation with a high survival rate of 46%. Resuscitation > 6 min and the use of vasoactive drugs were predictors of mortality; 16/23 patients were followed up, 10 of them with normal development for age at 6 months, six had pervasive developmental disorder. CONCLUSIONS: 4.1% of patients presented CRA, with a rate of 3.4 CRA per 1,000 patient-days. Survival at hospital discharge (n = 50) was 46%. Resuscitation > 6 min and the use of vasoactive drugs were independent predictors of mortality. At six months, 63% had normal neurological development for age.

ANTECEDENTES: Los niños con cardiopatías congénitas experimentan paro cardiorrespiratorio (PCR) con mayor frecuencia que la población pediátrica general. Se desconoce la epidemiología exacta del PCR en nuestro medio, al igual que el riesgo de mortalidad y los factores que influyen en la evolución neurológica. OBJETIVO: Describir la epidemiología y los resultados asociados con la reanimación cardiopulmonar pediátrica en una unidad de recuperación cardiovascular. El criterio de valoración primario fue la supervivencia al momento del alta hospitalaria; los secundarios fueron el retorno de la circulación espontánea, la supervivencia a las 24 horas y la condición neurológica en el largo plazo. MÉTODO: Estudio de cohorte longitudinal, descriptivo, prospectivo, en menores de 18 años que requirieron reanimación cardiopulmonar entre 2016 y 2019. Se analizaron las variables demográficas y las características del paro cardiorrespiratorio y de la reanimación, así como su resultado. Se realizaron análisis de una y múltiples variables para comparar a los pacientes sobrevivientes con los fallecidos. RESULTADOS: De los 1,842 pacientes internados, el 4.1% experimentó PCR. Se analizaron 50 pacientes con expedientes completos. Se logró el retorno de la circulación espontánea en el 78% (39), con una supervivencia alta del 46%. La reanimación > 6 min y el uso de fármacos vasoactivos fueron factores predictivos de mortalidad; se realizó el seguimiento de 16/23 pacientes, 10 de ellos con desarrollo normal para la edad luego de seis meses, seis tenían trastorno generalizado del desarrollo. CONCLUSIONES: El 4.1% de los pacientes presentó un PCR, con una tasa de 3.4 PCR por 1,000 días-paciente. La supervivencia al egreso hospitalario (n = 50) fue del 46%. La reanimación > 6 min y la utilización de fármacos vasoactivos fueron factores predictivos independientes de mortalidad. Luego de seis meses, el 63% tenía desarrollo neurológico normal para la edad.

[Skills in clinical communication: teaching-learning experience in a pediatric residence]. / Competencias en comunicación clínica: experiencia de enseñanza-aprendizaje en una residencia de pediatría.

Health communication is an essential medical activity for quality clinical practice. The ability to communicate properly is a professional competence that can and should be learned. The objective of this work is to describe the experiences of teaching, learning and evaluation of effective communication skills in pediatric residents and specifically, to report its design and curricular integration to the academic program, as well as the characteristics of its implementation. The program was structured in modules per year of residence, with sequential contents of increasing complexity; it was implemented through interactive meetings, reflection groups and high-fidelity simulation scenarios. The structured and objective clinical examination was used for performance evaluations through stations designed according to learning objectives with actors and a standardized scale. This implementation model could be replicated to other pediatric residencies through an Effective Communication Teaching Program.

La comunicación en salud es una actividad médica esencial para la práctica clínica y una competencia profesional que puede ser aprendida. El objetivo de este trabajo es describir las experiencias de enseñanza, aprendizaje y evaluación de las competencias en comunicación efectiva en residentes de pediatría, y en forma específica, reportar su diseño e integración curricular al programa académico, así como las características de su implementación. El programa se estructuró en módulos por año de residencia, con contenidos secuenciales de complejidad creciente, mediante encuentros interactivos, grupos de reflexión y escenarios de simulación de alta fidelidad. El examen clínico estructurado y objetivo fue utilizado para evaluar el desempeño en estaciones diseñadas según objetivos de aprendizaje, con la participación de actores y el uso de una escala estandarizada. Este modelo de implementación podría ser reproducido en otras residencias de pediatría mediante un programa de capacitación en comunicación efectiva.

Epidemiología y resultados del paro cardiorrespiratorio pediátrico en la unidad de recuperación cardiovascular de un hospital público en Argentina / Epidemiology and outcomes of pediatric cardiac arrest in a cardiovascular unit at a public hospital in Argentina

Resumen Antecedentes: Los niños con cardiopatías congénitas experimentan paro cardiorrespiratorio (PCR) con mayor frecuencia que la población pediátrica general. Se desconoce la epidemiología exacta del PCR en nuestro medio, al igual que el riesgo de mortalidad y los factores que influyen en la evolución neurológica. Objetivo: Describir la epidemiología y los resultados asociados con la reanimación cardiopulmonar pediátrica en una unidad de recuperación cardiovascular. El criterio de valoración primario fue la supervivencia al momento del alta hospitalaria; los secundarios fueron el retorno de la circulación espontánea, la supervivencia a las 24 horas y la condición neurológica en el largo plazo. Método: Estudio de cohorte longitudinal, descriptivo, prospectivo, en menores de 18 años que requirieron reanimación cardiopulmonar entre 2016 y 2019. Se analizaron las variables demográficas y las características del paro cardiorrespiratorio y de la reanimación, así como su resultado. Se realizaron análisis de una y múltiples variables para comparar a los pacientes sobrevivientes con los fallecidos. Resultados: De los 1,842 pacientes internados, el 4.1% experimentó PCR. Se analizaron 50 pacientes con expedientes completos. Se logró el retorno de la circulación espontánea en el 78% (39), con una supervivencia alta del 46%. La reanimación > 6 min y el uso de fármacos vasoactivos fueron factores predictivos de mortalidad; se realizó el seguimiento de 16/23 pacientes, 10 de ellos con desarrollo normal para la edad luego de seis meses, seis tenían trastorno generalizado del desarrollo. Conclusiones: El 4.1% de los pacientes presentó un PCR, con una tasa de 3.4 PCR por 1,000 días-paciente. La supervivencia al egreso hospitalario (n = 50) fue del 46%. La reanimación > 6 min y la utilización de fármacos vasoactivos fueron factores predictivos independientes de mortalidad. Luego de seis meses, el 63% tenía desarrollo neurológico normal para la edad.

