Critical Care Medicine Physicians Research Articles

Evolution of Pediatric Critical Care Medicine Physicians Clinical and Academic Profile by Gender.

To examine career trajectory and academic profile of Pediatric Critical Care Medicine (PCCM) physicians, with special focus on gender differences. Observational cross-sectional study of PCCM fellowship graduates using publicly available data. Publicly available databases including National Provider Identifier registry, American Board of Pediatrics, Doximity, official hospital websites, and Scopus. Two thousand one hundred twenty-nine PCCM fellowship graduates employed in clinical positions in U.S. practice locations. None. Physician demographic characteristics included gender and time since fellowship completion. Current career and academic characteristics included employment data, publication productivity (h-index), and academic rank. Data from 2129 career PCCM physicians was included, with recent graduates showing a notable increase in female representation. Workplace characteristics revealed that most PCCM physicians worked in university-affiliated hospitals, with higher percentages of female physicians working in university-affiliated hospitals compared with male physicians. The study also highlighted significant gender disparities in academic metrics, with male physicians having higher h-indices (3 vs. 2; p < 0.001) and more publications (6 vs. 4; p < 0.001) than their female counterparts across various career phases. Additionally, the analysis showed gender differences in academic rank, with a higher proportion of female faculty holding assistant and associate professor ranks (58.2% vs. 47.5%; p < 0.001), while a greater percentage of male faculty held the rank of professor (20.2% vs. 11.1%; p < 0.001). Multiple variable regression analysis identified both male gender and time since fellowship graduation as independently associated with a physician's h-index, while only time since fellowship graduation was linked to current academic rank. This is the first analysis of career and academic characteristics of practicing PCCM physicians, additionally studying the association of gender and career trajectory. Gender discrepancy was seen in employment hospital characteristics, h-indices, and academic rank. Additional studies are required to further explore the impact of gender on career trajectory.

Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know.

Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.

Beliefs of physician directors on the management of devastating brain injuries at the Canadian emergency department and intensive care unit interface: a national site-level survey.

Insufficient evidence-based recommendations to guide care for patients with devastating brain injuries (DBIs) leave patients vulnerable to inconsistent practice at the emergency department (ED) and intensive care unit (ICU) interface. We sought to characterize the beliefs of Canadian emergency medicine (EM) and critical care medicine (CCM) physician site directors regarding current management practices for patients with DBI. We conducted a cross-sectional survey of EM and CCM physician directors of adult EDs and ICUs across Canada (December 2022 to March 2023). Our primary outcome was the proportion of respondents who manage (or consult on) patients with DBI in the ED. We conducted subgroup analyses to compare beliefs of EM and CCM physicians. Of 303 eligible respondents, we received 98 (32%) completed surveys (EM physician directors, 46; CCM physician directors, 52). Most physician directors reported participating in the decision to withdraw life-sustaining measures (WLSM) for patients with DBI in the ED (80%, n=78), but 63% of these (n=62) said this was infrequent. Physician directors reported that existing neuroprognostication methods are rarely sufficient to support WLSM in the ED (49%, n=48) and believed that an ICU stay is required to improve confidence (99%, n=97). Most (96%, n=94) felt that providing caregiver visitation time prior to WLSM was a valid reason for ICU admission. In our survey of Canadian EM and CCM physician directors, 80% participated in WLSM in the ED for patients with DBI. Despite this, most supported ICU admission to optimize neuroprognostication and patient-centred end-of-life care, including organ donation.

