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Tabbutt S, Taylor MB, Krawczeski CD. Should Physicians Caring for Children With Critical Heart Disease Undergo Specialized Training and Certification? Pediatr Crit Care Med 2024; 25:580-582. [PMID: 38836715 DOI: 10.1097/pcc.0000000000003505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Affiliation(s)
- Sarah Tabbutt
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Mary B Taylor
- Department of Pediatrics, University of Mississippi, Jackson, MS
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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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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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Abstract
Congenital heart disease is a major public health concern in the United States. Outcomes of surgery for children with congenital heart disease have dramatically improved over the last several decades with current aggregate operative mortality rates approximating 3%, inclusive of all ages and defects. However, there remains significant variability among institutions, especially for higher-risk and more complex patients. As health care moves toward the quadruple aim of improving patient experience, improving the health of populations, lowering costs, and increasing satisfaction among providers, congenital heart surgery programs must evolve to meet the growing scrutiny, demands, and expectations of numerous stakeholders. Improved outcomes and reduced interinstitutional variability are achieved through prioritization of quality assurance and improvement.
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Affiliation(s)
- Timothy W Pettitt
- Department of Pediatric Cardiovascular Surgery, Children's Hospital of New Orleans, New Orleans, LA.,Department of Surgery, Louisiana State University Health Science Center, New Orleans, LA
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Johnson JT, Wilkes JF, Menon SC, Tani LY, Weng HY, Marino BS, Pinto NM. Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery. J Thorac Cardiovasc Surg 2018; 155:2606-2614.e5. [PMID: 29550071 DOI: 10.1016/j.jtcvs.2018.01.100] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/26/2017] [Accepted: 01/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. METHODS We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. RESULTS Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. CONCLUSIONS Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery.
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Affiliation(s)
- Joyce T Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill.
| | - Jacob F Wilkes
- Intermountain Healthcare, Pediatric Clinical Program, Salt Lake City, Utah
| | - Shaji C Menon
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah at Primary Children's Hospital, Salt Lake City, Utah
| | - Lloyd Y Tani
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah at Primary Children's Hospital, Salt Lake City, Utah
| | - Hsin-Yi Weng
- Study Design and Biostatistics Center, University of Utah, School of Medicine, Salt Lake City, Utah
| | - Bradley S Marino
- Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nelangi M Pinto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah at Primary Children's Hospital, Salt Lake City, Utah
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Murni IK, Musa NL. The Need for Specialized Pediatric Cardiac Critical Care Training Program in Limited Resource Settings. Front Pediatr 2018; 6:59. [PMID: 29594089 PMCID: PMC5861149 DOI: 10.3389/fped.2018.00059] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/27/2018] [Indexed: 12/30/2022] Open
Abstract
Congenital heart disease (CHD) is one of the major global health problems with the highest birth prevalence in low- and middle-income countries. In these populous countries, basic health services for the children with CHD, including surgery, are lacking. Even though surgery is performed, outcome after cardiac surgery is influenced by the quality of the postoperative management with a reported high morbidity and mortality. Henceforth, there is an urgent need for comprehensive interventions to provide high quality cardiac intensive care programs to improve the quality of pediatric cardiac surgery services in order to address high morbidity and mortality after cardiac surgery. The development and training of the health workers in the field of pediatric cardiac intensive care program is required. It is imperative to conduct this training prior to actual implementation of the program in limited resources settings.
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Affiliation(s)
- Indah K Murni
- Department of Pediatrics, Dr Sardjito Hospital, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ndidiamaka L Musa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, United States
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McBride ME, Beke DM, Fortenberry JD, Imprescia A, Callow L, Justice L, Bronicki RA. Education and Training in Pediatric Cardiac Critical Care. World J Pediatr Congenit Heart Surg 2017; 8:707-714. [PMID: 29187102 DOI: 10.1177/2150135117727258] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Mary E McBride
- 1 Division of Cardiology and Critical Care Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,2 Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - James D Fortenberry
- 4 Section of Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Louise Callow
- 5 Advanced Practice Nurse Cardiac Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Lindsey Justice
- 6 The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ronald A Bronicki
- 7 Department of Pediatrics, Section of Critical Care Medicine and Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Abstract
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.
