Growth and Changing Characteristics of Pediatric Intensive Care 2001-2016

A Snapshot of Chronic Critical Illness in Pediatric Intensive Care Units

Children with chronic critical illness (CCI) represent the sickest subgroup of children with medical complexity. In this article, we applied a proposed definition of pediatric CCI to assess point prevalence in medical, cardiovascular, and combined pediatric intensive care units (PICUs), screening all patients admitted to six academic medical centers in the United States on May 17, 2017, for pediatric CCI (PCCI) eligibility. We gathered descriptive data to understand medical complexity and resource needs of children with PCCI in PICUs including data regarding hospitalization characteristics, previous admissions, medical technology, and chronic multiorgan dysfunction. Descriptive statistics were used to characterize the study population and hospital data. The study cohort was divided between PICU-prolonged (stay > 14 days) and PICU-exposed (any time in PICU); comparative analyses were conducted. On the study day, 185 children met inclusion criteria, 66 (36%) PICU-prolonged and 119 (64%) PICU-exposed. Nearly all had home medical technology and most ( n  = 152; 82%) required mechanical ventilation in the PICU. The PICU-exposed cohort mirrored the PICU-prolonged with a few exceptions as follows: they were older, had fewer procedures and surgeries, and had more recurrent hospitalizations. Most ( n  = 44; 66%) of the PICU-prolonged cohort had never been discharged home. Children with PCCI were a sizable proportion of the unit census on the study day. We found that children with PCCI are a prevalent population in PICUs. Dividing the cohorts between PICU-prolonged and PICU-exposed helps to better understand the care needs of the PCCI population. Identifying and studying PCCI, including variables relevant to PICU-prolonged and PICU-exposed, could inform changes to PICU care models and training programs to better enable PICUs to meet their unique needs.

Child Health Needs and the Pediatric Critical Care Medicine Workforce: 2020-2040

This article, focused on the current and future pediatric critical care medicine (PCCM) workforce, is part of a supplement in Pediatrics anticipating the future supply of the pediatric subspecialty workforce. It draws on information available in the literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the American Board of Pediatrics Foundation in collaboration with the Carolina Workforce Research Center at the University of North Carolina at Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling and Analysis Ltd. A brief history of the field of PCCM is provided, followed by an in-depth examination of the current PCCM workforce and a subsequent evaluation of workforce forecasts from 2020 to 2040. Under baseline conditions, the PCCM workforce is expected to increase by 105% during the forecasted period, more than any other pediatric subspecialty. Forecasts are modeled under a variety of multifactorial conditions meant to simulate the effects of changes to the supply of PCCM subspecialists, with only modest changes observed. Future PCCM workforce demand is unclear, although some suggest an oversupply may exist and that market forces may correct this. The findings generate important questions regarding the future state of the PCCM workforce and should be used to guide trainees considering a PCCM career, subspecialty leaders responsible for hosting training programs, staffing ICUs, and governing bodies that oversee training program accreditation and subspecialist certification.

A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative

OBJECTIVES

To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs.

DESIGN

Cross-sectional survey conducted May 2021-January 2022.

SETTING

Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative.

SUBJECTS

Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%).

CONCLUSIONS

Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.

Time-motion observations to characterize the developmental environment in a paediatric post-acute care hospital

BACKGROUND

Chronically hospitalized children are at risk for neurodevelopmental delay, compounded by restricted social interactions, movement and environmental stimulation. We measured patients' movements and interactions to characterize developmentally relevant aspects of our inpatient environment and identify opportunities for developmental enrichment.

METHODS

As part of a quality improvement initiative to inform neurodevelopmental programming for children with medical complexity at our paediatric post-acute care specialty hospital, we conducted >232 hours of time-motion observations. Trained observers followed 0- to 5-year-old inpatients from 7 am to 7 pm on weekdays, categorizing observations within five domains: Where, With, Position, State and Environment. Observations were collected continuously utilizing REDCap on iPads. A change in any domain initiated a new observation.

RESULTS

Patients were median 1 year and 8 months of age (range 2 months to 3 years 9 months) with a median length of hospitalization of 514 days (range 66-1298). In total, 2636 unique observations (or median 134 observations per patient-day [range 95-210]) were collected. Patients left their rooms up to 4 times per day for median 1 h and 34 min (range 41 min to 4 h:30 min). Patients spent 4 h:6 min (2 h:57 min to 6 h:30 min) interacting with someone and 3 h:51 min (57 min to 6 h:36 min) out of bed each day. Patients were simultaneously out of their beds, interacting with someone and awake for 2 h:21 min (51 min to 4 h:19 min) each day.

CONCLUSIONS

Despite a care model prioritizing time out of bed and social interaction, time-motion observations indicate patients spent many of their waking hours in bed and alone. Quantifying our inpatients developmental opportunities will inform neurodevelopmental programming initiatives.

Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan

OBJECTIVES

To evaluate nationwide pediatric critical care facilities and resources in Pakistan.

DESIGN

Cross-sectional observational study.

SETTING

Accredited pediatric training facilities in Pakistan.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring.

CONCLUSIONS

There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

[Pediatric emergency patients in the emergency departments of a German metropolitan region : A retrospective cross-sectional study over a one-year period]

BACKGROUND

To date, no detailed analysis of pediatric emergencies treated in emergency departments (ED) exists. However, in the context of capacity planning and upcoming emergency care reform in Germany, these data are urgently needed.

METHODS

Retrospective, multicenter cross-sectional study for the period 01 July 2013 to 01 June 2014 of pediatric cases in emergency departments in Munich.