1198. More is not Merrier: Mitigating Meropenem Misuse in the ICU at an Academic Medical Center

Abstract Background Inappropriate use of carbapenems is a major driver of antimicrobial resistance. The intensive care unit (ICU) at Mayo Clinic Arizona had a higher meropenem (MER) days of therapy (DOT) per 1000 patient days (PD) compared to other Mayo Clinic Enterprise sites, despite low rates of Pseudomonal resistance to narrower spectrum anti-pseudomonal beta-lactams. Methods A multidisciplinary team of infectious diseases (ID) and critical care medicine (CCM) physicians and pharmacists was created to reduce inappropriate use of MER in the ICU. The baseline rate of appropriateness was determined by evaluating all MER days in the ICU during Q4 2019 and Q4 2020. Each MER day was designated as appropriate or inappropriate based on pre-determined criteria after review by at least one ID and one CCM member. Discordant days were evaluated by the whole team to achieve consensus. The team provided education to the CCM department on the initiative, baseline data, and strategies to reduce inappropriate MER use. The active intervention included prospective audit and feedback of all patients on MER performed by the ID clinical pharmacists Mon-Fri 0700-1530 in Q4 2022. DOT/1000 PD was assessed for the pre-intervention and intervention periods. Results The baseline rate of inappropriate MER use in the ICU was 52% (442/846 days). The two most common reasons for inappropriate MER use in the baseline period were: susceptible organism for which a narrower agent could have been used (93/442, 21%), and infectious workup/cultures negative (89/442, 20%). During the intervention period, the inappropriate rate of MER use was reduced to 23%, below the pre-determined goal of 30%. The MER DOT/1000 PD in the baseline period were 103.9 (Q4 2019) and 151.5 (Q4 2020) versus 66.1 (Q4 2022) in the intervention period. There was no difference in ICU sepsis-related mortality in the pre-intervention vs intervention period (13.4 vs 0%, p=0.04). Conclusion A multidisciplinary team approach, including education and prospective audit and feedback, reduced inappropriate MER use in the ICU of an academic medical center from 52 to 23%. An associated decrease in MER DOT/1000 patient days was also observed. Disclosures All Authors: No reported disclosures

A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative.

To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. Cross-sectional survey conducted May 2021-January 2022. Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. None. We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.

Physician and administrator experience of preparing to implement Ontario's intensive care unit Triage Emergency Standard of Care during the COVID-19 pandemic: a qualitative study.

As the COVID-19 pandemic created a surge in demand for critical care resources, the province of Ontario, Canada, released the Adult Critical Care Clinical Emergency Standard of Care for Major Surge (Emergency Standard of Care [ESoC]), a triage framework to guide the allocation of critical care resources in the expectation that intensive care units would be overwhelmed. Our aim was to understand physicians' and administrators' experiences and perceptions of planning to implement the ESoC, and to identify ways to improve critical care triage processes for future pandemics. We conducted semistructured qualitative interviews with critical care, emergency and internal medicine physicians, and hospital administrators from various Ontario health regions who were involved in their hospital's or region's ESoC implementation planning. Interviews were conducted virtually between April and October 2021. We analyzed the data using thematic analysis. We conducted interviews with 11 physicians and 10 hospital administrators representing 9 health regions. We identified 4 themes regarding participants' preparation to implement the ESoC: infrastructure to enable effective triage implementation; social, medical and political supports to enable effective triage implementation; moral dimensions of triage implementation; and communication of triage results. Participants outlined administrative and implementation-related improvements that could be provided at the provincial level, such as billing codes for ESoC. They also suggested improving ethical supports for the usability and quality of the ESoC (e.g., designating an ethicist in each region), and ways to improve the efficiency and usability of the tools for assessing short-term mortality risk (e.g., create information technology solutions such as a dashboard). The implementation of a jurisdiction-level triage framework poses moral challenges for a health care system, but it also requires dedicated infrastructure, as well as institutional supports. Lessons learned from Ontario's process to prepare for ESoC implementation, as well as participants' suggestions, can be used for planning for current and future pandemics.

Perspectives on Current Mechanical Ventilation Use and Training in Pediatric Critical Care Medicine Fellowship Programs in the United States

AbstractMechanical ventilation (MV) is an integral part of the care of the critically ill child, and contemporary MV includes a myriad of sophisticated modalities that should be tailored to specific disease pathology and severity. This requires Pediatric Critical Care Medicine (PCCM) physicians to have comprehensive training and experience with various modes. We sought to assess and describe the current landscape of MV practices and training from PCCM fellowship programs. To describe current MV practices and training in PCCM fellowship programs and assess the different modes of MV to which trainees are exposed, a piloted survey was sent to all 67 American PCCM fellowship program directors (PDs) in 2019. Forty-eight (71.6%) of PCCM PDs responded. Our survey shows that PCCM fellows are not uniformly exposed to the same MV modalities, and PDs' perception of fellows' competency in managing MV is variable. Our results suggest that there is a lack of exposure to the various modes of “conventional” MV, as well as inconsistent education about less-utilized “nonconventional” MV. Additionally, we found that PDs are aware of their fellows' limited exposure to various modalities, as many practice patterns are institution specific. This study identified gaps in MV education and training and advocates for PCCM fellowship programs to identify these deficiencies to equip all trainees with a solid knowledge base that will prepare them to utilize any mode of MV in their future practice.