Abstract Background: Children with congenital heart disease present a higher frequency of cardiorespiratory arrest (CRA) than the general pediatric population. The epidemiology of CRA is not exactly known in our setting, nor are the mortality risk or the neurological evolution factors. Objective: To describe the epidemiology and outcomes associated with pediatric cardiopulmonary resuscitation in a cardiovascular recovery unit. The primary endpoint was the survival to discharge and the secondary endpoints were the return to spontaneous circulation, the survival at 24 hours and the remote neurological condition. Methods: Descriptive, prospective, longitudinal cohort study in children under 18 years of age who required cardiopulmonary resuscitation between 2016 and 2019. Demographic variables, characteristics of cardiopulmonary arrest, resuscitation and outcome were analyzed. An uni- and multivariate analysis was performed comparing survivors and deceased. Results: Out of 1,842 hospitalized patients, 4.1% presented CRA. Fifty patients with complete records were analyzed. Seventy-eight percent (39) returned to spontaneous circulation with a high survival rate of 46%. Resuscitation > 6 min and the use of vasoactive drugs were predictors of mortality; 16/23 patients were followed up, 10 of them with normal development for age at 6 months, six had pervasive developmental disorder. Conclusions: 4.1% of patients presented CRA, with a rate of 3.4 CRA per 1,000 patient-days. Survival at hospital discharge (n = 50) was 46%. Resuscitation > 6 min and the use of vasoactive drugs were independent predictors of mortality. At six months, 63% had normal neurological development for age.

Impact of a program aimed at reducing catheter-related infections implemented in nine pediatric intensive care units in Argentina. / Impacto de un programa de reducción de infección asociada a catéter en 9 unidades de cuidado intensivo pediátrico en Argentina.

INTRODUCTION: Catheter-related infections (CRIs) cause a high level of morbidity and mortality with the increasing use of hospital resources. OBJECTIVE: To describe the outcomes of a program implemented to reduce the rate of CRIs in pediatric intensive care units in Argentina. POPULATION AND METHODS: Collaborative, multi center, clinical-epidemiological, quasiexperimental, before-and-after intervention study. Children who had a central venous catheter during hospitalization in 9 pediatric intensive care units in the Autonomous City of Buenos Aires, Greater Buenos Aires, and other provinces between June 2011 and April 2012 were included. A bundle of measures based on health care staff training on catheter insertion, hand hygiene, and checklists was put into practice and implemented measures were monitored. The number and annual rate of CRIs and the rate of central venous catheter use before and after the program implementation were compared (Stata 8.0). RESULTS: The total number of CRIs was 117 and 74 before and after the intervention, respectively. The rate of CRIs was 8.6/1000 days of central venous catheter use and 5.8/1000 days before and after the intervention, respectively; RR: 0.82 (95% confidence interval: 0.68-0.98), p= 0.015. The rate of central venous catheter use decreased from 54% to 49%, a non-significant difference. CONCLUSIONS: The program achieved a significant reduction in CRI rates. Based on the program, CRI surveillance was implemented in all participating pediatric intensive care units. Training and continuous surveillance are necessary to maintain and improve the outcomes accomplished with the program.

INTRODUCCIÓN: Las infecciones asociadas a catéteres (IAC) conllevan elevada morbimortalidad, con el aumento del uso de recursos hospitalarios. OBJETIVO: Describir los resultados de un programa para disminuir la tasa de IAC en las unidades de cuidados intensivos pediátricos de Argentina. POBLACIÓN Y MÉTODOS: Estudio colaborativo multicéntrico, clínico-epidemiológico, cuasi experimental, de intervención antes y después. Se incluyen niños con catéter venoso central internados en 9 unidades de cuidados intensivos pediátricos de la Ciudad Autónoma de Buenos Aires, conurbano y otras provincias desde junio de 2011 a abril de 2012. Se implementó un paquete de medidas basado en la educación del personal de salud para inserción de catéteres e higiene de manos y uso de listas de verificación con monitoreo de las medidas implementadas. Se compararon el número y la tasa anual de IAC y la tasa de uso de catéter venoso central previa y posterior a la implementación del programa (Stata 8.0). RESULTADOS: El total de IAC preintervención fue de 117 vs. 74 en el pos. La tasa previa fue 8,6/1000 días de uso y la posintervención, de 5,8/1000 días, RR 0,82 (IC 95%: 0,68-0,98), p= 0,015. La tasa de uso de catéter venoso central se redujo de 54% a 49%, diferencia no significativa. CONCLUSIONES: El programa logró un descenso significativo de las tasas de IAC. A partir de él, se implementó la vigilancia de las IAC en todas las unidades de cuidados intensivos pediátricos participantes. La educación y la vigilancia continua son necesarias para mantener y mejorar los resultados alcanzados.

In-hospital capacity-building in research and management for pediatric professionals. / Capacitación hospitalaria de profesionales pediátricos en investigación y gestión.