RESULTS

A total of 103,830 cases were analyzed (age: 6.9 ± 5.4 years, boys/girls 55%/45%). A total of 85.9% of cases were treated as outpatients, 12.4% (9.6 per 100,000 children) were admitted to normal and 1.7% (1.0 per 100,000 children) to intensive care. However, the real bed requirements exceeded these guideline numbers, with an absolute requirement of 4.9 ICU beds and 35.1 normal ward beds per day. Load peaks were seen on Wednesday and Friday afternoons and on weekends. Every 8th patient who presented to an ED as a self-referral was treated as an inpatient.

CONCLUSION

Capacity planning for inpatient emergency care of pediatric patients requires planning for more beds than can be expected on a population basis. The availability of panel physician care influences patient volume in the EDs. Initial medical assessment tools for treatment need and urgency are needed to distribute patients. The pediatric emergency centers planned as part of the current reform of emergency care must be adequately staffed and financed in order to be able to handle-in close cooperation with statutory health insurance-accredited medical care-the expected demand for care.

Using Two Statewide Medical Operations Coordination Centers to Load Balance in Pediatric Hospitals During a Severe Respiratory Surge in the United States

OBJECTIVES

Report on the use of two statewide Medical Operations Coordination Centers (MOCCs) to manage a rapid surge in pediatric acute and critical care patient needs.

DESIGN

Brief report.

SETTING

The states of Washington and Oregon during the pediatric respiratory surge in November 2022/December 2022 which overwhelmed existing pediatric acute and critical care hospital capacity.

PATIENTS

Pediatric patients requiring hospitalization in Washington and Oregon.

INTERVENTIONS

Adaptations to the use of two existing statewide MOCCs to provide pediatric patient load balancing through surveillance, modifications of existing referral agreements, coordinated expansion of resources, activation of regional crisis standards of care, and integration of pediatric critical care physicians from Harborview Medical Center as subject matter experts (SMEs).

MEASUREMENTS AND MAIN RESULTS

The Washington and Oregon MOCCs managed 183 pediatric requests from hospitals unable to transfer pediatric patients between November 1, 2022, and December 14, 2022. Sixteen percent of requests were for children younger than 3 months and 37% were for children between 3 months and 1 year; most had acute viral respiratory disease. Requests for children older than 13 years old were primarily intentional drug ingestions. Fifty-eight percent were for critically ill children and 17% originated from critical access hospitals. Washington's SMEs were utilized in nearly a quarter of cases with the disposition changing in 38% of these.

CONCLUSIONS

Washington and Oregon statewide MOCCs have leveraged centralized coordination to effectively load balance a surge in pediatric patients which has overwhelmed existing pediatric hospital resources. Centralized coordination and surveillance informed pediatric hospitals and policy makers of unmet clinical needs and facilitated rapid expansion of clinical capacity and modifications to referral processes. Integration of pediatric SMEs enabled efficient triage of these resources. MOCCs provide an adaptable centralized resource for addressing surge and have been effective in managing overwhelmed pediatric hospital resources in Washington and Oregon.

Epidemiology of Intensive Care Admissions for Children in the US From 2001 to 2019

Importance

Estimates of the number of US children receiving intensive care unit (ICU) care and ICU admission patterns over time are lacking.

Objective

To determine how ICU admission patterns, use of critical care services, and the characteristics and outcomes of critically ill children have changed from 2001 to 2019.

Design, Setting, and Participants

This population-based retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient databases from a total of 21 US states in 2001, 2004, 2010, 2016, and 2019. Hospitalized children aged 0 to 17 years, excluding newborns (during birth hospitalization), were included. Patients admitted to rehabilitation institutions or psychiatric hospitals were also excluded. Data were analyzed from July 2021 to December 2022.

Exposures

Care in a nonneonatal ICU.

Main Outcomes and Measures

From extracted patient data, International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision, Clinical Modification, codes were used to identify diagnoses, comorbid conditions, organ failures, and mechanical ventilation. Generalized linear Poisson regression and the Cuzick test were used to evaluate trends. US Census data were used to generate age- and sex-adjusted national estimates of ICU admissions and costs.

Results

Of 2 157 991 pediatric admissions, 275 656 (12.8%) included ICU care. The mean (SD) age was 6.43 (6.10) years; 121 894 individuals were female (44.2%), and 153 731 were male (55.8%). From 2001 to 2019, the prevalence of ICU care among hospitalized children increased from 10.6% to 15.5%. The percentage of ICU admissions in children's hospitals rose from 51.2% to 85.1% (relative risk [RR], 1.66; 95% CI, 1.64-1.68). The percentage of children admitted to an ICU with an underlying comorbidity increased from 46.2% to 57.0% (RR, 1.23; 95% CI, 1.22-1.25), and the percentage with preadmission technology dependence increased from 16.4% to 23.5% (RR, 1.44; 95% CI, 1.40-1.48). The prevalence of multiple organ dysfunction syndrome increased from 6.8% to 21.0% (RR, 3.12; 95% CI, 2.98-3.26), while mortality decreased from 2.5% to 1.8% (RR, 0.72; 95% CI, 0.66-0.79). Hospital length of stay increased by 0.96 days (95% CI, 0.73-1.18) for ICU admissions from 2001 to 2019. After inflation adjustment, total costs for a pediatric admission involving ICU care nearly doubled between 2001 and 2019. Nationally, an estimated 239 000 children were admitted to a US ICU in 2019, corresponding to $11.6 billion in hospital costs.

Conclusions and Relevance

In this study, the prevalence of children receiving ICU care in the US increased, as did length of stay, technology use, and associated costs. The US health care system must be equipped to care for these children in the future.

