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Chang N, Louderback L, Hammett H, Hildebrandt K, Prendergast E, Sperber A, Casazza M, Landess M, Little A, Rasmussen L. Multidisciplinary Consensus on Curricular Priorities for Pediatric Neurocritical Care Nursing Education: A Modified Delphi Study in the United States. Neurocrit Care 2024; 41:568-575. [PMID: 38570410 DOI: 10.1007/s12028-024-01976-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Nurses are vital partners in the development of pediatric neurocritical care (PNCC) programs. Nursing expertise is acknowledged to be an integral component of high-quality specialty patient care in the field, but little guidance exists regarding educational requirements to build that expertise. We sought to obtain expert consensus from nursing professionals and physicians on curricular priorities for specialized PNCC nursing education in pediatric centers across the United States. METHODS We used a modified Delphi study technique surveying a multidisciplinary expert panel of nursing professionals and physicians. Online surveys were distributed to 44 panelists over three rounds to achieve consensus on curricular topics deemed essential for PNCC nursing education. During each round, panelists were asked to rate topics as essential or not essential, as well as given opportunities to provide feedback and suggest changes. Feedback was shared anonymously to the panelist group throughout the process. RESULTS From 70 initial individual topics, the consensus process yielded 19 refined topics that were confirmed to be essential for a PNCC nursing curriculum by the expert panel. Discrepancies existed regarding how universally to recommend topics of advanced neuromonitoring, such as brain tissue oxygenation; specialized neurological assessments, such as the serial neurological assessment in pediatrics or National Institutes of Health Stroke Scale; and some disease-based populations. Panelists remarked that not all centers see specific diseases, and not all centers currently employ advanced neuromonitoring technologies and skills. CONCLUSIONS We report 19 widely accepted curricular priorities that can serve as a standard educational base for PNCC nursing. Developing education for nurses in PNCC will complement PNCC programs with targeted nursing expertise that extends comprehensive specialty care to the bedside. Further work is necessary to effectively execute educational certification programs, implement nursing standards in the field, and evaluate the impact of nursing expertise on patient care and outcomes.
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Affiliation(s)
- Nathan Chang
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA.
| | - Lauren Louderback
- Pediatric Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather Hammett
- Pediatric Critical Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Kara Hildebrandt
- Pediatric Neurocritical Care, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Erica Prendergast
- Pediatric Neurocritical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amelia Sperber
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA
| | - May Casazza
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA
| | - Megan Landess
- Pediatric Critical Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Aubree Little
- Pediatric Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsey Rasmussen
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA
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Cecil CA, Dziorny AC, Hall M, Kane JM, Kohne J, Olszewski AE, Rogerson CM, Slain KN, Toomey V, Goodman DM, Heneghan JA. Low-Resource Hospital Days for Children Following New Tracheostomy. Pediatrics 2024; 154:e2023064920. [PMID: 39113630 DOI: 10.1542/peds.2023-064920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence. METHODS This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression. RESULTS Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs. CONCLUSIONS Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.
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Affiliation(s)
- Cara A Cecil
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam C Dziorny
- School of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Jason M Kane
- Pritzker School of Medicine, University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Joseph Kohne
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Aleksandra E Olszewski
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Colin M Rogerson
- Division of Critical Care, Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Katherine N Slain
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Vanessa Toomey
- Children's Hospital Los Angeles; University of Southern California Keck School of Medicine, Los Angeles, California
| | - Denise M Goodman
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia A Heneghan
- University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Chang N, Casazza M, Sperber A, Ciraulo L, Rodriguez J, Marquiss K, D'Anjou L, Teeyagura P, Chaillou AL, Palmquist A, Rasmussen L. Sustainability of a Pediatric Neurointensive Care Unit Model Within a Mixed Pediatric Intensive Care Unit and Its Effect on Nursing Sentiment. J Neurosci Nurs 2024; 56:123-129. [PMID: 38833521 DOI: 10.1097/jnn.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
