Academic Pediatric Intensive Care Unit Research Articles

Extending the radius of family-centered care in the pediatric cardiac intensive care unit through virtual rounding.

The arrival of COVID-19 brought urgent limitation of visitation in hospitals across the country. Family-centered care and its delivery rapidly changed and left the family behind-unable to actively participate in their loved one's care. A southeastern academic medical center pediatric cardiac intensive care unit (PCICU) needed to augment family-centered medical rounds when parents could not be at the bedside. No alternative to physical presence for daily medical rounds existed in the PCICU. A virtual rounding (VR) program was implemented allowing parents of patients admitted to PCICU to join medical rounds remotely through teleconferencing. Preintervention and postintervention rounding times, staff perceptions of the program, and parental satisfaction scores using the Pediatric Family Satisfaction in the Intensive Care Unit (pFS-ICU) tool were measured. This quality improvement project implemented a VR program offered to all families of patients in the PCICU. VR did not increase rounding times after implementation (p = .673). Staff satisfaction surveys revealed that staff felt the VR program did not prolong rounding times (p ≤ 0.001), workload impact perceptions improved after intervention (p = <0.001), and staff felt VR should be offered to families in PCICU (p ≤ 0.001). Only nine pFS-ICU surveys were completed giving the family a limited voice in the evaluation of this project. This project demonstrates that VR can be successfully implemented for family engagement without increased burden on staff.

P0078 / #1967: QUIET TIME: IMPACT OF AN ENVIRONMENTAL INTERVENTION ON NOISE AND DELIRIUM SCREENING AND SCORES IN THE PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: Pediatric delirium increases mortality, cost, and length of hospital stay, yet is inconsistently screened for in our academic Pediatric Intensive Care Unit (PICU) using the Cornell Assessment of Pediatric Delirium (CAPD). We evaluate the impact of an environmental intervention, Quiet Time, on PICU noise and CAPD screening and scores. Methods: Quiet Time was implemented daily from 1-3pm indefinitely with text reminders to all PICU clinical staff to dim lights and lower voices. Nurses were surveyed to evaluate perceived noise level and impact on patient health. Chart review was used to assess four day’s duration of CAPD screening frequency and prevalence of patients screening positive for delirium (score ≥9/32), one week before and one month after Quiet Time implementation. Results: Before Quiet Time implementation, nurses (n=21) rated noise somewhat loud (81%), neither loud/quiet (14%), or somewhat quiet (5%). Noise impact was rated extremely disruptive (33%) or somewhat disruptive (67%). Of 35 patients, 57% were CAPD screened, of which 17% screened positive for delirium. After implementation, nurses (n=16) rated noise level somewhat loud (19%), neither loud/quiet (37%), or somewhat quiet (44%). Noise impact was rated somewhat restful (25%), neither disruptive nor restful (31%), somewhat disruptive (38%), or extremely disruptive (6%). Of 32 patients, 69% were CAPD screened, of which 25% screened positive for delirium. Conclusions: After Quiet Time implementation, noise level and disruption decreased while prevalence of patients screening positive for delirium increased, possibly due to increased CAPD screening frequency. Our data suggest that Quiet Time promotes a quieter environment and increases delirium screening.

Derivation and Validation of Novel Phenotypes of Multiple Organ Dysfunction Syndrome in Critically Ill Children