We describe an educational strategy aimed at capacity-building of hospital health care professionals in research and management initiated at a pediatric hospital in 2006, and the results obtained eight years after its implementation. Research and Management in Pediatrics (GIP) is an annual 250-hour course combining meetings and off-site assignments delivered through the Hospital's on-line campus. It provides students with practical tools for research (epidemiology, methodology, bibliographic search, evidencebased medicine, biostatistics) and management (strategic planning, management programs, health services research, quality improvement, health economics). Assessment methods included integrative exercises, a final evaluation, and a group research or management project. Results obtained over the 2006-2013 period were highly satisfactory. An intensive training program on research and management is a useful strategy for in-hospital capacity-building of pediatric health care professionals in basic tools for research activities, critical reading of biomedical literature and rational management of pediatric health services.

Se describe una estrategia de capacitación en investigación y gestión para profesionales hospitalarios iniciada en 2006 en un hospital pediátrico y sus resultados a ocho años de su implementación. Gestión e Investigación en Pediatría es un curso anual de 250 horas, teórico-práctico, semipresencial con soporte en campus virtual. Proporciona herramientas de investigación (epidemiología, metodología, búsqueda bibliográfica, medicina basada en evidencias, bioestadística) y gestión (planificación estratégica, programas de gestión, investigación en servicios de salud, calidad, economía de la salud). Se evalúa mediante ejercicios de integración, un examen final y un proyecto grupal de investigación o gestión. Los resultados obtenidos entre 2006 y 2013 fueron altamente satisfactorios. La implementación en el ámbito hospitalario de un programa de capacitación intensivo en gestión e investigación para profesionales de la salud es una estrategia útil para facilitar la incorporación y aplicación de herramientas prácticas para investigación, interpretación crítica de la bibliografía biomédica y gestión racional de servicios pediátricos

Competencias en comunicación clínica: experiencia de enseñanza-aprendizaje en una residencia de pediatría / Skills in clinical communication: teaching-learning experience in a pediatric residence

La comunicación en salud es una actividad médica esencial para la práctica clínica y una competencia profesional que puede ser aprendida. El objetivo de este trabajo es describir las experiencias de enseñanza, aprendizaje y evaluación de las competencias en comunicación efectiva en residentes de pediatría, y en forma específica, reportar su diseño e integración curricular al programa académico, así como las características de su implementación. El programa se estructuró en módulos por año de residencia, con contenidos secuenciales de complejidad creciente, mediante encuentros interactivos, grupos de reflexión y escenarios de simulación de alta fidelidad. El examen clínico estructurado y objetivo fue utilizado para evaluar el desempeño en estaciones diseñadas según objetivos de aprendizaje, con la participación de actores y el uso de una escala estandarizada. Este modelo de implementación podría ser reproducido en otras residencias de pediatría mediante un programa de capacitación en comunicación efectiva

Health communication is an essential medical activity for quality clinical practice. The ability to communicate properly is a professional competence that can and should be learned. The objectiveofthisworkistodescribetheexperiences of teaching, learning and evaluation of effective communication skills in pediatric residents and specifically, to report its design and curricular integration to the academic program, as well as the characteristics of its implementation. The program was structured in modules per year of residence, with sequential contents of increasing complexity; it was implemented through interactive meetings, reflection groups and high-fidelity simulation scenarios. The structured and objective clinical examination was used for performance evaluations through stations designed according to learning objectives with actors and a standardized scale. This implementation model could be replicated to other pediatric residencies through an Effective Communication Teaching Program

[Lumbar puncture training using simulation-based educational strategies: Experience in a clinical pediatric residency]. / Entrenamiento en punción lumbar utilizando estrategias educativas de simulación: Experiencia en una residencia de clínica pediátrica.

Pediatricians should acquire multiple skills during their professional training, including procedural skills. Skill acquisition requires knowledge on theoretical bases, direct observation and, lastly, supervised repetitive practice. Training using simulators allows to learn procedures in a controlled setting, ensuring patients' safety, integrating this as a learning stage prior to the actual contact with patients. Here we report on the teaching experience of a simulated lumbar puncture procedure. Training was provided to 112 first year pediatric residents who entered Hospital Prof. Dr. Juan P. Garrahan in the 2013-2014 period. Educational contents included communication with parents regarding the procedure, material preparation, compliance with biosafety standards, sepsis and general patient care, puncture and subsequent cerebrospinal fluid collection, and specimen collection. Strategies included, in a sequential order, the introduction of theoretical aspects using the bibliography and audiovisual resources available at the hospital's online campus and subsequent practice of lumbar puncture in a 3-month-old infant phantom on a lateral recumbent position that allowed to make a puncture and collect cerebrospinal fluid. At each training session, the level of confidence was measured before and after the procedure, and a checklist was developed to verify an adequate compliance with each step of the procedure. The simulated lumbar puncture training model has been introduced as an educational strategy of our Pediatric Residency Program.

Las competencias que debe adquirir un pediatra durante su formación profesional son múltiples; entre ellas, las destrezas en la realización de procedimientos. El proceso para la adquisición de estas destrezas requiere del conocimiento de bases teóricas, de la observación directa y, finalmente, de la práctica repetitiva bajo supervisión. El entrenamiento en simuladores permite aprender procedimientos en un marco controlado que protege la seguridad de los pacientes y que se integra como una instancia de aprendizaje previa a la realidad con el paciente. Reportamos la experiencia en el proceso de enseñanza del procedimiento de punción lumbar mediante simulación. Participaron del entrenamiento 112 residentes de Pediatría, de 1er año, que ingresaron al Hospital Prof. Dr. Juan P. Garrahan durante el ciclo 2013 y 2014. Los contenidos educativos abarcaron la comunicación a los padres sobre el procedimiento, la preparación del material, el cumplimiento de las normas de bioseguridad, asepsia y cuidados generales del paciente, la punción con obtención del líquido cefalorraquídeo y la recolección del material. La estrategia incluyó, en forma secuencial, la incorporación de aspectos teóricos mediante recursos bibliográficos y audiovisuales accesibles en el campus virtual del Hospital y la posterior práctica de la punción en un maniquí correspondiente a un lactante de 3 meses en posición acostado, que permitió la punción y obtención de líquido cefalorraquídeo. En cada entrenamiento se midió el nivel de confianza antes y después, y se elaboró una lista de cotejo para verificar el cumplimiento adecuado de cada paso del procedimiento. El módulo de entrenamiento en punción lumbar con simulación ha sido incorporado como estrategia educativa de nuestro Programa de Residencia en Pediatría

Characteristics of pediatric intensive care residency programs in Argentina: A national survey.