ABSTRACT BACKGROUND: Pediatric neurocritical care (PNCC) and pediatric neurointensive care units (neuro-PICU) are growing fields. Although some institutions have established independent neuro-PICUs meeting most Neurocritical Care Society (NCS) standards for neurocritical care units, many centers lack the resources to do so. We describe an alternative neuro-PICU model as a designated unit within a mixed pediatric intensive care unit (PICU) and its effects on nursing sentiment. METHODS: We established a 6-bed neuro-PICU within a 36-bed noncardiac PICU. Charge nurses were tasked with admitting PNCC patients into these beds. For nursing expertise, we used a core group of 12 PNCC specialty nurses and instituted PNCC nursing education to PICU nurses. We observed the number of PNCC patients admitted to neuro-PICU beds and surveyed charge nurses to identify barriers to assigning patients. We surveyed PICU nursing staff to explore sentiment regarding PNCC before and after establishing the neuro-PICU. Nursing criteria were compared with NCS standards. RESULTS: In the 40-month period, our PICU saw 2060 PNCC admissions. Overall, occupied neuro-PICU beds housed PNCC patients 74.1% of the time. The biggest barriers to patient placement were too many competing placement requests, not enough neuro-PICU beds when specialty census was high, and difficulty assigning one nurse to two PNCC patients. In surveys after establishing the neuro-PICU, compared to before, experienced nurses reported being more interested in obtaining Emergency Neurological Life Support certification (94.2% vs 80.6%, P = .0495), and inexperienced nurses reported being more familiar with PNCC clinical pathways (53.5% vs 31.7%, P = .0263). Most NCS criteria related to nursing organization were met. CONCLUSIONS: Focused neuro-PICUs should be developed to complement advances in the field of PNCC. Alternative neuro-PICU models are possible and can increase nursing interest in further education and awareness of clinical pathways, but barriers exist that require institutional commitment to nursing development to sustain the delivery of specialized care to this population.
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Esangbedo ID, Yu P, Choudhury TA, Tume SC, Lasa JJ. Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey. World J Pediatr Congenit Heart Surg 2024; 15:202-208. [PMID: 38128949 DOI: 10.1177/21501351231205804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.
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Affiliation(s)
- Ivie D Esangbedo
- Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Priscilla Yu
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarif A Choudhury
- Division of Critical Care Medicine, Division of Cardiology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Sebastian C Tume
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Javier J Lasa
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Schwartz JM, Levin AB, Booth LD, Shaffner DH. Advanced Practice Provider Tracheal Intubation in Pediatric Critical Care: Scarcity and Market Forces. Pediatr Crit Care Med 2024; 25:182-184. [PMID: 38240541 DOI: 10.1097/pcc.0000000000003409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Jamie McElrath Schwartz
- Departments of Anesthesiology and Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amanda Betine Levin
- Departments of Anesthesiology and Critical Care Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lauren D Booth
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Donald H Shaffner
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Frank LH, Glickstein J, Brown DW, Mink RB, Ross RD. Child Health Needs and the Pediatric Cardiology Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678E. [PMID: 38300014 PMCID: PMC10852197 DOI: 10.1542/peds.2023-063678e] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
This article evaluates the pediatric cardiology (PC) workforce and forecasts its future supply. Produced as part of a supplement in Pediatrics, this effort represents a collaboration among the American Board of Pediatrics Foundation, the University of North Carolina at Chapel Hill's Carolina Health Workforce Research Center, the Strategic Modeling and Analysis Ltd., and members of the pediatric subspecialty community. PC is a complex subspecialty including care from fetal life through adulthood and in practice settings that range from the outpatient clinic to procedural settings to the cardiac ICU. Complex subdisciplines include imaging, electrophysiology, heart failure, and interventional and critical care. Using American Board of Pediatrics data, US Census Bureau data, and data from the modeling project, projections were created to model the subspecialty workforce through 2040. Across all modeling scenarios considered, there is considerable projected growth in the supply of pediatric cardiologists by 2040. However, there is significant regional variation in the projected supply of trainees relative to demand in terms of local population growth, with evidence of a likely mismatch between areas surrounding training centers versus areas of greatest workforce need. In addition, this article highlights areas for future focus, including efforts to attract more residents to the subspecialty in general, particularly underrepresented minority members; increased support, more part-time career options, and improved academic career advancement for women in PC; and the development of better "real-time" workforce data to guide trainees and training programs in decisions regarding sub-subspecialty job availability.