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Abstract
BACKGROUND Although attention to neurologic injuries and illnesses in pediatric critical care is not new, a sub-specialized field of pediatric neurocritical care has only recently been recognized. Pediatric neurocritical care is an emerging area of clinical and investigative focus. Little is known about the prevalence of specialized pediatric neurocritical care services nor about perceptions regarding how it is impacting medical practice. This survey sought to capture perceptions about an emerging area of specialized pediatric neurocritical care among practitioners in intersecting disciplines, including pediatric intensivists, pediatric neurologits and pediatric neurosurgeons. METHODS A web-based survey was distributed via email to members of relevant professional societies and groups. Survey responses were analyzed using descriptive statistics. Differences in responses between groups of respondents were analyzed using Chi-squared analysis where appropriate. MAIN RESULTS Specialized clinical PNCC programs were not uncommon among the survey respondents with 20% currently having a PNCC service at their institution. Despite familiarity with this area of sub-specialization among the survey respondents, the survey did not find consensus regarding its value. Overall, 46% of respondents believed that a specialized clinical PNCC service improves the quality of care of critically ill children. Support for PNCC sub-specialization was more common among pediatric neurologists and pediatric neurosurgeons than pediatric intensivists. This survey found support across specialties for creating PNCC training pathways for both pediatric intensivists and pediatric neurologists with an interest in this specialized field. CONCLUSIONS PNCC programs are not uncommon; however, there is not clear agreement on the optimal role or benefit of this area of practice sub-specialization. A broader dialog should be undertaken regarding the emerging practice of pediatric neurocritical care, the potential benefits and drawbacks of this partitioning of neurology and critical care medicine practice, economic and other practical factors, the organization of clinical support services, and the formalization of training and certification pathways for sub-specialization.
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Reddy NS, Kappanayil M, Balachandran R, Jenkins KJ, Sudhakar A, Sunil GS, Raj RB, Kumar RK. Preoperative Determinants of Outcomes of Infant Heart Surgery in a Limited-Resource Setting. Semin Thorac Cardiovasc Surg 2015; 27:331-8. [PMID: 26708380 DOI: 10.1053/j.semtcvs.2015.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 11/11/2022]
Abstract
We studied the effect of preoperative determinants on early outcomes of 1028 consecutive infant heart operations in a limited-resource setting. Comprehensive data on pediatric heart surgery (January 2010-December 2012) were collected prospectively. Outcome measures included in-hospital mortality, prolonged ventilation (>48 hours), and bloodstream infection (BSI) after surgery. Preoperative variables that showed significant individual association with outcome measures were entered into a logistic regression model. Weight at birth was low in 224 infants (21.8%), and failure to thrive was common (mean-weight Z score at surgery was 2.72 ± 1.7). Preoperatively, 525 infants (51%) needed intensive care, 69 infants (6.7%) were ventilated, and 80 infants (7.8%) had BSI. In-hospital mortality (4.1%) was significantly associated with risk adjustment for congenital heart surgery-1 (RACHS-1) risk category (P < 0.001). Neonatal status, preoperative BSI, and requirement of preoperative intensive care and ventilation had significant individual association with adverse outcomes, whereas low birth weight, prematurity, and severe failure to thrive (weight Z score <-3) were not associated with adverse outcomes. On multivariable logistic regression analysis, preoperative sepsis (odds ratio = 2.86; 95% CI: 1.32-6.21; P = 0.008) was associated with mortality. Preoperative intensive care unit stay, ventilation, BSI, and RACHS-1 category were associated with prolonged postoperative ventilation and postoperative sepsis. Neonatal age group was additionally associated with postoperative sepsis. Although severe failure to thrive was common, it did not adversely affect outcomes. In conclusions, preoperative BSI, preoperative intensive care, and mechanical ventilation are strongly associated with adverse outcomes after infant cardiac surgery in this large single-center experience from a developing country. Failure to thrive and low birth weight do not appear to adversely affect surgical outcomes.