INTRODUCTION: Pediatric intensive care residency programs have been in place in Argentina for just a few years. Knowing their status offers the possibility to establish strategies to help with professional development and training. OBJECTIVES: 1) To describe the characteristics of pediatric intensive care residency programs across Argentina. 2) To assess whether certain characteristics are related to a higher vacancy filling rate. 3) To assess job placement in the hospital where residents are trained. DESIGN: Descriptive, observational study. National survey. INCLUSION CRITERIA: Pediatric intensive care residency programs in place between April 1st, 2014 and May 31st, 2014. RESULTS: Thirty-one residency programs were analyzed. Only 11/31 had an annual hospitalization volume >400 patients. There were no guidelines and/or criteria for care in 9/31. The program suited the national reference framework in 17/31. There was no head of residents or resident trainer in 13/31. Only 5/31 had been certified by the Ministry of Health. There were 65 vacancies; this number increased in the past four years; vacancy filling rate decreased from 59% in 2009 to 30% in 2013. Sixty percent of residents got a job in the pediatric intensive care unit where they were trained. A multivariate logistic regression analysis identified the outcome measure annual hospitalization volume >400 patients as an independent predictor of vacancy filling rate >60%. CONCLUSIONS: 1) Vacancy filling is deficient. 2) The number of certified residency programs is scarce. 3) Pediatric intensive care units with a higher number of hospitalizations were associated with a higher vacancy filling rate. 4) More than half of residents got a job in the pediatric intensive care unit where they were trained.

Dying in the intensive care unit: collaborative multicenter study about forgoing life-sustaining treatment in Argentine pediatric intensive care units.

OBJECTIVE: Describe modes of death and factors involved in decision-making together with life support limitation (LSL) procedures. DESIGN: Prospective, descriptive, longitudinal, and noninterventional study. SETTING: Sixteen pediatric intensive care units in Argentina. PATIENTS: Every patient who died during a 1-yr period was included. MEASUREMENTS AND MAIN RESULTS: Age, sex, length of stay (LOS), primary and admission diagnosis, underlying chronic disease (CD), postoperative condition (PO). Deaths were classified in four groups: a) failed cardiopulmonary resuscitation (CPR); b) do-not-resuscitate (DNR) status; c) withholding or withdrawing life-sustaining treatment (WH/WD); and d) brain death (BD). Justifications were classified as a) imminent death; b) poor long-term prognosis; c) poor quality of life; and d) family request. Data were collected from medical records and interviews with the attending physicians. Descriptive statistics were performed. Differences among groups were analyzed through contingency tables and analysis of variance when required. Relative risks and confidence intervals of variables potentially related to LSL were analyzed, and logistic regression was performed. There were 6358 admissions and 457 deaths. CPR was performed in 52%, DNR in 16%, WH/WD in 20%, and BD in 11% of dead patients. BD patients were older, LOS and CD prevalence were higher in the WH/WD group. Inotropic drugs were the most frequently limited treatment in 110 patients (55%), CPR in 72 (35.6%), and mechanical ventilation in 63 (31%). Imminent death was the most frequently reported justification for LSL. CD and more staff were associated with a higher probability of LSL. CONCLUSIONS: Most of the patients in Argentina underwent CPR before their death. We have a high proportion of patients with CD (65%) and low BD diagnosis. PO condition decreased LSL probability in chronically ill patients. Do-not-resuscitate orders and withholding new treatments were the most common LSL. Active withdrawal was exceptional. The Ethics Committee was consulted in 5% of the LSL population.

Impacto de un programa de reducción de infección asociada a catéter en 9 unidades de cuidado intensivo pediátrico en Argentina / Impact of a program aimed at reducing catheter-related infections implemented in nine pediatric intensive care units in Argentina

Las infecciones asociadas a catéteres (IAC) conllevan elevada morbimortalidad, con el aumento del uso de recursos hospitalarios. Objetivo. Describir los resultados de un programa para disminuir la tasa de IAC en las unidades de cuidados intensivos pediátricos de Argentina. Población y métodos. Estudio colaborativo multicéntrico, clínico-epidemiológico, cuasi experimental, de intervención antes y después. Se incluyen niños con catéter venoso central internados en 9 unidades de cuidados intensivos pediátricos de la Ciudad Autónoma de Buenos Aires, conurbano y otras provincias desde junio de 2011 a abril de 2012. Se implementó un paquete de medidas basado en la educación del personal de salud para inserción de catéteres e higiene de manos y uso de listas de verificación con monitoreo de las medidas implementadas. Se compararon el número y la tasa anual de IAC y la tasa de uso de catéter venoso central previa y posterior a la implementación del programa (Stata 8.0). Resultados. El total de IAC preintervención fue de 117 vs. 74 en el pos. La tasa previa fue 8,6/1000 días de uso y la posintervención, de 5,8/1000 días, RR 0,82 (IC 95%: 0,68-0,98), p= 0,015. La tasa de uso de catéter venoso central se redujo de 54% a 49%, diferencia no significativa. Conclusiones. El programa logró un descenso significativo de las tasas de IAC. A partir de él, se implementó la vigilancia de las IAC en todas las unidades de cuidados intensivos pediátricos participantes. La educación y la vigilancia continua son necesarias para mantener y mejorar los resultados alcanzados.