A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity

Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.

Development and Optimization of a Remote Pediatric Cardiac Critical Care Bootcamp Using Telesimulation

We developed a novel cardiac critical care bootcamp consisting of didactic, small group, and simulation sessions. The bootcamp was remote due to the COVID-19 pandemic and included telesimulation. We aimed to assess learners' reactions to the bootcamp and their perception of telesimulation. Paired anonymous surveys were administered before and after participation. Surveys assessed participants' comfort in independently managing cardiac critical care scenarios, perceptions of telesimulation, barriers to its effectiveness, and specific feedback on course components. Forty-three fellows from 10 institutions joined the bootcamp over 2 years. Thirty-eight pre- and 28 postcourse surveys were completed. The course was rated good or excellent by all respondents, and 27/28 rated the material as appropriate to their level of training. Based on feedback from 2020, the electrophysiology sessions were converted to a small group format in 2021; positive assessment of these sessions improved from 65 to 90–100%. The telesimulations were highly rated, with 83–94% of participants in 2020 and 90–100% in 2021 rating them as good or excellent. Participants' views on telesimulation improved following the course, with 78% (14/18) post- versus 50% preparticipation agreeing that telesimulation is an effective educational tool (p = 0.06) and 56% (10/18) post- versus 67% (12/18) pre-rating telesimulation as less effective than in person simulation (p = 0.04). Identified limitations of telesimulation were limited active participation, lack of realism, impaired flow of conversation, and audiovisual and technical concerns. Telesimulation is feasible in cardiac critical care education and was an acceptable alternative to in person simulation for course participants.

Impact of a multifaceted early mobility intervention for critically ill children - the PICU Up! trial: study protocol for a multicenter stepped-wedge cluster randomized controlled trial

BACKGROUND

Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery.

METHODS

The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial's primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery.

DISCUSSION

This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04989790. Registered on August 4, 2021.

Leveraging Clinical Informatics and Data Science to Improve Care and Facilitate Research in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

The use of electronic algorithms, clinical decision support systems, and other clinical informatics interventions is increasing in critical care. Pediatric acute respiratory distress syndrome (PARDS) is a complex, dynamic condition associated with large amounts of clinical data and frequent decisions at the bedside. Novel data-driven technologies that can help screen, prompt, and support clinician decision-making could have a significant impact on patient outcomes. We sought to identify and summarize relevant evidence related to clinical informatics interventions in both PARDS and adult respiratory distress syndrome (ARDS), for the second Pediatric Acute Lung Injury Consensus Conference.

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

We included studies of pediatric or adult critically ill patients with or at risk of ARDS that examined automated screening tools, electronic algorithms, or clinical decision support systems.

DATA EXTRACTION

Title/abstract review, full text review, and data extraction using a standardized data extraction form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-six studies were identified for full text extraction to address the Patient/Intervention/Comparator/Outcome questions, and 14 were used for the recommendations/statements. Two clinical recommendations were generated, related to the use of electronic screening tools and automated monitoring of compliance with best practice guidelines. Two research statements were generated, related to the development of multicenter data collaborations and the design of generalizable algorithms and electronic tools. One policy statement was generated, related to the provision of material and human resources by healthcare organizations to empower clinicians to develop clinical informatics interventions to improve the care of patients with PARDS.

CONCLUSIONS

We present two clinical recommendations and three statements (two research one policy) for the use of electronic algorithms and clinical informatics tools for patients with PARDS based on a systematic review of the literature and expert consensus.

Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review

OBJECTIVE

Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions.

DATA SOURCES

PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus.

STUDY SELECTION

We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication.

DATA EXTRACTION

Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology.

DATA SYNTHESIS

Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions.

CONCLUSIONS

Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.

Workforce demographics and unit structure in paediatric cardiac critical care in the United States

OBJECTIVE

To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States.

DESIGN

REDCap surveys were sent by email from May till August 2019 to medical directors ("directors") of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure.

MEASUREMENTS AND MAIN RESULTS

Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%).

CONCLUSIONS

Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

IMPORTANCE

Intravenous (IV) insulin infusion is the standard of care for treating diabetic ketoacidosis (DKA) worldwide. Subcutaneous (SC) insulin aspart could decrease the use of health care resources.

OBJECTIVE

To compare the cost-effectiveness of mild uncomplicated DKA management with SC insulin aspart vs IV insulin infusion among pediatric patients from the perspective of a public health care payer using clinical data.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation included children aged 2 to 14 years presenting to the emergency department of a single academic medical center with mild DKA between January 1, 2015, and March 15, 2020. The medical records for DKA treatment course and its associated hospitalization costs were reviewed. Data were analyzed from January 1, 2015, to March 15, 2020.

EXPOSURES

Subcutaneous insulin aspart vs IV regular insulin infusion.

MAIN OUTCOMES AND MEASURES

The incremental cost-effectiveness ratio (US dollars per hour), duration of DKA treatment, and length of hospital stay.

RESULTS

A total of 129 children with mild DKA episodes (mean [SD] age, 9.9 [3.1] years; 72 girls [55.8%]) were enrolled in the study. Seventy children received SC insulin aspart and 59 received IV regular insulin. Overall, the length of hospital stay in the SC insulin group was reduced (mean, 16.9 [95% CI, -31.0 to -2.9] hours) compared with the IV insulin group (P = .005). The mean (SD) cost of hospitalization in the SC insulin group (US $1071.99 [US $523.89]) was less than that in the IV insulin group (US $1648.90 [US $788.03]; P = .001). The incremental cost-effectiveness ratio was -34.08 (95% CI, -25.97 to -129.82) USD/h. The use of SC insulin aspart was associated with a lower likelihood of prolonged hospital stay (β = -17.22 [95% CI, -32.41 to -2.04]; P = .03) than IV regular insulin when controlling for age and sex.