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Affiliation(s)
- N Srinath Reddy
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - Mahesh Kappanayil
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Cochin, Kerala, India.
| | - Rakhi Balachandran
- Department of Cardiac Anesthesiology-Critical Care, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children׳s Hospital, Boston, Massachusetts
| | - Abish Sudhakar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - G S Sunil
- Department of Pediatric Cardiac Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - R Benedict Raj
- Department of Pediatric Cardiac Surgery, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - R Krishna Kumar
- Department of Cardiac Anesthesiology-Critical Care, Amrita Institute of Medical Sciences, Cochin, Kerala, India
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Kabbani MS, Hijazi O, Elbarbary M, Ismail S, Shaath G, Jijeh A. Pediatric cardiac intensive care at the King Abdulaziz Cardiac Center. Eur Heart J Suppl 2014. [DOI: 10.1093/eurheartj/suu017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Balachandran R, Nair SG, Gopalraj SS, Vaidyanathan B, Kumar RK. Dedicated pediatric cardiac intensive care unit in a developing country: Does it improve the outcome? Ann Pediatr Cardiol 2012; 4:122-6. [PMID: 21976869 PMCID: PMC3180967 DOI: 10.4103/0974-2069.84648] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION AND AIM Focussed cardiac intensive care is known to produce better outcomes. We have evaluated the benefits of a dedicated Pediatric Cardiac Intensive Care Unit (PCICU) in the early postoperative outcomes of patients undergoing surgery for congenital heart disease. METHODS Prospectively collected data of 634 consecutive patients who underwent congenital heart surgery from September 2008 to September 2009 were analyzed. Midway through this period a dedicated PCICU was started. The patients who were treated in this new PCICU formed the study group (Group B, n = 318). The patients who were treated in a common postoperative cardiac surgery ICU formed the control group (Group A, n = 316). Early postoperative outcomes between the two groups were compared. RESULTS The two groups were comparable with respect to demographic data and intraoperative variables. The duration of mechanical ventilation in the dedicated pediatric cardiac ICU group (32.22 ± 52.02 hours) was lower when compared with the combined adult and pediatric surgery ICU group (42.92 ± 74.24 hours, P= 0.04). There was a shorter duration of ICU stay in the dedicated pediatric cardiac ICU group (2.69 ± 2.9 days vs. 3.43 ± 3.80 days, P = 0.001). The study group also showed a shorter duration of inotropic support and duration of invasive lines. The incidence of blood stream infections was also lower in the dedicated pediatric ICU group (5.03 vs. 9.18%, P = 0.04). A subgroup analysis of neonates and infants <1 year showed that the advantages of a dedicated pediatric intensive care unit were more pronounced in this group of patients. CONCLUSIONS Establishment of a dedicated pediatric cardiac intensive care unit has shown better outcomes in terms of earlier extubation, de-intensification, and discharge from the ICU. Blood stream infections were also reduced.
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Affiliation(s)
- Rakhi Balachandran
- Department of Anesthesia, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
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Balachandran R, Nair SG, Kumar RK. Establishing a pediatric cardiac intensive care unit - Special considerations in a limited resources environment. Ann Pediatr Cardiol 2011; 3:40-9. [PMID: 20814475 PMCID: PMC2921517 DOI: 10.4103/0974-2069.64374] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Pediatric cardiac intensive care has evolved as a distinct discipline in well-established pediatric cardiac programs in developed nations. With increasing demand for pediatric heart surgery in emerging economies, a number of new programs are being established. The development of robust pediatric cardiac intensive care units (PCICU) is critical to the success of these programs. Because of substantial resource limitations existing models of PCICU care cannot be applied in their existing forms and structure. A number of challenges need to be addressed to deliver pediatric cardiac intensive care in the developing world. Limitations in infrastructure, human, and material resources call for a number of innovations and adaptations. Additionally, a variety of strategies are required to minimize costs of care to the individual patient. This review provides a framework for the establishment of a new PCICU program in face of resource limitations typically encountered in the developing world and emerging economies.
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Affiliation(s)
- Rakhi Balachandran
- Pediatric Cardiac Intensive Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Su L, Munoz R. Isn't it the right time to address the impact of pediatric cardiac intensive care units on medical education? Pediatrics 2007; 120:e1117-9. [PMID: 17846145 DOI: 10.1542/peds.2006-2487] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lillian Su
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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