Cardiac Critical Care Fellowship Training in the United States and Canada: Pediatric Cardiac Intensive Care Society-Endorsed Subcompetencies to the 2022 Entrustable Professional Activities.

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. Mixed methods study with sequential integration of qualitative and quantitative data. 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. Pediatric cardiac intensive care physicians. None. 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. 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.

The specialty of pediatric cardiac critical care has undergone rapid scientific and clinical growth in the last 25 years. The Board of Directors of the Pediatric Cardiac Intensive Care Society assembled an updated list of sentinel references focused on the critical care of children with congenital and acquired heart disease. We encouraged board members to select articles that have influenced and informed their current practice or helped to establish the standard of care. The objective of this article is to provide clinicians with a compilation and brief summary of these updated 100 useful references. The list of 'One Hundred Useful References for Pediatric Cardiac Intensive Care' (2004) and relevant literature to the practice of cardiac intensive care. A subset of Pediatric Cardiac Intensive Care Society board members compiled the initial list of useful references in 2004, which served as the basis of the new updated list. Suggestions for relevant articles were submitted by the Pediatric Cardiac Intensive Care Society board members and selected pediatric cardiac intensivists with an interest in this project following the Society's meeting in 2010. Articles were considered for inclusion if they were named in the original list from 2004 or were suggested by Pediatric Cardiac Intensive Care Society board members and published before December 31, 2011. Following submission of the complete list by the Pediatric Cardiac Intensive Care Society board and contributing Society members, articles were complied by the two co-first authors (D.A., D.K.). The authors also performed Medline searches to ensure comprehensive inclusion of all relevant articles. The final list was then submitted to the Pediatric Cardiac Intensive Care Society board members, who ranked each publication. Rankings were compiled and the top 100 articles with the highest scores were selected for inclusion in this publication. The two co-first authors (D.A., D.K.) reviewed all existing summaries and developed summaries of the newly submitted articles. An updated compilation of 100 useful references for the critical care of children with congenital and acquired heart disease has been compiled and summarized here. Clinicians and trainees may wish to use this document as a reference for education in this complex and challenging subspecialty.

In the vast majority of Children's Hospitals, the critically ill patient can be found in one of three locations: the PICU, the neonatal ICU, and the cardiac ICU. Training, certification, and maintenance of certification for neonatology and critical care medicine are over seen by the Accreditation Council for Graduate Medical Education and American Board of Pediatrics. There is no standardization of training or oversight of certification and maintenance of certification for pediatric cardiac critical care. The curricula from the twenty 4th year pediatric cardiac critical care training programs were collated, along with the learning objectives from the Pediatric Cardiac Intensive Care Society published "Curriculum for Pediatric Cardiac Critical Care Medicine." This initiative is endorsed by the Pediatric Cardiac Intensive Care Society as a first step toward Accreditation Council for Graduate Medical Education oversight of training and American Board of Pediatrics oversight of maintenance of certification. A taskforce was established of cardiac intensivists, including the directors of all 4th year pediatric cardiac critical care training programs. Using modified Delphi methodology, learning objectives, rotational requirements, and institutional requirements for providing training were developed. In the current era of increasing specialized care in pediatric cardiac critical care, standardized training for pediatric cardiac critical care is paramount to optimizing outcomes.

To determine the feasibility of developing and implementing a multidisciplinary bootcamp for early-career Paediatric Cardiac Critical Care practitioners. A one-day pre-conference bootcamp at the Pediatric Cardiac Intensive Care Society Annual Meeting in December 2022. Physicians, fellows, nurses, advanced practice registered nurses, and respiratory therapists who work primarily in paediatric cardiac critical care units. A modified Delphi needs assessment with interprofessional content experts for the development of a mixed didactic and simulation-based bootcamp at the Pediatric Cardiac Intensive Care Society Annual Meeting in December 2022, with pre- and post-testing to evaluate knowledge gain and additional surveys to assess perceived value. Eighty-three course participants came from a variety of professions and represented institutions nationally and internationally. Most participants (77%) had two or more years of professional experience, aligning with the bootcamp's focus on advanced learners. The bootcamp received strong participant evaluations: 84.1% (37/44) strongly agreed that the bootcamp improved their clinical knowledge. Ninety-seven percent (43/44) reported increased confidence in the ability to care for paediatric cardiac critical care patients. The bootcamp demonstrated a significant improvement in participant knowledge, with pre-test scores averaging 54.9% (95% CI: 49.9-59.9) compared to post-test scores of 64.5% (95% CI: 59.7-69.2), achieving statistical significance (p < 0.05). Our pilot bootcamp has shown an improvement in immediate knowledge retention with valuable insights gathered to enhance future bootcamps. The results of this advanced interprofessional bootcamp evaluation will inform future iterations for providers in paediatric cardiac critical care.