Multiple organ dysfunction syndrome (MODS) is a dynamic and heterogeneous process associated with high morbidity and mortality in critically ill children. To determine whether data-driven phenotypes of MODS based on the trajectories of 6 organ dysfunctions have prognostic and therapeutic relevance in critically ill children. This cohort study included 20 827 pediatric intensive care encounters among 14 285 children admitted to 2 large academic pediatric intensive care units (PICUs) between January 2010 and August 2016. Patients were excluded if they were older than 21 years or had undergone cardiac surgery. The 6 subscores of the pediatric Sequential Organ Failure Assessment (pSOFA) score were calculated for the first 3 days, including the subscores for respiratory, cardiovascular, coagulation, hepatic, neurologic, and renal dysfunctions. MODS was defined as a pSOFA subscore of at least 2 in at least 2 organs. Encounters were split in a 80:20 ratio for derivation and validation, respectively. The trajectories of the 6 subscores were used to derive a set of data-driven phenotypes of MODS using subgraph-augmented nonnegative matrix factorization in the derivation set. Data analysis was conducted from March to October 2019. The primary exposure was phenotype membership. In the subset of patients with vasoactive-dependent shock, the interaction between hydrocortisone and phenotype membership and its association with outcomes were examined in a matched cohort. The primary outcome was in-hospital mortality. Secondary outcomes included persistent MODS on day 7, and vasoactive-free, ventilator-free, and hospital-free days. Regression analysis was used to adjust for age, severity of illness, immunocompromised status, and study site. There were 14 285 patients with 20 827 encounters (median [interquartile range] age 5.2 years [1.5-12.7] years; 11 409 [54.8%; 95% CI, 54.1%-55.5%] male patients). Of these, 5297 encounters (25.4%; 95% CI, 24.8%-26.0%) were with patients who had MODS, of which 5054 (95.4%) met the subgraph count threshold and were included in the analysis. Subgraph augmented nonnegative matrix factorization uncovered 4 data-driven phenotypes of MODS, characterized by a combination of neurologic, respiratory, coagulation, and cardiovascular dysfunction, as follows: phenotype 1, severe, persistent encephalopathy (1019 patients [19.2%]); phenotype 2, moderate, resolving hypoxemia (1828 patients [34.5%]); phenotype 3, severe, persistent hypoxemia and shock (1012 patients [19.1%]); and phenotype 4, moderate, persistent thrombocytopenia and shock (1195 patients [22.6%]). These phenotypes were reproducible in a validation set of encounters, had distinct clinical characteristics, and were independently associated with outcomes. For example, using phenotype 2 as reference, the adjusted hazard ratios (aHRs) for death by 28 days were as follows: phenotype 1, aHR of 3.0 (IQR, 2.1-4.3); phenotype 3, aHR of 2.8 (IQR, 2.0-4.1); and phenotype 4, aHR of 1.8 (IQR, 1.2-2.6). Interaction analysis in a matched cohort of patients with vasoactive-dependent shock revealed that hydrocortisone had differential treatment association with vasoactive-free days across phenotypes. For example, patients in phenotype 3 who received hydrocortisone had more vasoactive-free days than those who did not (23 days vs 18 days; P for interaction < .001), whereas patients in other phenotypes who received hydrocortisone either had no difference or had less vasoactive-free days. In this study, data-driven phenotyping in critically ill children with MODS uncovered 4 distinct and reproducible phenotypes with prognostic relevance and possible therapeutic relevance. Further validation and characterization of these phenotypes is warranted.

Exploration of Sepsis-Associated Coagulopathy Severity and Pediatric Septic Shock Outcomes

The objective of this study was to explore correlations between sepsis-associated coagulopathy (SAC) in pediatric septic shock and clinical outcomes. This was a retrospective cohort study of all children admitted to a single, academic pediatric intensive care unit with septic shock over 6 years. The prevalence of SAC was 93.5% with 61% being severe. Those with severe SAC were more likely to have a positive blood culture and have longer median duration of ventilation. All observed mortalities occurred in the severe SAC and indeterminate SAC groups. SAC is highly prevalent in pediatric septic shock and may predict important outcomes.

Effects of hyperchloremia on renal recovery in critically ill children with acute kidney injury.