CONCLUSION AND RELEVANCE

Findings of this economic evaluation suggest that SC insulin aspart is dominant vs IV regular insulin in the management of mild uncomplicated DKA in children.

Pediatric Transport-Specific Illness Severity Scores Predict Clinical Deterioration of Transported Patients

OBJECTIVE

The Transport Risk Assessment in Pediatrics (TRAP) and Transport Pediatric Early Warning Scores (T-PEWS) are transport-specific pediatric illness severity scores that are adjunct assessment tools for determining disposition of transported patients. We hypothesized that these scores would predict the risk of clinical deterioration in transported patients admitted to general pediatric wards.

METHODS

Activation of a rapid response team (RRT) in the first 24 hours of admission was used as a marker of deterioration. All pediatric transports between March 2017 and February 2020 admitted via critical care transport were included. Transports to the emergency department (ED) were excluded. This retrospective chart review evaluated TRAP and T-PEWS scores at 3 points: (1) arrival of transport team at referring hospital, (2) admission to the children's hospital, and (3) RRT activation, if occurring within 24 hours of admission.

RESULTS

There were 1137 team transports during this period. Three hundred ninety-nine patients transported to the ED were excluded, leaving 738 included patients; 405 (55%) admitted to the general wards and 333 (45%) admitted to the pediatric intensive care unit. Twenty-five patients admitted to the wards (6%) had an RRT activation within 24 hours of admission. Statistical analysis used 2-sample t tests. There was a statistically significant difference in scores for ward admissions between those who had RRT activation and those who did not.

CONCLUSIONS

Both TRAP and T-PEWS can be used to predict the risk of clinical deterioration in transported patients admitted to general wards. These scores may assist in assessing which patients admitted to the wards need closer observation.

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

OBJECTIVES

To identify trends in the population of patients in PICUs over time.

DESIGN

Cross-sectional, retrospective cohort study using the Pediatric Health Information System database.

SETTING

Forty-three U.S. children's hospitals.

PATIENTS

All patients admitted to Pediatric Health Information System-participating hospitals from January 2014 to December 2019. Individuals greater than 65 years old and normal newborns were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

PICU care occurred in 13.8% of all pediatric hospital encounters and increased over the study period from 13.3% to 14.3%. Resource intensity, based on average Hospitalization Resource Intensity Scores for Kids score, increased significantly across epochs (6.5 in 2014-2015 vs 6.9 in 2018-2019; p < 0.001), although this was not consistently manifested as additional procedural exposure. Geometric mean PICU cost per patient encounter was stable. The two most common disease categories in PICU patients were respiratory failure and cardiac and circulatory congenital anomalies. Of all PICU encounters, 35.5% involved mechanical ventilation, and 25.9% involved vasoactive infusions. Hospital-level variation in the percentage of days spent in the PICU ranged from 15.1% to 63.5% across the participating sites. Of the total hospital costs for patients admitted to the PICU, 41.7% of costs were accrued during the patients' PICU stay.

CONCLUSIONS

The proportional use of PICU beds is increasing over time, although was variable across centers. Case-based resource use and complexity of pediatric patients are also increasing. Despite the higher use of PICU resources, the standardized costs of PICU care per patient encounter have remained stable. These data may help to inform current PICU resource allocation and future PICU capacity planning.

Setting up a Pediatric Intensive Care Unit in a Community/Rural Setting

Community pediatric intensive care units (PICUs) play a crucial role in providing high-quality care to critically ill children in the rural setting. Setting one up requires meticulous planning and allocation of limited resources. The design and layout of PICUs vary widely but need to meet the required minimum standards and follow local and federal policies and regulatory standards. The building block is investing in the education and training of health care providers. Collaboration with tertiary facilities and community organizations helps provide care closer to home. Care coordination necessitates partnering with the families and the community and including telemedicine to increase accessibility.

Employment Opportunities for Pediatric Critical Care Fellowship Trained Physicians in the United States

Pediatric Critical Care Medicine (PCCM) training programs and trained fellows in the United State increased steadily without a corresponding increase in population growth. PCCM trainees worry about limited employment prospects. This study aimed to quantify the demand for PCCM trained physicians in the United States by prospectively tracking full-time employment opportunities over 12 months. The number of advertised opportunities identified was low compared with number of fellows likely to be seeking jobs during same time period. If market demand remains stable, there is risk of excess supply if number of newly fellowship-trained PCCM physicians continues to rise.

PICU in the MICU: How Adult ICUs Can Support Pediatric Care in Public Health Emergencies

Initial waves of the COVID-19 pandemic have largely spared children. With the advent of vaccination in many older age groups and the spread of the highly contagious Delta variant, however, children now represent a growing percentage of COVID-19 cases. PICU capacity is far less than that of adult ICUs. Adult ICUs may need to support pediatric care, much as PICUs provided adult care earlier in the pandemic. Critically ill children selected for care in adult settings should be at least 12 years of age and ideally have conditions common in children and adults alike (eg, community-acquired sepsis, trauma). Children with complex, pediatric-specific disorders are best served in PICUs and are not recommended for transfer. The goal of such transfers is to maintain critical capacity for those children in greatest need of the PICU's unique abilities, therefore preserving systems of care for all children.