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Affiliation(s)
- Lowell H. Frank
- Division of Cardiology, Children’s National Hospital, Washington, District of Columbia
| | - Julie Glickstein
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York
| | - David W. Brown
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Richard B. Mink
- David Geffen School of Medicine at the University of California Los Angeles, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Robert D. Ross
- Division of Cardiology, Children’s Hospital of Michigan, Detroit, Michigan
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Mille F, Romer A, Choudhury TA, Zurca AD, Peddy SB, Widmeier K, Hamburger M, Shankar V. Development and Optimization of a Remote Pediatric Cardiac Critical Care Bootcamp Using Telesimulation. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1767736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
AbstractWe 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.
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High variability in cardiac education and experiences during United States paediatric critical care fellowships. Cardiol Young 2023; 33:366-370. [PMID: 35241196 PMCID: PMC9440946 DOI: 10.1017/s1047951122000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Paediatric cardiac critical care continues to become more sub-specialised, and many institutions have transitioned to dedicated cardiac ICUs. Literature regarding the effects of these changes on paediatric critical care medicine fellowship training is limited. OBJECTIVE To describe the current landscape of cardiac critical care education during paediatric critical care medicine fellowship in the United States and demonstrate its variability. METHODS A review of publicly available information in 2021 was completed. A supplemental REDCap survey focusing on cardiac ICU experiences during paediatric critical care medicine fellowships was e-mailed to all United States Accreditation Council of Graduate Medical Education-accredited paediatric critical care medicine fellowship programme coordinators/directors. Results are reported using inferential statistics. RESULTS Data from 71 paediatric critical care medicine fellowship programme websites and 41 leadership responses were included. Median fellow complement was 8 (interquartile range: 6, 12). The majority (76%, 31/41) of programmes had a designated cardiac ICU. Median percentage of paediatric critical care medicine attending physicians with cardiac training was 25% (interquartile range: 0%, 69%). Mandatory cardiac ICU time was 16 weeks (interquartile range: 13, 20) with variability in night coverage and number of other learners present. A minority of programmes (29%, 12/41) mandated other cardiac experiences. Median CHD surgical cases per year were 215 (interquartile range: 132, 338). When considering the number of annual cases per fellow, programmes with higher case volume were not always associated with the highest case number per fellow. CONCLUSIONS There is a continued trend toward dedicated cardiac ICUs in the United States, with significant variability in cardiac training during paediatric critical care medicine fellowship. As the trend toward dedicated cardiac ICUs continues and practices become more standardised, so should the education.
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Assessment of physician training and prediction of workforce needs in paediatric cardiac intensive care in the United States. Cardiol Young 2022; 32:1748-1753. [PMID: 34924098 DOI: 10.1017/s1047951121004893] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the training and the future workforce needs of paediatric cardiac critical care faculty. DESIGN REDCap surveys were sent May-August 2019 to medical directors and faculty at the 120 US centres participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database. Faculty and directors were asked about personal training pathway and planned employment changes. Directors were additionally asked for current faculty numbers, expected job openings, presence of training programmes, and numbers of trainees. Predictive modelling of the workforce was performed using respondents' data. Patient volume was projected from US Census data and compared to projected provider availability. MEASUREMENTS AND MAIN RESULTS Sixty-six per cent (79/120) of directors and 62% (294/477) of contacted faculty responded. Most respondents had training that incorporated critical care medicine with the majority completing training beyond categorical fellowship. Younger respondents and those in dedicated cardiac ICUs were more significantly likely to have advanced training or dual fellowships in cardiology and critical care medicine. An estimated 49-63 faculty enter the workforce annually from various training pathways. Based on modelling, these faculty will likely fill current and projected open positions over the next 5 years. CONCLUSIONS Paediatric cardiac critical care training has evolved, such that the majority of faculty now have dual fellowship or advanced training. The projected number of incoming faculty will likely fill open positions within the next 5 years. Institutions with existing or anticipated training programmes should be cognisant of these data and prepare graduates for an increasingly competitive market.