Serum chloride derangements are associated with poor clinical outcomes, including acute kidney injury (AKI) and mortality. We sought to determine the association between persistent hyperchloremia and renal recovery in critically ill children with AKI. We performed a retrospective cohort study of all patients with day 2 AKI admitted to a large academic pediatric intensive care unit from January 2014 to December 2015. After applying exclusion criteria, 348 patients were categorized as (1) hyperchloremia on both day 2 and day 7 (PersistentCl), (2) hyperchloremia on day 2 with normochloremia on day 7 (RecoveredCl), (3) normochloremia on day 2 with hyperchloremia on day 7 (DelayedCl), and (4) no hyperchloremia on day 2 nor day 7 (NormalCl). Hyperchloremia was defined as ≥ 110mEq/L. The primary outcome was renal recovery on day 7, defined as the absence of AKI criteria. Secondary outcomes included discharge renal recovery, mortality, duration of mechanical ventilation, and hospital length of stay. Day 7 renal recovery rates for PersistentCl, RecoveredCl, DelayedCl, and NormalCl were 37%, 66%, 71%, and 52% respectively. PersistentCl had lower odds of day 7 renal recovery (aOR = 0.29; 95% CI, 0.14 to 0.60; p = 0.0009), lower odds of discharge renal recovery (aOR = 0.22; 95% CI, 0.11 to 0.48; p = 0.0001), and higher odds of mortality (aOR = 3.50; 95% CI, 1.11 to 11.10; p = 0.03) when compared with RecoveredCl after adjusting for confounders. Persistent hyperchloremia is independently associated with impaired renal recovery as well as higher mortality. Prospective studies are indicated to determine if serum chloride represents a modifiable risk factor for poor outcomes. Graphical abstract.

Retrospective study on 48-h fluid balance and outcome in mechanically ventilated critically ill children

Background and Aim: There is limited data on the outcome of mechanically ventilated critically ill children in low- and middle-income countries. The aim was to study the association of fluid balance in mechanically ventilated critically ill children and outcomes. Methodology: This retrospective study was conducted in an academic hospital's pediatric intensive care unit (PICU) from January 2015 to December 2016. Children aged 1 month to 12 years ventilated for more than 24 h with 48-h fluid balance were included in the study. Patients were divided into ≤10% and >10% fluid overload (FO) groups. The primary outcome was all-cause PICU mortality. The secondary outcomes were the durations of mechanical ventilation, PICU and hospital stay; organ failure; and extubation failure. Results: A total of 107 patients (23 in >10%-FO and 84 in ≤10%-FO groups) were enrolled. The median (interquartile range) age and pediatric risk of mortality III score were similar in both groups (12, 7–36 months vs. 11, 3–32 months; P = 0.37; and 16, 12–20 vs. 15, 12–18; P = 0.71, respectively). The most common indication for ventilation was disordered control of breathing (55% vs. 42%) followed by respiratory pathology (30% vs. 39%). In >10%-FO group, higher proportion of patients had acute respiratory distress syndrome (13 [56%] vs. 28 [35%], P = 0.06) and acute kidney injury (15 [65%] vs. 37 [44%)], P = 0.07), of which a significant number required renal replacement therapy (10 [43%] vs. 15 [17%], P = 0.01). More patients had septic shock in >10%-FO group (13 [56%] vs. 27 [32%], P = 0.03). There was no significant difference in all-cause PICU mortality in >10%-FO groups (13 [57%]) as compared to ≤10%-FO group (32 [38%]) (relative risk = 1.2, 95% confidence interval [CI]: 1.0–1.5, P = 0.11; and adjusted hazard ratio = 1.52, 95% CI: 0.78–2.97, P = 0.22). No differences were noted in other outcome variables. Conclusion: There was no significant difference in mortality and morbidity noted in 10% FO cutoff in critically ill mechanically ventilated children. A larger sample size, preferably a multicentric study, is warranted.

Human Rhinovirus/Enterovirus in Pediatric Acute Respiratory Distress Syndrome.

The role of human rhinovirus/enterovirus (HRV/HEV) in severe lower respiratory tract infections remains unclear. We characterized the respiratory status of children admitted to a large academic pediatric intensive care unit (PICU) who tested positive for only HRV/HEV. One hundred and fifty-five children met inclusion criteria with 62% requiring positive pressure respiratory support of 5 cm of water pressure or more within the first 24 hours of admission. Among them, 34% had SaO 2 to FiO 2 ratios of 264 or less with 22 patients (14%) meeting criteria for pediatric acute respiratory distress syndrome. HRV/HEV is associated with significant respiratory disease in children admitted to the PICU.

Creation of a Rudimentary Electronic Pediatric Intensive Care Unit Model to Explore Resident-Attending Communication.