Mobilization Safety of Critically Ill Children

BACKGROUND

Children in PICUs experience negative sequelae of immobility; however, interprofessional staff concerns about safety are a barrier to early mobilization. Our objective was to determine the safety profile of early mobilization in PICU patients.

METHODS

We conducted a secondary analysis of a 2-day study focused on physical rehabilitation in 82 PICUs in 65 US hospitals. Patients who had ≥72-hour admissions and participated in a mobility event were included. The primary outcome was occurrence of a potential safety event during mobilizations.

RESULTS

On 1433 patient days, 4658 mobility events occurred with a potential safety event rate of 4% (95% confidence interval [CI], 3.6%-4.7%). Most potential safety events were transient physiologic changes. Medical equipment dislodgement was rare (0.3%), with no falls or cardiac arrests. Potential safety event rates did not differ by patient age or sex. Patients had higher potential safety event rates if they screened positive for delirium (7.8%; adjusted odds ratio, 5.86; 95% CI, 2.17-15.86) or were not screened for delirium (4.7%; adjusted odds ratio, 3.98; 95% CI, 1.82-8.72). There were no differences in potential safety event rates by PICU intervention, including respiratory support or vasoactive support.

CONCLUSIONS

Early PICU mobilization has a strong safety profile and medical equipment dislodgement is rare. No PICU interventions were associated with increased potential safety event rates. Delirium is associated with higher potential safety event rates. These findings highlight the need to improve provider education and confidence in mobilizing critically ill children.

Continuing Care For Critically Ill Children Beyond Hospital Discharge: Current State of Follow-up

OBJECTIVES

Survivors of the PICU face long-term morbidities across health domains. In this study, we detail active PICU follow-up programs (PFUPs) and identify perceptions and barriers about development and maintenance of PFUPs.

METHODS

A web link to an adaptive survey was distributed through organizational listservs. Descriptive statistics characterized the sample and details of existing PFUPs. Likert responses regarding benefits and barriers were summarized.

RESULTS

One hundred eleven respondents represented 60 institutions located in the United States (n = 55), Canada (n = 3), Australia (n = 1), and the United Kingdom (n = 1). Details for 17 active programs were provided. Five programs included broad PICU populations, while the majority were neurocritical care (53%) focused. Despite strong agreement on the need to assess and treat morbidity across multiple health domains, 29% were physician only programs, and considerable variation existed in services provided by programs across settings. More than 80% of all respondents agreed PFUPs provide direct benefits and are essential to advancing knowledge on long-term PICU outcomes. Respondents identified "lack of support" as the most important barrier, particularly funding for providers and staff, and lack of clinical space, though successful programs overcome this challenge using a variety of funding resources.

CONCLUSIONS

Few systematic multidisciplinary PFUPs exist despite strong agreement about importance of this care and direct benefit to patients and families. We recommend stakeholders use our description of successful programs as a framework to develop multidisciplinary models to elevate continuity across inpatient and outpatient settings, improve patient care, and foster collaboration to advance knowledge.

The Child With Severe Chronic Illness in the ICU: A Concise Review

OBJECTIVES

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs.

DATA SOURCES

English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed.

STUDY SELECTION

Original articles, review articles, and commentaries were considered.

DATA EXTRACTION

Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review.

DATA SYNTHESIS

Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured.

CONCLUSIONS

The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience

OBJECTIVE

To describe the characteristics of pediatric intensive care neurologists and their practice in the United States and Canada.

METHODS

We performed a survey-based study of child neurologists who self-identify as 'intensive care neurologists'. The survey included questions about demographics, training, pediatric neurocritical care service and job structure, teaching, academics, challenges, and views on the future of pediatric neurocritical care.

RESULTS

We analyzed 55 surveys. Most respondents were 31-50 years of age with ≤10 years of practice experience. Fifty-four percent identified as female. Most completed subspecialty training after child neurology residency. The majority practice at highly resourced centers with >45 intensive care unit beds. Respondents cover a variety of inpatient (critical and noncritical care) services, at times simultaneously, for a median of 19.5 weeks/y and work >70 hours/wk when on service for pediatric neurocritical care. The top 3 challenges reported were competing demands for time, excess volume, and communication with critical care medicine. Top priorities for the "ideal pediatric neurocritical care service" were attendings with training in pediatric neurocritical care or a related field and joint rounding with critical care medicine.

CONCLUSION

We report a survey-based analysis of the demographics and scope of practice of pediatric critical care neurologists. We highlight challenges faced and provide a framework for the further development of this rapidly growing field.

Transport Medical Control Education for Pediatric Critical Care Fellows: A National Needs Assessment Study

OBJECTIVES

Characterize transport medical control education in Pediatric Critical Care Medicine fellowship.

DESIGN

Cross-sectional survey study.

SETTING

Pediatric Critical Care Medicine fellowship programs in the United States.

SUBJECTS

Pediatric Critical Care Medicine fellowship program directors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We achieved a 74% (53/72) response rate. A majority of programs (85%) require fellows to serve as transport medical control, usually while carrying out other clinical responsibilities and sometimes without supervision. Fellows at most programs (80%) also accompany the transport team on patient retrievals. Most respondents (72%) reported formalized transport medical control teaching, primarily in a didactic format (76%). Few programs (25%) use a standardized assessment tool. Transport medical control was identified as requiring all six Accreditation Council for Graduate Medical Education competencies, with emphasis on professionalism and interpersonal and communication skills.