Catheter-related infections (CRIs) cause a high level of morbidity and mortality with the increasing use of hospital resources. Objective. To describe the outcomes of a program implemented to reduce the rate of CRIs in pediatric intensive care units in Argentina. Population and methods. Collaborative, multi center, clinical-epidemiological, quasiexperimental, before-and-after intervention study. Children who had a central venous catheter during hospitalization in 9 pediatric intensive care units in the Autonomous City of Buenos Aires, Greater Buenos Aires, and other provinces between June 2011 and April 2012 were included. A bundle of measures based on health care staff training on catheter insertion, hand hygiene, and checklists was put into practice and implemented measures were monitored. The number and annual rate of CRIs and the rate of central venous catheter use before and after the program implementation were compared (Stata 8.0). Results. The total number of CRIs was 117 and 74 before and after the intervention, respectively. The rate of CRIs was 8.6/1000 days of central venous catheter use and 5.8/1000 days before and after the intervention, respectively; RR: 0.82 (95% confidence interval: 0.68-0.98), p= 0.015. The rate of central venous catheter use decreased from 54% to 49%, a non-significant difference. Conclusions. The program achieved a significant reduction in CRI rates. Based on the program, CRI surveillance was implemented in all participating pediatric intensive care units. Training and continuous surveillance are necessary to maintain and improve the outcomes accomplished with the program.

Capacitación hospitalaria de profesionales pediátricos en investigación y gestión / In-hospital capacity-building in research and management for pediatric professionals

Se describe una estrategia de capacitación en investigación y gestión para profesionales hospitalarios iniciada en 2006 en un hospital pediátrico y sus resultados a ocho años de su implementación. Gestión e Investigación en Pediatría es un curso anual de 250 horas, teórico-práctico, semipresencial con soporte en campus virtual. Proporciona herramientas de investigación (epidemiología, metodología, búsqueda bibliográfica, medicina basada en evidencias, bioestadistica) y gestión (planificación estratégica, programas de gestión, investigación en servicios de salud, calidad, economía de la salud). Se evalúa mediante ejercicios de integración, un examen final y un proyecto grupal de investigación o gestión. Los resultados obtenidos entre 2006 y 2013 fueron altamente satisfactorios. La implementación en el ámbito hospitalario de un programa de capacitación intensivo en gestión e investigación para profesionales de la salud es una estrategia útil para facilitar la incorporación y aplicación de herramientas prácticas para investigación, interpretación crítica de la bibliografía biomédica y gestión racional de servicios pediátricos.

We describe an educational strategy aimed at capacity-building of hospital health care professionals in research and management initiated at a pediatric hospital in 2006, and the results obtained eight years after its implementation. Research and Management in Pediatrics (GIP) is an annual 250-hour course combining meetings and off-site assignments delivered through the Hospital's on-line campus. It provides students with practical tools for research (epidemiology, methodology, bibliographic search, evidence-based medicine, biostatistics) and management (strategic planning, management programs, health services research, quality improvement, health economics). Assessment methods included integrative exercises, a final evaluation, and a group research or management project. Results obtained over the 2006-2013 period were highly satisfactory. An intensive training program on research and management is a useful strategy for in-hospital capacity-building of pediatric health care professionals in basic tools for research activities, critical reading of biomedical literature and rational management ofpediatric health services.

Professional burnout in pediatric intensive care units in Argentina.

INTRODUCTION: There is currently a deficiency of physicians in pediatric intensive care units (PICU). The cause of this deficit is multifactorial, although the burnout phenomenon has been described as relevant. OBJECTIVE: To analyze the situation of human resource in the pediatric intensive care units in Argentina and measure the level of burnout. METHODS: An observational cross-sectional study through surveys administered electronically; the Maslach Burnout Inventory was used. Physicians that work at public o private pediatric intensive care units in Argentina during at least 24 hours per week were invited to participate. RESULTS: A total of 162 surveys were completed (response rate 60%). We observed a high risk of burnout in emotional exhaustion in 40 therapists (25%), in fulfillment in 9 (6%), and depersonalization in 31 (19%). In combination, 66 professionals (41%) had a high risk of burnout to some extent; there were independent protective factors of this risk as to be certified in the specialty (ORA 0.38, 95% CI 0.19 to 0.75) and work in public sector PICU (ORA 0.31, 95% CI 0.15 to 0.65), while working more than 36 hours/week on duty increased the risk (ORA 1.94, 95% CI 1.1 to 3.85). Additionally, 31% said that they did not plan to continue working in intensive care, and 86% did not think to continue with on call duties in the following years. Over 60% of respondents reported that changes in professional practice (salary, staff positions, early retirement, fewer loads on call) could prolong the expectation of continuing activities in PICU. CONCLUSIONS: A significant percentage of doctors working in the PICU of Argentina have a high risk of burnout syndrome and a low expectation of continuing in the field.