Differing Conceptualizations of the Goals of Care Discussion: A Critical Discourse Analysis

ContextThe goals of care discussion (GOCD) has been positioned as an improvement strategy to address discordance between care decisions made by seriously ill patients and care received. Interventions aimed at improving GOCDs however have had limited success. This may in part be due to the considerable variation in views on the essential components and expected outcomes of a GOCD. This variability, and consequently clinical approaches to GOCDs, may reflect fundamental differences in how the GOCD is conceptualized. ObjectiveTo identify and characterize differing conceptualizations of the GOCD. MethodsCritical discourse analysis was used to qualitatively examine GOCDs documented for inpatients of 35 Canadian palliative medicine (PM), critical care medicine (CCM) and general internal medicine (GIM) physicians. Patterns in the ways the GOCD had been constructed were characterized by identifying different aspects of the approaches used by clinicians. ResultsGOCD notes varied in the predominant style and tone (from narrative to biomedical), predominant information source (patient/family to physician), and contribution of the patient's perspective. Notably binary differences were also found in the locus of goals and located either with the patient or with the broad concept of treatments. Although not exclusively, locus of goals tended to be with the patient among PM physicians and with treatments among CCM and GIM physicians. ConclusionThese findings offer clinical evidence for differing conceptualizations of the GOCD and orientations to goals as either person-centered or treatment-centered. This phenomenon may be in part discipline-based and has important implications for both clinical practice and training experiences.

Critical care ultrasound training: a survey exploring the \u201ceducation gap\u201d between potential and reality in Canada

BackgroundCritical care ultrasound (CCUS) is now a core competency for Canadian critical care medicine (CCM) physicians, but little is known about what education is delivered, how competence is assessed, and what challenges exist. We evaluated the Canadian CCUS education landscape and compared it against published recommendations.MethodsA 23-item survey was developed and incorporated a literature review, national recommendations, and expert input. It was sent in the spring of 2019 to all 13 Canadian Adult CCM training programs via their respective program directors. Three months were allowed for data collection and descriptive statistics were compiled.ResultsEleven of 13 (85%) programs responded, of which only 7/11 (64%) followed national recommendations. Curricula differed, as did how education was delivered: 8/11 (72%) used hands-on training; 7/11 (64%) used educational rounds; 5/11 (45%) used image interpretation sessions, and 5/11 (45%) used scan-based feedback. All 11 employed academic half-days, but only 7/11 (64%) used experience gained during clinical service. Only 2/11 (18%) delivered multiday courses, and 2/11 (18%) had mandatory ultrasound rotations. Most programs had only 1 or 2 local CCUS expert-champions, and only 4/11 (36%) assessed learner competency. Common barriers included educators receiving insufficient time and/or support.ConclusionsOur national survey is the first in Canada to explore CCUS education in critical care. It suggests that while CCUS education is rapidly developing, gaps persist. These include variation in curriculum and delivery, insufficient access to experts, and support for educators.

Stress Coping Strategies among Critical Care Medicine Physicians during COVID-19 Pandemic in Egypt: A Qualitative Study

BACKGROUND: Exposure of health care workers to COVID-19 virus and its consequences together with fear of being infected and died or passing the infection to their families creates negative emotions with high stress in the working environment that impact their physiological and psychological health. AIM: The objectives of the study were to explore the different stress coping strategies that reduce stress among physicians in Egypt during the COVID-19 pandemic. METHODS: A qualitative study conducted among critical care medicine physicians (n = 32) who are working in two isolation hospitals where COVID-19-confirmed patients are being treated. Semi-structured audiotaped interviews with open-ended questions for up to 45 min were conducted from March 20, 2020, to April 15, 2020. Data processing was performed based on thematic content analysis. RESULTS: The enrolled physicians (n = 32) were 35 ± 1.5 years old and about two-thirds of them were women (66%). Thematic analysis revealed that knowledge of the disease together with training of physicians on providing care in a healthy work environment, where adequate personal protective equipment are available, was important factors in reducing stress. Personal coping strategies, including psychological adjustment, spiritual interventions, and support systems, were mostly used among the interviewees. CONCLUSION: Different stress-reducing strategies were recommended by participants, and these strategies focused mainly on safety and support. Implementing and promoting these strategies by organizations and individual physicians are expected to reduce their stress and consequently promote productivity and endurance throughout the current pandemic.