Outcomes for children with heart disease improved over the past decades. Quality improvement (QI) research in paediatric cardiac critical care is a key driver of improvement. The availability and variability of QI research across the field is unknown. This project represents a step in understanding the role. The Pediatric Cardiac Intensive Care Society (PCICS) can serve to support institutions' needs, drive collaborations, and utilise available infrastructure at member institutions for improvement work. The PCICS Quality Improvement and Safety Committee developed a survey to assess the state of QI research. The survey was disseminated over several months and available via QR code at the World Congress of Pediatric Cardiology and Cardiac Surgery in 2023. Fifty-eight respondents completed the survey representing at least 38 unique institutions. Most respondents participated in QI research (52/58, 90%). Most QI projects were single centre (41% of respondents), and of those, the majority were from a minority of institutions (13 institutions [34% of total institutions]). QI support is available at slightly more than half of units, and 55% (32/58) have access to a QI specialist. QI support and rate of publications is significantly lower for small/medium units as compared to large units. Respondents suggested most interest from PCICS in networking with other members with similar project ideas (50/58, 86%). PCICS member institutions are committed to QI research, with limitations in support, local specialists, and networking. Increasing connectivity and accessibility to QI resources may reduce burden to individual members and institutions to achieve QI research.

To determine both the number of cardiac intensivists being trained by member institutions of the Pediatric Cardiac Intensive Care Society and the perceived need for these professionals. Web-based survey of pediatric cardiac intensive care unit program directors. A total of 54 directors completed the survey (41% response rate). Twelve pediatric cardiac critical care fellowship positions are offered each year among the responding Pediatric Cardiac Intensive Care Society institutions in the United States and Canada-only six of the 12 positions were filled in the academic year 2002-2003. Cardiac intensivist recruitment was ongoing at 25 of the programs surveyed (46%). An additional 45 cardiac intensivists will be sought during the next 1-3 yrs and 36 during the subsequent 3- to 5-yr period. There is a discrepancy between the current and growing need for trained pediatric cardiac intensivists and the graduation rate of these professionals from teaching programs.

Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.

Nursing turnover is a significant vulnerability in healthcare systems. Although adult critical care nurses are among the highest group of nurses leaving the workforce, we do not have information about pediatric cardiac critical care (PCCC) nurse turnover. We have, therefore, explored PCCC nursing turnover in focus groups recruited from interprofessional members of the Pediatric Cardiac Intensive Care Society (PCICS). Qualitative descriptive inquiry using focus groups and interviews. Interprofessional focus group discussions in 2022-2023. Thirty-four participants (representing < 4% of the PCICS membership) were involved in focus groups and interviews. The transcripts of focus groups/interviews were used to explore perspectives regarding PCCC nurse turnover, its potential impact, and the potential solutions to enhance retention. Content analysis coding was used to identify themes and subcategories to support data interpretation. Data were organized into three main themes: Nursing Turnover, Nursing Retention, and Solutions. For the themes of nursing turnover and nursing retention, there were two subcategories, meaning and impact. All participants reported that increased levels of nursing turnover impacted ICU morale. Higher turnover was also believed to increase patient vulnerability at the bedside, requiring higher levels of surveillance and support from the interprofessional team. Potential solutions to enhance retention included competitive salary and benefits packages, professional development for the multigenerational workforce, and a commitment to a healthy work environment. In 2022-2023, 34 PCICS members from the United States gave their perspectives and understanding of turnover in PCCC nurses. Nursing turnover and its impact on the team highlights the urgent need to collaboratively identify and implement solutions to enhance nurse retention in this area of highly specialized practice. The PCICS and other such organizations may have a role in addressing nursing shortages and continued turnover.