CONCLUSIONS

Transport medical control responsibilities are common for Pediatric Critical Care Medicine fellows, but training is inconsistent, assessment is not standardized, and supervision may be lacking. Fellow performance in transport medical control may help inform assessment in multiple domains of competencies. Further study is needed to identify effective methods for transport medical control education.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Nursing-Sensitive Outcomes among Patients Cared for in Paediatric Intensive Care Units: A Scoping Review

Measuring the effectiveness of nursing interventions in intensive care units has been established as a priority. However, little is reported about the paediatric population. The aims of this study were (a) to map the state of the art of the science in the field of nursing-sensitive outcomes (NSOs) in paediatric intensive care units (PICUs) and (b) to identify all reported NSOs documented to date in PICUs by also describing their metrics. A scoping review was conducted by following the framework proposed by Arksey and O’Malley. Fifty-eight articles were included. Publications were mainly authored in the United States and Canada (n = 28, 48.3%), and the majority (n = 30, 51.7%) had an observational design. A total of 46 NSOs were documented. The most reported were related to the clinical (n = 83), followed by safety (n = 41) and functional (n = 18) domains. Regarding their metrics, the majority of NSOs were measured in their occurrence using quantitative single measures, and a few validated tools were used to a lesser extent. No NSOs were reported in the perceptual domain. Nursing care of critically ill children encompasses three levels: improvement in clinical performance, as measured by clinical outcomes; assurance of patient care safety, as measured by safety outcomes; and promotion of fundamental care needs, as measured by functional outcomes. Perceptual outcomes deserve to be explored.

The Relationship between Bronchiolitis Severity and Vitamin D Status

BACKGROUND/AIM

Acute bronchiolitis is mostly caused by viral agents in children under 2 years of age. The disease mostly has a mild clinical course however severe cases are not uncommon. Vitamin D is known to exert immune-regulatory functions. We aimed to examine the association between the clinical severity of acute bronchiolitis and serum vitamin D levels in infants.

MATERIALS AND METHODS

A total of 182 children with acute bronchiolitis were prospectively enrolled. The disease severity was assessed using the Modified Tal Scoring System and their vitamin D levels were evaluated.

RESULTS

Vitamin D deficiency or insufficiency was as high as 47.8% in infants with bronchiolitis. Infants with low vitamin D levels comprised a significantly larger proportion of patients with severe bronchiolitis (p = 0.002). Infants admitted to intensive care unit had significantly higher degrees of vitamin D deficiency or insufficiency (p < 0.001).

CONCLUSION

Vitamin D deficiency is closely linked with severe bronchiolitis and the need for intensive care unit admission in infants. We believe that assessment of vitamin D levels in infants prior to bronchiolitis season and appropriate supplementation may have a protective effect against severe bronchiolitis.

Characteristics of Burn-Injured Children in 117 U.S. PICUs (2009-2017): A Retrospective Virtual Pediatric Systems Database Study

OBJECTIVES

To describe characteristics and outcomes of children with burn injury treated in U.S. PICUs.

DESIGN

Retrospective study of admissions in the Virtual Pediatric Systems, LLC, database from 2009 to 2017.

SETTING

One hundred and seventeen PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted with an active diagnosis of burn at admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,056 patients were included. They were predominantly male (62.6%) and less than 6 years old (66.7%). Cutaneous burns were recorded in 92.1% of patients, mouth/pharynx burns in 5.8%, inhalation injury in 5.1%, and larynx/trachea/lung burns in 4.5%. Among those with an etiology recorded (n = 861), scald was most common (38.6%), particularly in children less than 2 years old (67.8%). Fire/flame burns were most common (46.6%) in children greater than or equal to 2 years. Multiple organ failure was present in 26.2% of patients. Most patients (89%) were at facilities without American Burn Association pediatric verification. PICU mortality occurred in 4.5% of patients. On multivariable analysis using Pediatric Index of Mortality 2, greater than or equal to 30% total body surface area burned was significantly associated with mortality (odds ratio, 5.40; 95% CI, 2.16-13.51; p = 0.0003). When Pediatric Risk of Mortality III was used, greater than or equal to 30% total body surface area burned (odds ratio, 5.45; 95% CI, 1.95-15.26; p = 0.001) and inhalation injury (odds ratio, 5.39; 95% CI, 1.58-18.42; p = 0.007) were significantly associated with mortality. Among 366 survivors (18.6%) with Pediatric Cerebral Performance Category or Pediatric Overall Performance Category data, 190 (51.9%) had a greater than or equal to 1 point increase in Pediatric Cerebral Performance Category or Pediatric Overall Performance Category disability category and 80 (21.9%) had a new designation of moderate or severe disability, or persistent vegetative state.

CONCLUSIONS

Burn-injured patients in U.S. PICUs have a substantial burden of organ failure, morbidity, and mortality. Coordination among specialized facilities may be particularly important in this population, especially for those with higher % total body surface area burned or inhalation injury.

Advanced Practice Provider-inclusive Staffing Models and Patient Outcomes in Pediatric Critical Care

BACKGROUND

Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models.

OBJECTIVES

We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs.

RESEARCH DESIGN

Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes.

MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay.

RESULTS

The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay.

CONCLUSIONS

Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.

Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States

OBJECTIVES

With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers.

DESIGN

National 2-day point prevalence study.

SETTING

Eighty-two PICUs in 65 hospitals across the United States.

PATIENTS

All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs < 3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6).

CONCLUSIONS

Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.

Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children

OBJECTIVES

We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale.

DESIGN

Mixed-methods, observational cohort.

SETTING

Pediatric and neonatal ICUs.

SUBJECTS

Critical care nurses and patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale.

CONCLUSIONS

When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.