Intravenous immune globulin in septic shock: a Canadian national survey of critical care medicine and infectious disease specialist physicians.

This national survey evaluated the perceived efficacy and safety of intravenous immune globulin (IVIG) in septic shock, self-reported utilization patterns, barriers to use, the population of interest for further trials and willingness to participate in future research of IVIG in septic shock. We conducted a cross-sectional survey of critical care and infectious diseases physicians across Canada. We summarized categorical item responses as counts and proportions. We developed a multivariable logistic regression model to identify physician-level predictors of IVIG use in septic shock. Our survey was disseminated to 674 eligible respondents with a final response rate of 60%. Most (91%) respondents reported having prescribed IVIG to patients with septic shock at least once, 86% for septic shock due to necrotizing fasciitis, 52% for other bacterial toxin-mediated causes of septic shock, and 5% for undifferentiated septic shock. The majority of respondents expressed uncertainty regarding the impact of IVIG on mortality (97%) and safety (95%) in septic shock. Respondents were willing to participate in further IVIG research with 98% stating they would consider enrolling their patients into a trial of IVIG in septic shock. Familiarity with published evidence was the single greatest predictor of IVIG use in septic shock (odds ratio, 10.2; 95% confidence interval, 3.4 to 30.5; P < 0.001). Most Canadian critical care and infectious diseases specialist physicians reported previous experience using IVIG in septic shock. Respondents identified inadequacy of existing research as the greatest barrier to routine use of IVIG in septic shock. Most respondents support the need for further studies on IVIG in septic shock, and would consider enrolling their own patients into a trial of IVIG in septic shock.

Preliminary Report: US Physician Stress During the Early Days of the COVID-19 Pandemic

ObjectiveTo assess the impact of the COVID-19 crisis on physician stress and mental health. MethodsThe 10-item Coping With COVID survey assessed stress among 2373 physicians from April 4 to May 27, 2020. A stress summary score with 4 items (a single-item [overall] stress measure, fear of exposure, perceived anxiety/depression due to COVID, and work overload, each scored 1-4) ranged from 4 to 16. Hypothesized stress mitigators included enhanced purpose and feeling valued by one’s organization. Multilevel linear regression tested associations of variables with overall stress and stress summary scores. ResultsIn 2373 physicians in 17 organizations (median response rate of 32%), mean stress summary score was 9.1 (SD 2.6). Stress was highest among women (stress summary score, 9.4 [SD 2.5] vs 8.7 [SD 2.6] in men; P <.001), inpatient physicians (stress summary score, 9.4 [SD 2.8] vs 8.9 [SD 2.5] in outpatient physicians; P <.001), early- and mid-career physicians (stress summary score, 9.5 [SD 2.6] vs 8.6 [SD 2.5] in late-career physicians; P <.001), and physicians in critical care (stress summary score, 10.8), emergency departments (10.2), and hospital medicine (10.1). Increases in perceived anxiety/depression (regression coefficient, 0.30), workload (0.28), and fear (0.14) were associated with higher overall stress (P values <.001). Increases in feeling valued were associated with lower stress summary scores (regression coefficient, −0.67; P <.001) and explained 11% of stress summary score variance at the physician level and 31% of variance at the organizational level. ConclusionMental health support, modulation of workload, and noting physicians’ organizational value should be explored as means to reduce COVID-related stress.