Off-label drug use in pediatrics has challenged the U.S. Food and Drug Administration (FDA). Historically, pharmaceutical companies have been willing to fund pediatric safety and efficacy trials but only for medications with a large market (vaccines and antibiotics). In the field of pediatric cardiac intensive care, the small number of patients and the widely varying physiologies challenge prospective clinical drug trials. There is a limited, if any, return on investment for the pharmaceutical company. However, in the past decade, there has been an increase in pediatric safety and efficacy trials as a result of the 1997 FDA Modernization Act (FDAMA) that was extended in 2002 under the Best Pharmaceutical for Children Act. The FDAMA allows companies performing an FDA-approved pediatric drug trial to extend their patent for an additional six months. Unfortunately, even well-run exclusivity clinical trials under the FDAMA do not necessarily result in a FDA-approved pediatric drug label. An example is milrinone, that has been shown to decrease low cardiac output syndrome in young infants following biventricular repair but remains off-label. Of perhaps greater challenge are drugs that are available in generic form (dopamine for example), where the incentives of the FDAMA do not apply. Maltz and associates, in a study published in this issue of World Journal for Pediatric and Congenital Heart Surgery, investigated off-label drug use in a pediatric cardiac intensive care unit (PCICU). They found that 36% of the prescribed drugs were off-label, with 94% of the patients receiving at least one off-label drug and 46% of the patients receiving greater than three off-label drugs. This is an important educational point, as most practitioners are likely unaware of which pharmaceutical agents are FDA approved for pediatrics. Not surprising, patients at higher risk were shown to receive more medications and more off-label medications. Other publications have described the off-label drug use in pediatric anesthesia and intensive care and in hospitalized children with congenital and acquired heart disease. Offlabel drug use is not confined to the pediatric critical care population but has also been described in adult critical care units. The report by Maltz and associates offers a description of the frequency of off-label drug use in one PCICU. It is important to discount any conclusion that off-label drug use was a causative factor for increased length of stay. Increased length of stay has been shown to be a surrogate for complexity of disease and intensity of care. In the study by Maltz and associates, there are far too many risk variables that were not included in the analysis. In addition, the number of patients enrolled in their study was small. It is primarily an observational study. The descriptive analysis does not control for severity of illness and complexity of disease. One should not conclude that the off-label drug use was unsafe or contributed to harm. The field of pediatric cardiac critical care has evolved since its infancy three decades ago. Due in part to advancements in pharmaceutical options, survival following neonatal heart surgery has improved, hospital length of stay has become shorter, and our ability to recover a patient from a significant event has improved. Many drugs used in pediatric cardiac critical care are brought into our environment through the expertise of other specialties (pediatric critical care, neonatology, adult critical care, anesthesiology), with modifications in their dosage and indications over time. A current example is the rapidly increasing use of dexmedetomidine, despite limited trials evaluating dose ranging or efficacy, complications, or potential drug interactions. Thus, safety and efficacy for many drugs used in pediatric cardiac critical care are a result of years of experience rather than clinical trials. The use of off-label medications is to benefit the individual patient, and the FDA is very clear that practitioners are able to use their professional judgment to determine these uses. Offlabel drug use is therefore common in both pediatric and adult critical care settings. Does this mean patients are at risk? There is no plausible data to support such a contention. Obviously, we all want to prescribe drugs that have been adequately tested so that we understand their safety and efficacy. We also want protection from litigation if there is an adverse event perceived to be related to off-label use of a medication. How do we get this data? Clinical trials are the gold standard for changes in

At the 14th Annual International Meeting for the Pediatric Cardiac Intensive Care Society, the authors presented a simulation workshop for junior multidisciplinary providers focused on cardiopulmonary interactions. We provide an overview of educational theories of particular relevance to curricular design for simulation-based or enhanced activities. We then demonstrate how these theories are applied to curriculum development for individuals to teams and for novice to experts. We review the role of simulation in cardiac intensive care education and the education theories that support its use. Finally, we demonstrate how a conceptual framework, SIMZones, can be applied to design effective simulation-based teaching.