Daytime admission is associated with higher 1-month survival for pediatric out-of-hospital cardiac arrest: Analysis of a nationwide multicenter observational study in Japan

OBJECTIVE

Hospital characteristics, such as hospital type and admission time, have been reported to be associated with survival in adult out-of-hospital cardiac arrest (OHCA) patients. However, findings regarding the effects of hospital types on pediatric OHCA patients have been limited. The aim of this study was to analyze the relationship between the hospital characteristics and the outcomes of pediatric OHCA patients.

METHODS

This study was a retrospective secondary analysis of the Japanese Association for Acute Medicine-out-of-hospital cardiac arrest registry. The period of this study was from 1 June 2014 to 31 December 2015. We enrolled all pediatric patients (those 0-17 years of age) experiencing OHCA in this study. We enrolled all types of OHCA. The primary outcome of this study was 1-month survival after the onset of cardiac arrest.

RESULTS

We analyzed 310 pediatric patients (those 0-17 years of age) with OHCA. In survivors, the rate of witnessed arrest and daytime admission was significantly higher than nonsurvivors (56% vs. 28%, p < 0.001: 49% vs. 31%; p = 0.03, respectively). The multiple logistic regression model showed that daytime admission was related to 1-month survival (odds ratio, OR: 95% confidence interval, CI, 3.64: 1.23-10.80) (p = 0.02). OHCA of presumed cardiac etiology and witnessed OHCA were associated with higher 1-month survival. (OR: 95% CI, 3.92: 1.23-12.47, and 6.25: 1.98-19.74, respectively). Further analyses based on the time of admission showed that there were no significant differences in the proportions of patients with witnessed arrest and who received bystander cardiopulmonary resuscitation and emergency medical service response time by admission time.

CONCLUSION

Pediatric OHCA patients who were admitted during the day had a higher 1-month survival rate after cardiac arrest than patients who were admitted at night.

Repurposing a PICU for Adult Care in a State Mandated COVID-19 Only Hospital: Outcome Comparison to the MICU Cohort to Determine Safety and Effectiveness

Objective: The ongoing coronavirus 2019 (COVID-19) pandemic is disproportionally impacting the adult population. This study describes the experiences after repurposing a PICU and its staff for adult critical care within a state mandated COVID-19 hospital and compares the outcomes to adult patients admitted to the institution's MICU during the same period. Design: A retrospective chart review was performed to analyze outcomes for the adults admitted to the PICU and MICU during the 27-day period the PICU was incorporated into the institution's adult critical care surge plan. Setting: Tertiary care state University hospital. Patients: Critically ill adult patients with proven or suspected COVID-19. Interventions: To select the most ideal adult patients for PICU admission a tiered approach that incorporated older patients with more comorbidities at each stage was implemented. Measurements and Main Results: There were 140 patients admitted to the MICU and 9 patients admitted to the PICU during this period. The mean age of the adult patients admitted to the PICU was lower (49.1 vs. 63.2 p = 0.017). There was no statistically significant difference in the number of comorbidities, intubation rates, days of ventilation, dialysis or LOS. Patients selected for PICU care did not have coronary artery disease, CHF, cerebrovascular disease or COPD. Mean admission Sequential Organ Failure Assessment (SOFA) score was lower in patients admitted to the PICU (4 vs. 6.4, p = 0.017) with similar rates of survival to discharge (66.7 vs. 44.4%, p = 0.64). Conclusion: Outcomes for the adult patients who received care in the PICU did not appear to be worse than those who were admitted to the MICU during this time. While limited by a small sample size, this single center cohort study revealed that careful assessment of critical illness considering age and type of co-morbidities may be a safe and effective approach in determining which critically ill adult patients with known or suspected COVID-19 are the most appropriate for PICU admission in general hospitals with primary management by its physicians and nurses.

The Association of Pediatric Critical Care Medicine Training Programs with Research Publication Productivity and Employment Outcomes of Their Graduates

Our objective was to associate characteristics of pediatric critical care medicine (PCCM) fellowship training programs with career outcomes of PCCM physicians, including research publication productivity and employment characteristics. This is a descriptive study using publicly available data from 2557 PCCM physicians from the National Provider Index registry. We analyzed data on a systematic sample of 690 PCCM physicians representing 62 fellowship programs. There was substantial diversity in the characteristics of fellowship training programs in terms of fellowship size, intensive care unit (ICU) bed numbers, age of program, location, research rank of affiliated medical school, and academic metrics based on publication productivity of their graduates standardized over time. The clinical and academic attributes of fellowship training programs were associated with publication success and characteristics of their graduates' employment hospital. Programs with greater publication rate per graduate had more ICU beds and were associated with higher ranked medical schools. At the physician level, training program attributes including larger size, older program, and higher academic metrics were associated with graduates with greater publication productivity. There were varied characteristics of current employment hospitals, with graduates from larger, more academic fellowship training programs more likely to work in larger pediatric intensive care units (24 [interquartile range, IQR: 16–35] vs. 19 [IQR: 12–24] beds; p < 0.001), freestanding children's hospitals (52.6 vs. 26.3%; p < 0.001), hospitals with fellowship programs (57.3 vs. 40.3%; p = 0.01), and higher affiliated medical school research ranks (35.5 [IQR: 14–72] vs. 62 [IQR: 32, unranked]; p < 0.001). Large programs with higher academic metrics train physicians with greater publication success (H index 3 [IQR: 1–7] vs. 2 [IQR: 0–6]; p < 0.001) and greater likelihood of working in large academic centers. These associations may guide prospective trainees as they choose training programs that may foster their career values.