Background: At-home attending intensivists often must return to the hospital to assist residents. Introduction: To determine if using telemedicine communication between in-house pediatric residents and at-home attending intensivists impacts the rate of attending return to the hospital and improves resident education. Methods: In this single-center prospective study at an academic children's hospital's pediatric intensive care unit (PICU), 40 patients younger than 18 years were randomized into video or telephone arms. Residents and intensivists completed anonymous surveys after each encounter. Video-conferencing encounters between residents and at-home, on-call intensivists were compared with standard telephone calls for admissions to PICU. Results: Video and telephone arms had 21 and 19 patients enrolled, respectively. Data comparison was performed using Mann-Whitney U, chi-square, and Kruskal-Wallis analysis. Clinical illness severity rating for intensivists and residents was not significantly different for video communication compared with telephone (p = 0.63 and p = 0.42, respectively). Intensivists reported no significant difference in ease of use (p = 0.87). There was perceived improvement in resident education with the use of telemedicine (52.6% vs. 76.2%; p = 0.11). Discussion: Video communication was easy to use but did not change the rating of illness severity or need for intensivist to return to the hospital. There was perceived improvement in resident education with the use of telemedicine, and it may serve as a useful tool in demonstrating acute clinical changes to out-of-hospital intensivists. Conclusions: Larger-scale studies in teaching hospitals with out-of-hospital pediatric intensivists need to be conducted to further evaluate the role of telemedicine in patient management and resident education.

Impact of Anticoagulation and Circuit Technology on Complications During Extracorporeal Membrane Oxygenation.

The objective of this study is to evaluate the impact a change in anticoagulation protocol and circuit technology had on bleeding and thrombotic complications in patients supported on extracorporeal membrane oxygenation (ECMO). A retrospective review at a tertiary, academic pediatric intensive care unit was undertaken. The anticoagulation protocol changed from targeting an activated clotting time (ACT) to anti-Xa level. Significant changes in the ECMO circuit were undertaken concurrently. One-hundred and fifty-two ECMO runs in 129 patients in the ACT target group were compared with 122 ECMO runs in 101 patients in the anti-Xa target group. Improved probability of survival by ECMO duration, decreased rate of surgical exploration, increased time to first surgical exploration, decreased incidence of intracranial hemorrhage, increased time to identification of intracranial hemorrhage, decreased blood loss and transfused product volumes, decreased rate of circuit changes, and increased time to first circuit change were all observed in the anti-Xa targeted group. Heparin dosing was similar in both groups with fewer bolus doses of heparin and fewer changes in the infusion rate in the anti-Xa targeted group. The change in anticoagulation protocol and circuit technology was associated with an improvement in survival, a decrease in hemorrhagic complications, and a decrease in circuit changes.

Dexmedetomidine is effective and safe during NIV in infants and young children with acute respiratory failure

BackgroundNoninvasive ventilation (NIV) is increasingly utilized in infants and young children, though associated with high failure rates due to agitation and poor compliance, mostly if patient-ventilator synchronization is required.MethodsA retrospective cohort study was carried out in an academic pediatric intensive care unit (PICU). Dexmedetomidine (DEX) was infused as unique sedative in 40 consecutive pediatric patients (median age 16 months) previously showing intolerance and agitation during NIV application.ResultsDuring NIV clinical application both COMFORT-B Score and Richmond Agitation-Sedation Scale (RASS) were serially evaluated. Four patients experiencing NIV failure, all due to pulmonary condition worsening, required intubation and invasive ventilation. 36 patients were successfully weaned from NIV under DEX sedation and discharged from PICU. All patients survived until home discharge.ConclusionOur data suggest that DEX may represent an effective sedative agent in infants and children showing agitation during NIV. Early use of DEX in infants/children receiving NIV for acute respiratory failure (ARF) should be considered safe and capable of improving NIV, thus permitting both lung recruitment and patient-ventilator synchronization.

Random serum free cortisol and total cortisol measurements in pediatric septic shock.