Remarkable achievements have occurred in pediatric cardiac critical care over the past two decades. The specialty has become well defined and extremely resource intense. A great deal of focus has been centered on optimizing patient outcomes, particularly mortality and early morbidity, and this has been achieved through a focused and multidisciplinary approach to management. Delivering high-quality and safe care is our goal, and during the Risky Business symposium and simulation sessions at the Eighth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, December 2010, human factors, systems analysis, team training, and lessons learned from malpractice claims were presented.

Pediatric cardiac intensive care continues to evolve, with rapid advances in knowledge and improvement in clinical outcomes. In the past, the Board of Directors of the Pediatric Cardiac Intensive Care Society created and subsequently updated a list of sentinel references focused on the care of critically ill children with congenital and acquired heart disease. The objective of this article is to provide clinicians with a compilation and brief summary of updated and useful references that have been published since 2012. Pediatric Cardiac Intensive Care Society members were solicited via a survey sent out between March 20, 2017, and April 28, 2017, to provide important references that have impacted clinical care. The survey was sent to approximately 523 members. Responses were received from 45 members, of which some included multiple references. Following review of the list of references, and removing editorials, references were compiled by the first and last author. The final list was submitted to members of the society's Research Briefs Committee, who ranked each publication. Rankings were compiled and the references with the highest scores included. Research Briefs Committee members ranked the articles from 1 to 3, with one being highly relevant and should be included and 3 being less important and should be excluded. Averages were computed, and the top articles included in this article. The first (K.C.U.) and last author (K.M.G.) reviewed and developed summaries of each article. This article contains a compilation of useful references for the critical care of children with congenital and acquired heart disease published in the last 5 years. In conjunction with the prior version of this update in 2012, this article may be used as an educational reference in pediatric cardiac intensive care.

To present our center's experience with terminal extubation in 3 palliative critical care home transports from the Pediatric Cardiac Intensive Unit. All cases were identified from our Cardiovascular intensive care unit ( CVICU). Patients were terminally ill children with no other surgical or medical option who were transported home between 2014 and 2018, for terminal extubation and end-of-life care according to their families' wishes. The patients were 7, 9 months, and 19 years; and they had very complex and chronic conditions. The families were approached by the CVICU staff during multidisciplinary meetings, where goals of care were established. Parental expectations were clarified, and palliative care team was involved, as well as home hospice was arranged pre transfer. The transfer process was discussed and all the needs were established. All patients had unstable medical conditions, with needs for transport for withdrawal of life support and death at home. Each case needed a highly trained team to support life while in transport. The need of these patients required coordination with home palliative care services, as well as community resources due to difficulty to get in their homes. Transportation of pediatric cardiac critical care patients for terminal extubation at home is a relatively infrequent practice. It is a feasible alternative for families seeking out of the hospital end-of-life care for their critically ill and technology dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports.

There are substantial knowledge gaps, practice variation, and paucity of controlled trials owing to the relatively small number of patients with critical heart disease. The Pediatric Cardiac Intensive Care Society has recognised this knowledge gap as an area needing a more comprehensive and evidence-based approach to the management of the critically ill child with heart disease. To address this, the Pediatric Cardiac Intensive Care Society created a scientific statements and white papers committee. Scientific statements and white papers will present the current state-of-the-art in areas where controversy exists, providing clinicians with guidance in diagnostic and therapeutic strategies, particularly where evidence-based data are lacking. This paper provides a template for other societies and organisations faced with the task of developing scientific statements and white papers. We describe the methods used to perform a systematic literature search and evidence rating that will be used by all scientific statements and white papers emerging from the Pediatric Cardiac Intensive Care Society. The Pediatric Cardiac Intensive Care Society aims to revolutionise the care of children with heart disease by shifting our efforts from individual institution-based practices to national standardised protocols and to lay the ground work for multicentre high-impact research directions.

To assess the training and the future workforce needs of paediatric cardiac critical care faculty. 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. 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. 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.