Uso de descriptores durante la implementación de Mini-CEX en la residencia de pediatría / Using descriptors during the implementation of Mini-CEX at pediatric residency

El Mini Clinical Evaluation Exercise (Mini-CEX) es una herramienta formativa de evaluación aplicada durante la observación directa del desempeño en la clínica. Nuestro objetivo fue evaluar la confiabilidad y factibilidad del Mini-CEX utilizando descriptores pediátricos en dos programas de residencia de pediatría. El diseño fue de tipo observacional y corte transversal. Se consensuaron descriptores de la consulta pediátrica para cada una de las dimensiones del Mini-CEX. Los operadores fueron capacitados en el uso de esta herramienta por medio de descriptores, así como en las estrategias informativas. Finalmente, se realizaron 2 evaluaciones independientes y simultáneas por cada observación de desempeño. Análisis: a) Puntaje global y por dimensión del Mini-CEX, b) Concordancia de puntajes entre operadores (promedios de diferencias e IC95%); c) Frecuencias de descriptores no evaluables y d) Duración y satisfacción en su uso. Se realizaron 80 observaciones en 40 consultas pediátricas. Puntaje global 7.5 ± 0.9 (6.4 ± 2 a 8.3 ± 1.1 según dimensión), sin diferencias significativas entre instituciones. Se observó alta concordancia entre observadores (Media, diferencia 0.1 a 0.3; IC 95% -0.8 a 0.3). La frecuencia de descriptores no evaluables fue 5 a 28 (9% a 51%) y no se asoció con el lugar de aplicación. El tiempo promedio de implementación fue 20 minutos. El uso resultó altamente satisfactorio para docentes y residentes. Se implementó el Mini-CEX luego de consensuar descriptores de la consulta pediátrica. La experiencia conjunta fue satisfactoria y a la vez confirmó el valor de la evaluación y entrega de sus resultados: la devolución formativa.

The Mini Clinical Evaluation Exercise (Mini-CEX) is an assessment tool, which emphasizes the educational value and is based on direct performance observation. The objective was to evaluate the reliability and feasibility of Mini-CEX using pediatric descriptors during its implementation in two pediatric residency programs. The design was observational, exploratory and feasibility in the use of this evaluation tool. Based on the original format, descriptors related to the pediatric consult for each Mini-CEX dimension´s were agreed. Operators were trained in the use of this tool by means of descriptors as well as in debriefing strategies. Finally, there were two simultaneous and independent evaluations for each observation. Analysis: a) Mini-CEX global and dimension score; b) Concordance between operators scores (mean differences and 95% CI); c) Non evaluable descriptors frequency; d) Duration and satisfaction in use. There were 80 observations in 40 pediatric consults. Overall score 7.5 ± 0.9 (6.4 ± 2 to 8.3 ± 1.1 depending on dimension), with no significant differences between the two institutions. There was high agreement between observers (Mean, difference between 0.1 and 0.3, 95% CI -0.8 to 0.3). The frequency of non evaluable descriptors ranged 5-28 (9% to 51%) and it was not associated with the implementation stage. The average implementation time was 20 minutes, and satisfaction in use was high among both operators and residents. Mini-CEX tool using pediatric descriptors showed high reliability. The joint experience was satisfactory and simultaneously confirmed the value of debriefing.

[Prevention of catheter-related infection: usefulness and cost-effectiveness of antiseptic catheters in children]. / Prevención de la infección asociada a catéteres: utilidad y costo-eficacia de los catéteres con antisépticos en pediatría.

OBJECTIVE: To evaluate the cost-effectiveness of the antiseptic-impregnated catheter compared with conventional catheters in preventing catheter- related blood stream infections (CR-BSI). DESIGN: Cost-effectiveness analysis; clinical trial, experimental, randomized, controlled, prospective, open label. Patients and methods. A 172 patient cohort, under 1-year-old or less than 10 kg, postoperative cardiovascular children with central venous catheters (CVC) admitted to Cardiac Intensive Care Unit (UCI 35) at Hospital Nacional de Pediatría "Prof. Dr. Juan P. Garrahan", since September 2005 to December 2007. Demographic and CVC data were retrieved to compare: age, gender, weight, diagnosis, surgery, CVC days, costs and complications. Intervention. CVC Arrow, double-lumen, > 48 h of duration; intervention group: antiseptic-impregnated CVC vs. control group: CVC without antiseptics (conventional). RESULTS: The incidence of CR-IE (CR-Infected Events: colonization, local infection and/or CRBSI; combined end point) was 27% for antiseptic- impregnated CVC vs. 31% for conventional catheters (p= 0.6) with similar accumulated incidence of CR- BSI: 2.8 vs. 3.3 per 1000 dayscatheter. We found no differences between groups, except in weight: median 4.0 kg (r 2-17) vs. 4.7 kg (r 2-9) p= 0.0002 and age, median 2 months (r 1- 48) vs. 5 months (r 1- 24) p= 0.0019 in antiseptic-impregnated CVC group. These differences, though statistically significant were clinically non relevant. Median cost per patient during intensive care stay in the conventional CVC group was $3.417 (359-9.453) and in the antiseptic-impregnated-CVC group was $4.962 (239-24.532), p= 0.10. CONCLUSIONS: The use of antiseptic-impregnated CVC compared with conventional CVC did not decrease CR-BSI in this population. The cost per patients was higher in the antiseptic impregnated CVC group. These results do not support the routine use of this type of CVC in our population.

[Cardiopulmonary resuscitation in nine pediatric intensive care units of the Argentine Republic]. / Estudio colaborativo multicéntrico sobre reanimación cardiopulmonar en nueve unidades de cuidados intensivos pediátricos de la República Argentina: A multicentric study.