Background The aim of the study was to examine the relationship between serum total cortisol (TC) and free cortisol (FC) levels in children with septic shock and the relationship of these levels with baseline illness severity. Methods A sub-study of a randomized controlled trial (RCT) of hydrocortisone vs. placebo in pediatric septic shock conducted in seven academic pediatric intensive care units (PICUs) in Canada on children aged newborn to 17 years. Thirty children with septic shock had serum sent for TC and FC measurement within 6 h of meeting the study eligibility criteria. Results Baseline FC and TC levels were strongly correlated with baseline Pediatric Risk of Mortality (PRISM) score (R2=0.759, p<0.001; R2=0.717, p<0.001) and moderately correlated with admission Vasotropic Inotropic Score (VIS) (R2=0.489, p<0.001; R2=0.316, p<0.001). Serum TC levels were highly correlated with FC levels (R2=0.92, p<0.001) and showed strong agreement (R2=0.98, p<0.001 on a Bland-Altman plot). The ratio of FC to TC moderately correlated with TC levels (R2=0.46, p<0.001) but did not correlate with baseline albumin levels (R2=0.19, p=0.13). Conclusions Random TC and FC levels are strongly correlated, show strong agreement and are reflective of illness severity in children with septic shock. As such, isolated FC measurement does not appear to provide added information relative to TC in acutely ill children with septic shock.

Abstract P-039: DEFINING LONG-STAY PATIENTS IN THE PEDIATRIC INTENSIVE CARE UNIT: A SURVEY OF MEDICAL DIRECTORS, NURSE MANAGERS AND HOSPITAL ADMINISTRATORS

Aims & Objectives: Long-stay patients (LSPs) account for ~8% of admissions to pediatric intensive care units (PICUs) and use up to 50% of hospital resources, but there is no consensus definition for LSPs. Therefore, we surveyed key PICU stakeholders to assess their perspectives regarding the importance of defining LSPs, the components the definition should include, the preferred method for deriving the definition, and the definitions’ characteristics. Methods We identified a purposive sample of one medical director, nurse manager and hospital administrator in each of 14 tertiary care academic PICUs across Canada. An internet-based survey was sent to 40 of 42 eligible participants in February and March of 2017. Results The participant flow diagram is shown in Figure 1. We had a response rate of 70% (28/40). 75% (21/28) of respondents stated it was important to define LSPs. Respondents thought such a definition was important to determine: PICU resource needs (86%, 18/21), alternative models of care (86%, 18/21), and current resource utilization (76%, 16/21) (Table 1). Respondents valued a definition that was consistent, and incorporated a percentile cut-off. 86% of respondents (24/28) felt the definition of LSPs should include factors other than PICU length of stay (Table 2).Conclusions PICU stakeholders believed defining LSPs is important. They indicated that this definition should be consistent, include a percentile cut-off for length of stay, and incorporate patient and unit-based factors along with PICU length of stay. Our results provide a basis for developing a consensus definition for LSPs in the PICU.

Effect of the Procalcitonin Assay on Antibiotic Use in Critically Ill Children.

We retrospectively studied the effect of introducing procalcitonin into clinical practice on antibiotic use within a large academic pediatric intensive care unit. In the absence of a standardized algorithm, availability of the procalcitonin assay did not reduce the frequency of antibiotic initiations or the continuation of antibiotics for greater than 72 hours.

Current Use of Invasive and Noninvasive Monitors in Academic Pediatric Intensive Care Units.

To describe the current use of noninvasive monitoring compared with traditional invasive monitoring in Pediatric Critical Care Medicine (PCCM) accredited fellowship programs in the United States. A web-based survey with the primary aim of describing the utilization of noninvasive monitoring compared with invasive monitoring was distributed to PCCM program directors (PDs) at the 64 accredited fellowship training programs. Questions focused on demographics and the utilization of invasive and noninvasive monitoring for specific patient populations and disease states. Forty-two (66%) PDs responded to the survey. Capnography and near-infrared spectroscopy (NIRS) were the most commonly reported noninvasive monitoring technology. Arterial and central venous catheters were widely used. Other invasive monitoring devices were used sparingly. Despite widespread use of both invasive and noninvasive monitoring in academic pediatric critical care units across the United States, there is significant variability in the use of noninvasive monitoring compared with invasive monitoring. Further investigation is needed to define the standard of care for the use of noninvasive monitors as practitioners attempt to optimize care while minimizing risks and complications.