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Workforce demographics and unit structure in paediatric cardiac critical care in the United States. Cardiol Young 2022; 32:1628-1632. [PMID: 34857058 DOI: 10.1017/s1047951121004753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Epidemiology of Pediatric Critical Care Admissions in 43 United States Children's Hospitals, 2014-2019. Pediatr Crit Care Med 2022; 23:484-492. [PMID: 35435887 DOI: 10.1097/pcc.0000000000002956] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Cardiovascular Critical Care in Children. Pediatr Clin North Am 2022; 69:403-413. [PMID: 35667753 DOI: 10.1016/j.pcl.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pediatric cardiac critical care has evolved with advances in congenital heart surgery, interventional cardiac catheterization, and diagnostic advances. Debate remains over the optimal location of care and training background despite data showing that systems established in collaboration with multidisciplinary experts in the care of children with congenital heart disease are associated with the best outcomes. Operative mortality is low, and preventing morbidity is the new focus of the future. Advances in screening and fetal diagnosis, mechanical circulatory support, and collaborative research and quality improvement initiatives are reviewed in this article.
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Steurer MA, Tonna JE, Coyan GN, Burki S, Sciortino CM, Oishi PE. On-Hours Compared to Off-Hours Pediatric Extracorporeal Life Support Initiation in the United States Between 2009 and 2018-An Analysis of the Extracorporeal Life Support Organization Registry. Crit Care Explor 2022; 4:e0698. [PMID: 35620766 PMCID: PMC9113205 DOI: 10.1097/cce.0000000000000698] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We aimed to investigate whether there are differences in outcome for pediatric patients when extracorporeal life support (ECLS) is initiated on-hours compared with off-hours. DESIGN Retrospective cohort study. SETTING Ten-year period (2009-2018) in United States centers, from the Extracorporeal Life Support Organization registry. PATIENTS Pediatric (>30 d and <18 yr old) patients undergoing venovenous and venoarterial ECLS. INTERVENTIONS The primary predictor was on versus off-hours cannulation. On-hours were defined as 0700-1859 from Monday to Friday. Off-hours were defined as 1900-0659 from Monday to Thursday or 1900 Friday to 0659 Monday or any time during a United States national holiday. The primary outcome was inhospital mortality. The secondary outcomes were complications related to ECLS and length of hospital stay. MEASUREMENTS AND MAIN RESULTS In a cohort of 9,400 patients, 4,331 (46.1%) were cannulated on-hours and 5,069 (53.9%) off-hours. In the off-hours group, 2,220/5,069 patients died (44.0%) versus 1,894/4,331 (44.1%) in the on-hours group (p = 0.93). Hemorrhagic complications were lower in the off-hours group versus the on-hours group (hemorrhagic 18.4% vs 21.0%; p = 0.002). After adjusting for patient complexity and other confounders, there were no differences between the groups in mortality (odds ratio [OR], 0.95; 95% CI, 0.85-1.07; p = 0.41) or any complications (OR, 1.02; 95% CI, 0.89-1.17; p = 0.75). CONCLUSIONS Survival and complication rates are similar for pediatric patients when ECLS is initiated on-hours compared with off-hours. This finding suggests that, in aggregate, the current pediatric ECLS infrastructure in the United States provides adequate capabilities for the initiation of ECLS across all hours of the day.
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Affiliation(s)
- Martina A Steurer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health; Salt Lake City, UT
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Garrett N Coyan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, PA
| | - Sarah Burki
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, PA
| | - Christopher M Sciortino
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, PA
| | - Peter E Oishi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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Abstract
OBJECTIVES Define a set of entrustable professional activities for pediatric cardiac critical care that are recognized as the core activities of the subspecialty by a diverse group of pediatric cardiac critical care physicians and that can be broadly and consistently applied irrespective of training pathway. DESIGN Mixed methods study with sequential integration of qualitative and quantitative data. SETTING Structured telephone interviews of pediatric cardiac critical care medical directors at Pediatric Cardiac Critical Care Consortium centers followed by an electronic survey of pediatric cardiac critical care physician members of the Pediatric Cardiac Intensive Care Society from across the United States and internationally. SUBJECTS Pediatric cardiac intensive care physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty-four of 26 eligible Pediatric Cardiac Critical Care Consortium medical directors participated in the interviews. Based on qualitative analyses of interview data, we identified an initial set of nine entrustable professional activities. Fifty-eight of 185 eligible physicians completed a subsequent survey asking them to rate their agreement with the entrustable professional activities. It showed consensus (> 80% agreement) with the entire initial set of entrustable professional activities, with greater than 96% agreement in most cases. The feedback from free-text survey responses was incorporated to generate a final set of entrustable professional activities. CONCLUSIONS We generated a set of nine entrustable professional activities, which we believe can be broadly applied to any physician training in pediatric cardiac critical care, irrespective of individual training pathway. Next steps include incorporation of these entrustable professional activities into curriculum design and trainee assessment tools.