INTRODUCTION: The cardiopulmonary resuscitation (CPR) is a common setting in the pediatric intensive care unit (PICU). There are very few reports or publications that evaluate the form of CPR administered in children. OBJECTIVES: 1) Identify the etiology and epidemiology of the CPR in the PICU. 2) Describe how to conduct CPR. 3) Describe the drugs used. 4) Knowing the patient outcomes. 5) Knowing CPR training of physicians in the PICU. PATIENTS AND METHODS: All children with cardiopulmonary arrest who were resuscitated in the PICU between 01/04/2004- 31/03/2005. A prospective cohort study. RESULTS: There were 2065 admissions in nine 9 PICU and CPR was conducted in 132 patients (6.39%). Most common etiologies of PCR were hypoxia and hypotension (65.9% of total). The initial rates of PCR were 43.94% bradycardia, asystolia 43.18%, 9.85% ventricular arrhythmias. The average beginning of time of CPR was 0.08 minutes (SD 0.25) and the average total duration was 25.91 minutes (SD 18.56). Patients who require drugs were 131. The number (mean) dose of adrenaline was 4.03 (SD 2.78). Increased number of doses of adrenaline was associated with less chance of recovery of spontaneous circulation (ROSC), OR 0.48 95% CI 0.37-0.63. (p= 0.000). The duration of CPR was inversely associated and significantly related to achieve ROSC, OR 0.93 95% CI 0.87-0.99. One hundred and four (78.79%) patients died and 28 survived. All survived were discharged from PICU, but 26 from hospital. In 22 patients there were not evidence of severe neurological damage when discharged home. CONCLUSIONS: Most common etiologies of PCR were hypoxia and shock. Most children received drugs. The drugs most used were the association adrenaline-bicarbonate and adrenaline alone. The chances of recovery were not favorable when CPR was conducted for over sixty minutes or more than six doses of adrenaline were given, without response. CPR in PICU children has a high mortality. Most patients discharged from hospital, had neurological normal state or slight disability. PICU physicians were highly trained in CPR with resuscitation courses.

Características de las residencias de terapia intensiva pediátrica de la República Argentina: Encuesta nacional / Characteristics of pediatric intensive care residency programs in Argentina: A national survey

Introducción. La residencia de terapia intensiva pediátrica (TIP) tiene pocos años de desarrollo en nuestro país. Conocer su situación brinda la posibilidad de establecer estrategias para contribuir al desarrollo y capacitación de profesionales. Objetivos. 1) Describir las características de las residencias de TIP del país. 2) Evaluar si existen características que se relacionen con una mayor ocupación de las vacantes. 3) Explorar la inserción laboral en el hospital formador de los residentes. Diseño. Descriptivo, observacional. Encuesta nacional. Criterios de inclusión. Residencias de TIP funcionales entre el 1/4/2014 y el 31/5/2014. Resultados. Se analizaron 31 residencias. Solo 11/31 tenían volumen de internación anual >400 pacientes. No había normas y/o criterios de atención en 9/31. En 17/31, el programa estuvo adecuado al marco de referencia nacional. Hubo 13/31 que no contaban con jefe ni instructor de residentes. Fueron acreditadas por el Ministerio de Salud 5/31. Hubo 65 vacantes; el número aumentó en los últimos 4 años; la ocupación disminuyó de 59% en 2009 a 30% en 2013. El 60% de los residentes tuvo inserción laboral en la TIP formadora. El análisis de regresión logística multivariado identificó la variable ingresos anuales > 400 pacientes como predictora independiente de ocupación de vacantes > 60%. Conclusiones. 1) Hay un déficit en la ocupación de cargos. 2) El número de residencias acreditadas es escaso. 3) Las unidades de cuidados intensivos pediátricos con mayor número de ingresos se asociaron a una mayor cobertura de vacantes. 4) Más de la mitad de los residentes se insertaron laboralmente en la TIP formadora.

Introduction. Pediatric intensive care residency programs have been in place in Argentina for just a few years. Knowing their status offers the possibility to establish strategies to help with professional development and training. Objectives. 1) To describe the characteristics of pediatric intensive care residency programs across Argentina. 2) To assess whether certain characteristics are related to a higher vacancy filling rate. 3) To assess job placement in the hospital where residents are trained. Design. Descriptive, observational study. National survey. Inclusion criteria. Pediatric intensive care residency programs in place between April 1st, 2014 and May 31st, 2014. Results. Thirty-one residency programs were analyzed. Only 11/31 had an annual hospitalization volume >400patients. There were no guidelines and/or criteria for care in 9/31. The program suited the national reference frameworkin17/31. There was no head ofresidents or resident trainer in 13/31. Only 5/31 had been certified by the Ministry of Health. There were 65 vacancies; this number increased in the past four years; vacancy filling rate decreased from 59% in 2009 to 30% in 2013. Sixty percent of residents got a job in the pediatric intensive care unit where they were trained. A multivariate logistic regression analysis identified the outcome measure annual hospitalization volume >400 patients as an independent predictor of vacancy filling rate >60%. Conclusions. 1) Vacancy filling is deficient. 2) The number of certified residency programs is scarce. 3) Pediatric intensive care units with a higher number of hospitalizations were associated with a higher vacancy filling rate. 4) More than half of residents got a job in the pediatric intensive care unit where they were trained.

[Levosimendan, a new inotropic drug: experience in children with acute heart failure]. / Levosimendán, un nuevo agente inotrópico: experiencia en niños con fallo cardíaco agudo.

INTRODUCTION: Low cardiac output syndrome occurs frequently in pediatric patients after cardiac surgery. Catecholamines are used as inotropic drugs to treat this threatening condition, but may cause undesirable and potentially harmful side effects. This study was performed to evaluate the efficacy and safety of levosimendan (LEVO) in pediatric patients with low cardiac output syndrome. PATIENTS AND METHODS: Open prospective, quasi-experimental cohort. LEVO was given as compassionate treatment in patients with refractory post-surgical low cardiac output syndrome. Every patient received an IV infusion of LEVO at 6 microg/kg during a fifteen minutes period, followed by a 24 h IV infusion at 0.1 microg/kg/min. Clinical improvement of cardiac output was the primary end point of the study. Two independent observers performed clinical evaluation, bidimensional echocardiogram, hemodynamic and laboratory tests were performed pre and after LEVO infusion. RESULTS: LEVO was infused in 18 opportunities (fourteen children). The response was considered successful in 9/18 interventions (50%; p= 0.004). Both inotropic score (12.1 vs. 6,1, p= 0.01) and A-VDO(2)2 (26.78 +/- 11.5% vs. 20.81 +/- 7.72%, p= 0.029) showed reduction, while SvO2 improved (69.5 +/- 11.4% vs. 76 +/- 9.29%, p= 0.03). No adverse effects were noticed. Four patients died, none of them related to LEVO administration. CONCLUSIONS: LEVO improved cardiac output in 50% of the interventions with post-surgical LCOS and no adverse effect was observed.