Preventing Underfeeding and Overfeeding: A Clinician's Guide to the Acquisition and Implementation of Indirect Calorimetry.

In critically ill patients, indirect calorimetry (IC) is the gold standard to determine energy needs, as the use of predictive equations can result in underfeeding or overfeeding. The aim of this quality improvement (QI) initiative was to describe the rationale for and implementation of a process to target energy provision according to IC measurements in a tertiary academic medical center pediatric intensive care unit (PICU). To justify the purchase of an indirect calorimeter for clinical use, a needs assessment was conducted, followed by a training and implementation period. PICU patients were selected for IC according to published guidelines. Measured energy expenditure was compared with predicted energy expenditure and the provided energy prescription. The dietitians assessed IC results and adjusted energy prescriptions, if indicated. Thirty-five total tests were completed with 24 patients. Sixty-nine percent of measurements resulted in energy delivery adjustments. Fifteen (47%) energy prescriptions decreased by a mean of 27% ± 11%, and 7 (22%) increased by a mean of 17% ± 15%. Staff and patient/guardians accommodated the use of IC, and PICU dietitian recommendations for IC tests and to adjust nutrition regimens were universally implemented. Data to support the procurement of IC are vital to promote best practice to measure energy expenditure. Critically ill pediatric patients exhibit metabolic alterations that cannot be predicted by standard equations. Our QI initiative demonstrated the implementation and application of IC in the critically ill population and the ability to target energy provision to prevent energy imbalances.

Prospective Evaluation of Physical Contact with Critically Ill Child on Caregiver Spiritual Wellbeing

To evaluate whether a pediatric intensive care unit initiative promoting physical contact between caregiver and patient improves caregiver spiritual wellbeing. The secondary objectives were to evaluate caregiver perceptions of care before and after the initiative and to follow unplanned extubation rate as a marker of safety of the initiative. We hypothesized that caregiver spiritual wellbeing and caregiver perceptions of care would improve with implementation of our physical contact initiative known as Project ROSE (Reach Out, Soothe, and Embrace). Project ROSE was a practice change initiative promoting physical contact between caregiver and hospitalized child in an academic quaternary care pediatric intensive care unit. Caregivers' spiritual wellbeing and perceptions of care were surveyed at days 1 and 4, then compared pre- and postimplementation of the unit-wide initiative. Wilcoxon rank sum tests compared groups (pre- and post-Project ROSE). A total of 331 caregivers returned surveys. We analyzed 331 surveys (pre, n = 174/post, n = 157). Caregiver spiritual wellbeing at enrollment (day 1) was no different between groups (P = .47). Caregiver spiritual wellbeing on day 4 was greater in the postintervention group (pre 40.0 [32.0, 44.0] vs post 42.0 [37.5, 45.0] P = .03). Caregiver perceptions of care improved postintervention. There was no change in the unplanned extubation rate between groups. Project ROSE improved caregiver spiritual wellbeing and perceptions of care, was implemented safely, addresses a need in family-centered care of critically ill pediatric patients, and merits consideration for integration into practice.

Quality Improvement Initiative to Reduce Pediatric Intensive Care Unit Noise Pollution With the Use of a Pediatric Delirium Bundle.

Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]). Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.

Association of Delayed Antimicrobial Therapy with One-Year Mortality in Pediatric Sepsis.

