1
|
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.
Collapse
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
| |
Collapse
|
2
|
Alcamo AM, Becker AE, Barren GJ, Hayes K, Pennington JW, Curley MA, Tasker RC, Balamuth F, Weiss SL, Fitzgerald JC, Topjian AA. Diagnostic Identification of Acute Brain Dysfunction in Pediatric Sepsis and Septic Shock in the Electronic Health Record: A Comparison of Four Definitions in a Reference Dataset. Pediatr Crit Care Med 2024; 25:740-747. [PMID: 38738953 PMCID: PMC11300159 DOI: 10.1097/pcc.0000000000003529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Acute brain dysfunction (ABD) in pediatric sepsis has a prevalence of 20%, but can be difficult to identify. Our previously validated ABD computational phenotype (CP ABD ) used variables obtained from the electronic health record indicative of clinician concern for acute neurologic or behavioral change. We tested whether the CP ABD has better diagnostic performance to identify confirmed ABD than other definitions using the Glasgow Coma Scale or delirium scores. DESIGN Diagnostic testing in a curated cohort of pediatric sepsis/septic shock patients. SETTING Quaternary freestanding children's hospital. SUBJECTS The test dataset comprised 527 children with sepsis/septic shock managed between 2011 and 2021 with a prevalence (pretest probability) of confirmed ABD of 30% (159/527). MEASUREMENTS AND MAIN RESULTS CP ABD was based on use of neuroimaging, electroencephalogram, and/or administration of new antipsychotic medication. We compared the performance of the CP ABD with three GCS/delirium-based definitions of ABD-Proulx et al, International Pediatric Sepsis Consensus Conference, and Pediatric Organ Dysfunction Information Update Mandate. The posttest probability of identifying ABD was highest in CP ABD (0.84) compared with other definitions. CP ABD also had the highest sensitivity (83%; 95% CI, 76-89%) and specificity (93%; 95% CI, 90-96%). The false discovery rate was lowest in CP ABD (1-in-6) as was the false omission rate (1-in-14). Finally, the prevalence threshold for the definitions varied, with the CP ABD being the definition closest to 20%. CONCLUSIONS In our curated dataset of pediatric sepsis/septic shock, CP ABD had favorable characteristics to identify confirmed ABD compared with GCS/delirium-based definitions. The CP ABD can be used to further study the impact of ABD in studies using large electronic health datasets.
Collapse
Affiliation(s)
- Alicia M. Alcamo
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew E. Becker
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory J. Barren
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Katie Hayes
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey W. Pennington
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Martha A.Q. Curley
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, The University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
| | - Fran Balamuth
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott L. Weiss
- Division of Critical Care Medicine, Nemours Children’s Hospital, Wilmington, Delaware, USA
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexis A. Topjian
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Agrawal S, Abecasis F, Jalloh I. Neuromonitoring in Children with Traumatic Brain Injury. Neurocrit Care 2024; 40:147-158. [PMID: 37386341 PMCID: PMC10861621 DOI: 10.1007/s12028-023-01779-1] [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: 05/19/2022] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
Traumatic brain injury remains a major cause of mortality and morbidity in children across the world. Current management based on international guidelines focuses on a fixed therapeutic target of less than 20 mm Hg for managing intracranial pressure and 40-50 mm Hg for cerebral perfusion pressure across the pediatric age group. To improve outcome from this complex disease, it is essential to understand the pathophysiological mechanisms responsible for disease evolution by using different monitoring tools. In this narrative review, we discuss the neuromonitoring tools available for use to help guide management of severe traumatic brain injury in children and some of the techniques that can in future help with individualizing treatment targets based on advanced cerebral physiology monitoring.
Collapse
Affiliation(s)
- Shruti Agrawal
- Department of Paediatric Intensive Care, Cambridge University Hospitals National Health Service Foundation Trust, Level 3, Box 7, Addenbrookes Hospital Hills Road, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
| | - Francisco Abecasis
- Paediatric Intensive Care Unit, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ibrahim Jalloh
- University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| |
Collapse
|
4
|
Riggs BJ, Carpenter JL. Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care. Pediatr Neurol 2023; 149:187-198. [PMID: 37748977 DOI: 10.1016/j.pediatrneurol.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023]
Abstract
The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.