[Cardiac surgical repair in newborns: five years' experience in neonatal open surgery]. / Cirugía cardíaca reparadora en recién nacidos: experiencia de 5 años en cirugía neonatal con circulación extracorpórea.

INTRODUCTION: Four hundred newborns die every year in our country suffering from congenital heart disease. Definitive surgical repair, whenever possible, is nowadays the optimal therapeutic strategy. Our goal is to describe mortality and morbidity in neonatal surgery with cardiopulmonary bypass in a tertiary public hospital in Argentina. PATIENTS AND METHODS: Descriptive, retrospective study. Every patient, younger than 45 days, with cardiac surgery requiring cardiopulmonary bypass, at the Garrahan Hospital between 2004 and 2008 was included. Demographic, surgical and postoperative data were collected. Adjusted mortality risk analysis, and descriptive statistics from the most frequent diagnosis were performed. Results are expressed as median and rank or percentage. RESULTS: 200 newborns were operated, 62% males. Median age was 21 days (r 1- 45) and median weight 3.1 kg (r 1.6-6.2). Total anomalous pulmonary venous return, transposition of great arteries an hypoplastic left heart syndrome diagnoses accounted for 75% of the procedures. Median length of stay was 12 days (r 0-191), and 6 days of mechanical ventilation (r 0-180). Eighteen percent of the patients required peritoneal dialysis. Whole series mortality was 19% and fell to 14% in 2008. Unstable preoperative condition and postoperative complications increased mortality, OR= 2.23 (1.02-4.89) and OR= 10 (3.6-33.4), respectively. CONCLUSIONS: Our postoperative mortality is similar to those reported in foreign countries databases. Patients with unstable preoperative condition and post-operative complications had higher mortality.

Síndrome de desgaste profesional (burnout) en médicos de unidades de cuidados intensivos pediátricos en la Argentina / Physician's burnout in pediatric intensive care units from Argentina

Introducción. En la actualidad hay escasez de médicos en unidades de cuidados intensivos pediátricos (UCIP). La causa de este déficit es multifactorial, pero el "fenómeno de burnout" o agotamiento profesional se ha descripto como relevante. Objetivo. Analizar la situación del recurso humano en las UCIP de Argentina y medir el grado de agotamiento profesional. Métodos. Estudio observacional de corte transversal, mediante la administración de encuestas por vía electrónica; se usó el cuestionario Maslach Burnout Inventory. Se invitó a participar a médicos terapistas pediátricos que se desempeñaran en el sector público o privado de la Argentina durante al menos 24 h por semana. Resultados. Fueron completadas 162 encuestas (tasa de respuesta 60%). Presentaron alto riesgo de burnout en agotamiento emocional 40 terapistas (25%), en realización personal 9 (6%) y en despersonalización 31 (19%). En forma combinada, 66 profesionales (41%) tuvieron riesgo alto de burnout en alguna de las dimensiones; resultaron factores protectores e independientes de este riesgo estar certificado en la especialidad (ORA 0,38 IC 95% 0,19-0,75) y trabajar en UCIP del sector público (ORA 0,31 IC 95% 0,15-0,65), mientras que hacer más de 36 h/semana de guardia aumentó el riesgo (ORA 1,94 IC95% 1,1-3,85). El 31 % afirmó que no planeaba continuar con actividad en cuidados intensivos y 86% no pensaban continuar con guardias en los siguientes años. La mayoría de los encuestados comunicó que modificaciones en la práctica profesional (remuneración, cargos de planta, jubilación temprana, menor carga de guardia), podrían prolongar la expectativa de continuar con actividades en UCIP. Conclusiones. Un porcentaje significativo de médicos que trabajan en las UCIP de la Argentina tienen alto riesgo de burnout y baja expectativa de continuar en la especialidad.

Introduction: there is currently a deficiency of physicians in pediatric intensive care units (PICU). The cause of this deficit is multifactorial, although the burnout phenomenon has been described as relevant. Objective: to analyze the situation of human resource in the pediatric intensive care units in Argentina and measure the level of burnout. Methods: an observational cross-sectional study through surveys administered electronically; the Maslach Burnout Inventory was used. Physicians that work at public o private pediatric intensive care units in Argentina during at least 24 hours per week were invited to participate. Results: a total of 162 surveys were completed (response rate 60%). We observed a high risk of burnout in emotional exhaustion in 40 therapists (25%), in fulfillment in 9 (6%), and depersonalization in 31 (19%). In combination, 66 professionals (41%) had a high risk of burnout to some extent; there were independent protective factors of this risk as to be certified in the specialty (ORA 0.38, 95% CI 0.19 to 0.75) and work in public sector PICU (ORA 0.31, 95% CI 0.15 to 0.65), while working more than 36 hours/week on duty increased the risk (ORA 1.94, 95% CI 1.1 to 3.85). Additionally, 31% said that they did not plan to continue working in intensive care, and 86% did not think to continue with on call duties in the following years. Over 60% of respondents reported that changes in professional practice (salary, staff positions, early retirement, fewer loads on call) could prolong the expectation of continuing activities in PICU. Conclusions: a significant percentage of doctors working in the PICU of Argentina have a high risk of burnout syndrome and a low expectation of continuing in the field.