Delayed antimicrobial therapy in sepsis is associated with increased hospital mortality, but the impact of antimicrobial timing on long-term outcomes is unknown. We tested the hypothesis that hourly delays to antimicrobial therapy are associated with 1-year mortality in pediatric severe sepsis. Retrospective observational study. Quaternary academic pediatric intensive care unit (PICU) from February 1, 2012 to June 30, 2013. One hundred sixty patients aged ≤21 years treated for severe sepsis. None. We tested the association of hourly delays from sepsis recognition to antimicrobial administration with 1-year mortality using multivariable Cox and logistic regression. Overall 1-year mortality was 24% (39 patients), of whom 46% died after index PICU discharge. Median time from sepsis recognition to antimicrobial therapy was 137 min (IQR 65-287). After adjusting for severity of illness and comorbid conditions, hourly delays up to 3 h were not associated with 1-year mortality. However, increased 1-year mortality was evident in patients who received antimicrobials ≤1 h (aOR 3.8, 95% CI 1.2, 11.7) or >3 h (aOR 3.5, 95% CI 1.3, 9.8) compared with patients who received antimicrobials within 1 to 3 h from sepsis recognition. For the subset of patients who survived index PICU admission, antimicrobial therapy ≤1 h was also associated with increased 1-year mortality (aOR 5.5, 95% CI 1.1, 27.4), while antimicrobial therapy >3 h was not associated with 1-year mortality (aOR 2.2, 95% CI 0.5, 11.0). Hourly delays to antimicrobial therapy, up to 3 h, were not associated with 1-year mortality in pediatric severe sepsis in this study. The finding that antimicrobial therapy ≤1 h from sepsis recognition was associated with increased 1-year mortality should be regarded as hypothesis-generating for future studies.

An Analysis of the Daily Work-Rounding Process in a Pediatric Intensive Care Unit.

To complete an objective analysis of the activities that occur during the course of daily rounds in a high acuity academic tertiary care pediatric intensive care unit (PICU). Prospective observational work sampling design. Tertiary care academic Children's Hospital Pediatric Intensive Care Unit. Multidisciplinary PICU teams. None. Intensive care unit rounds were observed as part of an initiative to improve efficiency over a 2-month period. The number of observations required was determined by Neibel's work sampling method. Rounds were broken into various constituent events and then later classified as "value-added/essential," "value-added/nonessential," and "nonessential" based on whether the observed event was essential to the core mission of PICU rounds. The mean time spent per patient for all observed teams was 17.9 min (SD 1.3 min). Teams spent 64% of their time doing value-added/essential tasks (11.2 min, SD 2.2 min) and 13% of their time doing value-added/nonessential tasks (2.4 min, SD 0.9 min). Teams spent 23% of their time on non-value-added activities (4.1 min, SD 2.3 min). The top three non-value-added activities conducted during rounds were travel, waiting, and interruptions regarding care of other patients. Given the consistency of time spent on value-added activities among attendings, these non-value-added activities might explain the significant variability observed among attendings in total time spent rounding. This was an observational study to characterize the activities that occur during the course of a routine PICU work rounds. Although there was significant consistency in the time spent per patient in value-added activities, there was significant disparity in time spent on nonessential activities, such as travel and waiting. A dedicated attempt to reduce time spent on nonessential activities can substantially reduce rounding times and improve the efficiency and value of rounds.

Value of Procalcitonin Measurement for Early Evidence of Severe Bacterial Infections in the Pediatric Intensive Care Unit

To determine whether peak blood procalcitonin (PCT) measured within 48 hours of pediatric intensive care unit (PICU) admission can differentiate severe bacterial infections from sterile inflammation and viral infection and identify potential subgroups of PICU patients for whom PCT may not have clinical utility. This was a retrospective, observational study of 646 critically ill children who had PCT measured within 48 hours of admission to an urban, academic PICU. Patients were stratified into 6 categories by infection status. We compared test characteristics for peak PCT, C-reactive protein (CRP), white blood cell count (WBC), absolute neutrophil count (ANC), and % immature neutrophils. The area under the receiver operating characteristic curve was determined for each biomarker to discriminate bacterial infection. The area under the receiver operating characteristic curve was similar for PCT (0.73, 95% CI 0.69, 0.77) and CRP (0.75, 95% CI 0.71, 0.79; P = .36), but both outperformed WBC, ANC, and % immature neutrophils (P < .01 for all pairwise comparisons). The combination of PCT and CRP was no better than either PCT or CRP alone. Diagnostic patterns prone to false-positive and false-negative PCT values were identified. Peak blood PCT measured close to PICU admission was not superior to CRP in differentiating severe bacterial infection from viral illness and sterile inflammation; both PCT and CRP outperformed WBC, ANC, and % immature neutrophils. PCT appeared especially prone to inaccuracies in detecting localized bacterial central nervous system infections or bacterial coinfection in acute viral illness causing respiratory failure.