Key Physician Behaviors that Predict Prudent, Preference Concordant Decisions at the End of Life

Background This study introduces an empirical approach for studying the role of prudence in physician treatment of end-of-life (EOL) decision making. Methods A mixed-methods analysis of transcripts from 88 simulated patient encounters in a multicenter study on EOL decision making. Physicians in internal medicine, emergency medicine, and critical care medicine were asked to evaluate a decompensating, end-stage cancer patient. Transcripts of the encounters were coded for actor, action, and content to capture the concept of Aristotelian prudence, and then quantitatively and qualitatively analyzed to identify actions associated with preference-concordant treatment. Results Focusing on codes that describe characteristics of physician-patient interaction, the code for physicians restating patient preferences was associated with avoiding intubation. Multiple codes were associated with secondary measures of preference-concordant treatment. Conclusions Prudent actions can be identified empirically, and research focused on the virtue of prudence may provide a new avenue for assessment and training in EOL care.

EStablish And Formalize Expert Criteria for Avoidable Resuscitation Review (SAFECARR) Electronic Delphi: Development of a Consensus Framework for Classifying and Reviewing Cardiac Arrests Within the PICU.

To develop a consensus framework that can guide the process of classifying and reviewing pediatric in-hospital cardiac arrest in the PICU. A three-round electronic Delphi consensus study with an additional in-person session with pediatric resuscitation experts. The modified electronic Delphi consisted of survey questions sent to the expert panel with the goals of (1) achieving consensus on definitions of avoidable, potentially avoidable, and unavoidable PICU in-hospital cardiac arrest and (2) achieving consensus and ranking of a list of factors that contribute to potentially avoidable PICU in-hospital cardiac arrest. Electronic surveys of resuscitation experts including pediatric critical care, cardiac critical care, emergency medicine, and hospital medicine physicians, nurses, advance practice nurses, and resuscitation researchers. Not applicable. Not applicable. Over three rounds of an electronic Delphi, 24 resuscitation experts participated. In Round 1, consensus was reached for the definitions of potentially avoidable and unavoidable cardiac arrest. Consensus was not reached for avoidable cardiac arrest. In Round 2, the expert panel agreed with seven factors from the literature and achieved consensus on an additional seven factors. Consensus was achieved on the modified definition of avoidable cardiac arrest. In Round 3, participants were asked to rank the contributing factors in order of their importance. For the in-person session, the consensus definitions and contributing factors from the modified electronic Delphi were presented to a multidisciplinary group of pediatric resuscitation experts and reached consensus for all three definitions. A multidisciplinary group of pediatric resuscitation experts generated a consensus-based framework to classify and review pediatric in-hospital cardiac arrest in the PICU. Future work will focus on the application of this framework and further validation of these definitions and contributing factors for in-hospital cardiac arrest both within and outside the PICU.

Using machine learning to selectively highlight patient information.

Electronic medical record (EMR) systems need functionality that decreases cognitive overload by drawing the clinician's attention to the right data, at the right time. We developed a Learning EMR (LEMR) system that learns statistical models of clinician information-seeking behavior and applies those models to direct the display of data in future patients. We evaluated the performance of the system in identifying relevant patient data in intensive care unit (ICU) patient cases. To capture information-seeking behavior, we enlisted critical care medicine physicians who reviewed a set of patient cases and selected data items relevant to the task of presenting at morning rounds. Using patient EMR data as predictors, we built machine learning models to predict their relevancy. We prospectively evaluated the predictions of a set of high performing models. On an independent evaluation data set, 25 models achieved precision of 0.52, 95% CI [0.49, 0.54] and recall of 0.77, 95% CI [0.75, 0.80] in identifying relevant patient data items. For data items missed by the system, the reviewers rated the effect of not seeing those data from no impact to minor impact on patient care in about 82% of the cases. Data-driven approaches for adaptively displaying data in EMR systems, like the LEMR system, show promise in using information-seeking behavior of clinicians to identify and highlight relevant patient data.

