The American Heart Association's recent scientific statement on cardiac critical care: implications for pediatric practice

High variability in cardiac education and experiences during United States paediatric critical care fellowships

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.

An International Survey Comparing Different Physician Models for Health Care Delivery to Critically Ill Children With Heart Disease

OBJECTIVES

To explore relationships between the training background of cardiac critical care attending physicians and self-reported perceived strengths and weaknesses in their ability to provide clinical care.

DESIGN

Cross-sectional observational survey sent worldwide to ~550 practicing cardiac ICU attending physicians.

SETTING

Hospitals providing cardiac critical care.

SUBJECTS

Practicing cardiac critical care physicians.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We received responses from 243 ICU attending physicians from 82 centers (14 countries). The primary training background of the respondents included critical care (62%), dual training in critical care and cardiology (16%), cardiology (14%), and other (8%). We received 49 responses from medical directors in nine countries, who reported that the predominant training background for attending physicians who provide cardiac intensive care at their institutions were critical care (58%), dual trained (18%), cardiology (12%), and other (11%). A greater proportion of physicians trained in either critical care or dual-training reported feeling confident managing multiple organ failure, neurologic conditions, brain death, cardiac arrest, and performing procedures like advanced airway placement and inserting chest- and abdominal-drains. In contrast, physicians with cardiology and dual-training reported feeling more confident managing intractable arrhythmias, understanding cardiopulmonary interactions, and interpreting echocardiogram, electrocardiogram, and cardiac catheterization. Overall, only 57% of the respondents felt comfortable based on their current training background to manage patients with complex cardiac issues without collaboration with other specialists.

CONCLUSIONS

Our survey demonstrates that intensivists trained in critical care are more comfortable with critical care skills, cardiology-trained intensivists are more comfortable with cardiology skills, and dual-trained physicians are comfortable with both critical care skills and cardiology skills. These findings may help inform future efforts to optimize the educational curriculum and training pathways for future cardiac intensivists. These data may also be used to shape continuing medical education activities for cardiac intensivists who have already completed their training.

Opportunities for training to advance the care for adults with congenital heart disease with advanced circulatory failure

Heart failure is an emerging issue with important implications in adult patients with congenital heart disease. Practitioners with expertise in both adult congenital heart disease and heart failure are needed to manage this growing and often complex population. In the United States, the optimal training pathway to enable practitioners to best care for these patients is ill-defined. This article explores possibilities and issues that interested trainees may encounter during their training experience.

Clinical and laboratory variables associated with mortality outcome in the post-operative pediatric cardiac surgery

Abstract Objective: To identify clinical and laboratory variables associated with mortality outcome in the post-operative pediatric cardiac surgery. Method: Descriptive, retrospective study carried out in three reference centers in Rio de Janeiro State, Brazil, from the collection in 120 medical reports of children with Congenital Heart Disease undergoing surgery. Data were analyzed by using central tendency measures and association tests between variables and mortality. p < 0.05 was considered. Results: We observed the mortality outcome in 10 (7.2%) of the children after analyzing all medical records. The dialysis and extracorporeal circulation times, aortic and surgical clamping variables were associated with mortality outcome (p < 0.05). Conclusion and Implications for practice: The identification of these variables is a major factor for the control of the main post-operative complications, allowing the recognition of subtle clinical alterations requiring attention and immediate intervention with consequent reduction of mortality.

Education and Training in Pediatric Cardiac Critical Care

Pediatric cardiac critical care is a new and emerging field. There is no standardization to the current education provided, and high-quality patient outcomes require such standardization. For physicians, this includes fellowship training, specific competencies, and a certification process. For advanced practice providers, a standardized curriculum as well as a certification process is needed. There is evidence that supports a finding that critical care nursing experience may have a positive impact on outcomes from pediatric cardiac surgery. A rigorous orientation and meaningful continuing education may augment that. For all disciplines and levels of expertise, simulation is a useful modality in the education in pediatric cardiac critical care.

Training fellows and residents in paediatric cardiac critical care

As pediatric cardiac critical care becomes more sub-specialized it is reasonable to assume that dedicated units may provide a better infrastructure for improved multidisciplinary care, cardiac-specific patient safety initiatives, and dedicated training of fellows and residents. The knowledge base required to optimally manage pediatric patients with critical cardiac disease has evolved sufficiently to consider a standardized training curriculum and board certification for pediatric cardiac critical care. This strategy would potentially provide consistency of training and healthcare and improve quality of care and patient safety.

Diagnósticos de Enfermagem em crianças com cardiopatias congênitas: mapeamento cruzado

Resumo Objetivo Identificar Diagnósticos de Enfermagem da NANDA International a partir dos termos encontrados nos registros de Enfermagem de crianças com cardiopatias congênitas hospitalizadas e verificar associação entre estes termos e os Diagnósticos de Enfermagem mapeados. Métodos Estudo observacional, transversal desenvolvido por mapeamento dos termos nos registros de Enfermagem de crianças hospitalizadas de até 2 anos com cardiopatia congênita. A associação entre os termos e os Diagnósticos de Enfermagem mais frequentes foi avaliada pelo teste t de Student ou qui quadrado. Resultados Nos 82 registros analisados, os Diagnósticos de Enfermagem mais frequentes foram Risco de infecção (81,7%), Troca de gases prejudicada (46,3%) e Intolerância à atividade (36,6%). O termo “cianótico” e “hipocorado” tiveram relação estatisticamente significativa com o diagnóstico Troca de gases prejudicada. Conclusão Observou-se que os termos registrados em prontuários de crianças com cardiopatias congênitas permitiram a identificação dos Diagnósticos de Enfermagem da NANDA International, além da verificação das associações.

An impact evaluation of a newly developed pediatric cardiac intensive care unit

PURPOSE

The highly complex pediatric patients with congenital heart disease require interprofessional teamwork and collaboration to ensure high-quality outcomes with low mortality and morbidity (Congenit Heart Dis. 2013;8:3-19). The purpose of this study was to conduct an impact evaluation for a newly formed pediatric cardiac intensive care unit (PCICU) and to answer: Is there a difference between the pediatric intensive care unit and the PCICU on clinical outcome measures of pediatric cardiac postoperative patients and nursing resources?

DESIGN

A retrospective pretest/posttest design was used with the independent variables being type of intensive care unit. The confounding variables included demographic data, clinical outcome data, registered nurse (RN) staffing data, and RN turnover data.

SETTING

The setting was a large, level I pediatric medical and surgical intensive care unit (ICU) located at a children's hospital within an academic medical center.

SAMPLE

The population was pediatric cardiac postoperative patients. Patients excluded were those older than 18 years or cases without a Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality Category score of 1 through 5.

METHODS

Owen's impact evaluation method and descriptive statistical measures, t test and Pearson χ test, were used for analysis.

RESULTS

Demographic data were comparable between the pediatric intensive care unit (n = 296) and PCICU (n = 333). No statistical differences were found in several of the clinical outcome measures. Statistically significant differences were found in surgeon (P = .00) and RN nursing hours per patient day for all cardiac patients (P = .01). The PCICU time frame had a higher RN turnover rate.

CONCLUSIONS

The majority of quality measures were not statistically different between the 2 ICUs. Even though statistical significance was not reached, the clinical impact of the PCICU's reduction in patient infections, mortality, and ICU length of stay was noted.

IMPLICATIONS

This evaluation has provided organizational leaders the quality indicators and costs that have been impacted with the addition of interprofessional teamwork and coordination of care through the development of a PCICU.