Collapse
Affiliation(s)
- Becky J Riggs
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, Maryland
| |
Collapse
|
5
|
Tasker RC. Editor's Choice Articles for October. Pediatr Crit Care Med 2023; 24:791-794. [PMID: 38412367 DOI: 10.1097/pcc.0000000000003353] [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: 02/29/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
| |
Collapse
|
6
|
Miksa M. Beyond Survival: Insights From the Phenotyping Sepsis-Induced Multiple Organ Failure Study on the Neurological Impact of Pediatric Sepsis. Pediatr Crit Care Med 2023; 24:877-880. [PMID: 38412371 DOI: 10.1097/pcc.0000000000003316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Michael Miksa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| |
Collapse
|
7
|
Brown KL, Agrawal S, Kirschen MP, Traube C, Topjian A, Pressler R, Hahn CD, Scholefield BR, Kanthimathinathan HK, Hoskote A, D'Arco F, Bembea M, Manning JC, Hunfeld M, Buysse C, Tasker RC. The brain in pediatric critical care: unique aspects of assessment, monitoring, investigations, and follow-up. Intensive Care Med 2022; 48:535-547. [PMID: 35445823 PMCID: PMC10082392 DOI: 10.1007/s00134-022-06683-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/15/2022] [Indexed: 02/05/2023]
Abstract
As survival after pediatric intensive care unit (PICU) admission has improved over recent years, a key focus now is the reduction of morbidities and optimization of quality of life for survivors. Neurologic disorders and direct brain injuries are the reason for 11-16% of admissions to PICU. In addition, many critically ill children are at heightened risk of brain injury and neurodevelopmental difficulties affecting later life, e.g., complex heart disease and premature birth. Hence, assessment, monitoring and protection of the brain, using fundamental principles of neurocritical care, are crucial to the practice of pediatric intensive care medicine. The assessment of brain function, necessary to direct appropriate care, is uniquely challenging amongst children admitted to the PICU. Challenges in assessment arise in children who are unstable, or pharmacologically sedated and muscle relaxed, or who have premorbid abnormality in development. Moreover, the heterogeneity of diseases and ages in PICU patients, means that high caliber evidence is harder to accrue than in adult practice, nonetheless, great progress has been made over recent years. In this 'state of the art' paper about critically ill children, we discuss (1) patient types at risk of brain injury, (2) new standardized clinical assessment tools for age-appropriate, clinical evaluation of brain function, (3) latest evidence related to cranial imaging, non-invasive and invasive monitoring of the brain, (4) the concept of childhood 'post intensive are syndrome' and approaches for neurodevelopmental follow-up. Better understanding of these concepts is vital for taking PICU survivorship to the next level.
Collapse
Affiliation(s)
- Kate L Brown
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK. .,Institute of Cardiovascular, Science University College London, London, UK.
| | - Shruti Agrawal
- Paediatric Intensive Care Unit Addenbrookes Hospital, Cambridge, UK
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, USA, Philadelphia.,University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Chani Traube
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, USA, Philadelphia.,University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ronit Pressler
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK.,University College London Institute of Child Health, London, UK
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Barnaby R Scholefield
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Hari Krishnan Kanthimathinathan
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Aparna Hoskote
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK.,Institute of Cardiovascular, Science University College London, London, UK
| | - Felice D'Arco
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK.,University College London Institute of Child Health, London, UK
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph C Manning
- Nottingham Children's Hospital and Neonatology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Centre for Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatric Neurology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corinne Buysse
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Selwyn College, Cambridge University, Cambridge, UK
| |
Collapse
|
8
|
Tasker RC. Editor's Choice Articles for May. Pediatr Crit Care Med 2021; 22:443-444. [PMID: 37611931 DOI: 10.1097/pcc.0000000000002752] [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]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Selwyn College, Cambridge University, Cambridge, United Kingdom
| |
Collapse
|
9
|
Improving "Neuro Checks" in Neonatal ICU and PICU Is a Serial Neurologic Assessment in Pediatrics. Pediatr Crit Care Med 2021; 22:512-514. [PMID: 33953135 DOI: 10.1097/pcc.0000000000002711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|