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Workload in the Cardiac ICU: You Down With APPs? Pediatr Crit Care Med 2021; 22:753-755. [PMID: 34397990 DOI: 10.1097/pcc.0000000000002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Simulation as an Educational Tool in the Pediatric Cardiac Intensive Care Unit. CURRENT PEDIATRICS REPORTS 2021; 9:52-59. [PMID: 34055476 PMCID: PMC8144691 DOI: 10.1007/s40124-021-00241-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 10/25/2022]
Abstract
Purpose of Review This review highlights the use of simulation as an educational tool in the highly specialized pediatric cardiac intensive care unit (PCICU). Recent Findings Healthcare simulation is used in high acuity medical environments to test healthcare systems. Healthcare simulation can improve team training, patient safety, and improve medical decision-making. Complex physiologies in the PCICU demand effective teamwork to consistently deliver high-quality patient care. Simulation-based PCICU learning objectives depend on a structured cognitive load framework to account for individual learner abilities, team constructs, and healthcare resources. Summary PCICU simulation programs are strengthened by utilizing traditional education theory, with careful consideration of complex physiologies, interprofessional personnel, and center-specific resources. Virtual platforms should continue to evolve to provide additional, more convenient venues for individual learners and teams. Healthcare systems should frequently intersect with simulation educators to create relevant learning objectives that will contribute to patient safety, improve team performance, and patient outcomes.
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Elia EG, Ge S, Bergersen L, Thiagarajan RR, Thornton J, Sleeper LA, Fynn-Thompson F, Mathieu D, Alexander PMA. A Monte Carlo Simulation Approach to Optimizing Capacity in a High-Volume Congenital Heart Pediatric Surgical Center. FRONTIERS IN HEALTH SERVICES 2021; 1:787358. [PMID: 36926489 PMCID: PMC10012657 DOI: 10.3389/frhs.2021.787358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022]
Abstract
Importance Elective surgeries are primarily scheduled according to surgeon availability with less consideration of patients' postoperative cardiac intensive care unit (CICU) length of stay. Furthermore, the CICU census can exhibit a high rate of variation in which the CICU is operating at over-capacity, resulting in admission delays and cancellations; or under-capacity, resulting in underutilized labor and overhead expenditures. Objective To identify strategies to reduce variation in CICU occupancy levels and avoid late patient surgery cancellation. Design Monte Carlo simulation study of the daily and weekly CICU census at Boston Children's Hospital Heart Center. Data on all surgical admissions to and discharges from the CICU at Boston Children's Hospital between September 1, 2009 and November 2019 were included to obtain the distribution of length of stay for the simulation study. The available data allows us to model realistic length of stay samples that include short and extended lengths of stay. Main Outcomes Annual number of patient surgical cancellations and change in average daily census. Results We demonstrate that the models of strategic scheduling would result in up to 57% reduction in patient surgical cancellations, increase the historically low Monday census and decrease the historically higher late-mid-week (Wednesday and Thursday) censuses in our center. Conclusions and Relevance Use of strategic scheduling may improve surgical capacity and reduce the number of annual cancellations. The reduction of peaks and valleys in the weekly census corresponds to a reduction of underutilization and overutilization of the system.
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Affiliation(s)
- Eleni G Elia
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
| | - Shirley Ge
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Jason Thornton
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States.,Department of Surgery, Harvard Medical School, Boston, MA, United States
| | - Derek Mathieu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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The Lay of the Land: Pediatric Cardiac Critical Care. Pediatr Crit Care Med 2020; 21:835-837. [PMID: 32890083 DOI: 10.1097/pcc.0000000000002458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Laussen PC. Sharing and learning through the Pediatric Cardiac Critical Care Consortium: Moving toward precision care. J Thorac Cardiovasc Surg 2020; 161:2195-2199. [PMID: 32680641 PMCID: PMC7286268 DOI: 10.1016/j.jtcvs.2020.05.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 10/27/2022]
Affiliation(s)
- Peter C Laussen
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
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