Pediatric Critical Care Simulation Curriculum: Training Nurse Practitioners to Lead in the Management of Critically Ill Children

INTRODUCTION

Acute care pediatric nurse practitioners have become frontline providers in the critical care environment and are expected to provide leadership in acutely critical situations. We describe a 2-day, high-fidelity, simulation-based curriculum focused on training the pediatric nurse practitioners for leadership in critical care scenarios.

METHOD

This prospective pre-post interventional study used simulation-based pedagogy. Knowledge tests, time-to-task, and a follow-up survey were used to determine the effectiveness of the training.

RESULTS

Participants (n = 23) improved their knowledge scores by 27% (pretest: 35.2% [standard deviation = 12.1%]; posttest: 62.2% [standard deviation = 13.8%], p < .001). In addition, time-to-task for resuscitation variables improved significantly. At 3 months, 100% of the participants who responded either agreed (15.4%) or strongly agreed (84.6%) that the boot camp prepared them to lead in a critical emergency.

DISCUSSION

Simulation-based training is an effective strategy for educating critical care pediatric nurse practitioners and improves their ability to manage pediatric emergencies rapidly, which can be lifesaving.

Pediatric Cardiac Intensive Care Distribution, Service Delivery, and Staffing in the United States in 2018

OBJECTIVES

To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States.

DESIGN

Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders.

SETTING

Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease.

PARTICIPANTS

Cardiac ICU or mixed ICU physician medical directors or designees.

MEASUREMENTS AND MAIN RESULTS

One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001).

CONCLUSIONS

Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.

Emergency room endotracheal intubation in children with bronchiolitis: A cohort study using a multicenter database

BACKGROUND AND AIMS

Bronchiolitis and asthma have a clinical overlap, and it has been shown that pediatric intensive care unit (PICU) patients with asthma undergoing endotracheal intubation in a community hospital emergency room (ER) have a shorter duration of mechanical ventilation (MV) and PICU length of stay (LOS) vs children undergoing intubation in a children's hospital. We aimed to determine if the setting of intubation (community vs children's hospital ER) is associated with the duration of MV and PICU LOS among children with bronchiolitis.

METHODS

With IRB approval, data in the Virtual Pediatric Systems (VPS, LLC) database were queried for bronchiolitis patients <24 months of age admitted to one of 103 predominantly North American PICUs between 1/2009 and 1/2016 who had an endotracheal tube in place at PICU admission. There were no exclusion criteria. Extracted data included ER type (community/external or children's hospital/internal), demographics, and reported comorbidities. Outcomes analyzed were duration of MV and PICU LOS. Multivariable linear regression was used to evaluate if intubation location was independently associated with the outcomes of interest.

RESULTS

Among 1934 patients, median age was 2.0 (IQR: 1.0-4.8) months, 51% were admitted from an external ER, 41% were White, 61% were male, and 28% had ≥1 comorbidity. Median duration of MV was 6.6 (4.6-9.5) days and the median PICU LOS was 7.0 (4.6-10.6) days. Children who underwent endotracheal intubation in a children's hospital ER had a modestly longer duration of MV (6.7 [4.4-9.4] vs 6.5 [5.2-9.6] days, P < .001, Mann-Whitney U) and longer PICU LOS (7.2 [4.8-10.8] vs 6.9 [4.2-10.1] days, P = .004, Mann-Whitney U). After adjusting for confounding variables, we did not observe a significant association between the location of endotracheal intubation and duration of MV or PICU LOS.

CONCLUSION

In this cohort, and unlike outcomes of near-fatal asthma, we observed that clinical outcomes of critical bronchiolitis were similar regardless of location of endotracheal intubation.

COVID-19 in Children in the United States: Intensive Care Admissions, Estimated Total Infected, and Projected Numbers of Severe Pediatric Cases in 2020

Supplemental Digital Content is Available in the Text.

Importance:

A surge in severe cases of COVID-19 (coronavirus disease 2019) in children would present unique challenges for hospitals and public health preparedness efforts in the United States.

Objective:

To provide evidence-based estimates of children infected with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and projected cumulative numbers of severely ill pediatric COVID-19 cases requiring hospitalization during the US 2020 pandemic.

Design:

Empirical case projection study.

Main Outcomes and Measures:

Adjusted pediatric severity proportions and adjusted pediatric criticality proportions were derived from clinical and spatiotemporal modeling studies of the COVID-19 epidemic in China for the period January-February 2020. Estimates of total children infected with SARS-CoV-2 in the United States through April 6, 2020, were calculated using US pediatric intensive care unit (PICU) cases and the adjusted pediatric criticality proportion. Projected numbers of severely and critically ill children with COVID-19 were derived by applying the adjusted severity and criticality proportions to US population data, under several scenarios of cumulative pediatric infection proportion (CPIP).

Results:

By April 6, 2020, there were 74 children who had been reported admitted to PICUs in 19 states, reflecting an estimated 176 190 children nationwide infected with SARS-CoV-2 (52 381 infants and toddlers younger than 2 years, 42 857 children aged 2-11 years, and 80 952 children aged 12-17 years). Under a CPIP scenario of 5%, there would be 3.7 million children infected with SARS-CoV-2, 9907 severely ill children requiring hospitalization, and 1086 critically ill children requiring PICU admission. Under a CPIP scenario of 50%, 10 865 children would require PICU admission, 99 073 would require hospitalization for severe pneumonia, and 37.0 million would be infected with SARS-CoV-2.

Conclusions and Relevance:

Because there are 74.0 million children 0 to 17 years old in the United States, the projected numbers of severe cases could overextend available pediatric hospital care resources under several moderate CPIP scenarios for 2020 despite lower severity of COVID-19 in children than in adults.