Effect of goal orientation combined with plan-do-check-act cycle improvement on the professional teaching of critical care medicine

Objective To investigate the promotional effect of the new teaching method of goal orientation combined with plan-do-check-act (PDCA) cyclic improvement on specialized medical knowledge and operation skills among physicians in critical care medicine. Methods A total of 84 physicians who received critical care medicine training in Department of Critical Care Medicine in Foshan Hospital of Traditional Chinese Medicine from January 2013 to December 2015 were selected, and according to the time of admission, they were divided into control group with 41 physicians and experimental group with 43 physicians. The physicians in the experimental group received the new teaching method of goal orientation combined with PDCA cyclic improvement, i.e., the physicians started systematic learning according to the learning goals sent out by the teaching secretary, summarized problems during learning and looked for optimal solutions every week, and then continued learning in the next week through PDCA cyclic improvement. The physicians in the control group received traditional teaching combined with bedside teaching, but no learning goals were set for them. The two groups were compared in terms of theoretical examination scores, clinical operation skills, and results of the questionnaire survey. The t-test and Wilcoxon ranksum test were used for comparison of scores between the two groups by SPSS 18.0. Results Compared with the control group, the experimental group had significant increases in the scores of theoretical examination (91.50±4.18 vs. 87.80±3.63) and operation skills (88.80±3.34 vs. 85.40±2.88). The questionnaire survey showed that compared with the control group, the experimental group had a significantly higher degree of satisfaction, significantly greater learning interests, and significantly greater improvements in operation skills, clinical thinking ability, and self-confidence. Conclusion The new teaching method of goal orientation combined with PDCA cyclic improvement can stimulate learning interests, clarify learning goals, help physicians to master important and difficult issues, and thus improve their learning outcomes and scores in Department of Critical Care Medicine. Key words: Goal orientation; Plan-do-check-act; Critical care medicine; Teaching method

Development of a Process and Infrastructure to Outreach Stakeholders for Capturing Healthcare System Stress in Emergency Response Situations.

Real time data provided by frontline clinicians could be used to direct immediate resources during a public health emergency and inform increased preparedness for future events. The United States Critical Illness and Injury Trials Group Program for Emergency Preparedness (USCIIT-PREP), a group of expert critical care and emergency medicine physicians at various academic medical centers across the US, aims to enhance the national capability of rapid electronic data collection, along with analysis and dissemination of findings. To achieve these aims, USCIIT-PREP created a process for real-time data capture that relies on a curated and engaged network of clinical providers from various geographical regions to respond to short online "Pulse" queries about healthcare system stress. During a period of three years, five queries were created and distributed. The first two queries were used to develop and validate the data collection infrastructure. Results are reported for the last three queries between June 2015 and March 2016. Response rates consistently ranged from 39% to 42%. Our team demonstrated that our system and processes were ready for creation and rapid dissemination of episodic queries for rapid data collection, transmittal, and analysis through a curated national network of clinician responders during a public health emergency. USCIIT-PREP aims to further increase the response rate through additional engagement efforts within the network, to continue to grow the clinician responder database, and to optimize additional query content.

State of the Unit: Physician Gender Diversity in Pediatric Critical Care Medicine Leadership.

Gender disparities in leadership are receiving increased attention throughout medicine and medical subspecialties. Little is known about the disparities in Pediatric Critical Care Medicine. In this piece, we explore gender disparities in Pediatric Critical Care Medicine physician leadership. We examine physician leadership in the Accreditation Council for Graduate Medical Education fellowship programs, as well as a limited sample of major Pediatric Critical Care Medicine textbooks and societies. Overall, the gender composition of division directors is not significantly different from that of workforce composition, although regional differences exist. More women than men lead fellowship programs, at a higher ratio compared with workforce composition. However, greater gender disparities are present in editorial leadership in this limited analysis. We conclude by recommending potential paths forward for further study and intervention, such as tracking gender diversity and being cognizant of the unique challenges that women currently experience in professional advancement.

Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters.

Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography. We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS. Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion "most of the time" or "always," none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion. Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.

Technical specification for clinical application of critical ultrasonography

Critical ultrasonography(CUS) is different from the traditional diagnostic ultrasound, the examiner and interpreter of the image are critical care medicine physicians. The core content of CUS is to evaluate the pathophysiological changes of organs and systems and etiology changes. With the idea of critical care medicine as the soul, it can integrate the above information and clinical information, bedside real-time diagnosis and titration treatment, and evaluate the therapeutic effect so as to improve the outcome. CUS is a traditional technique which is applied as a new application method. The consensus of experts on critical ultrasonography in China released in 2016 put forward consensus suggestions on the concept, implementation and application of CUS. It should be further emphasized that the accurate and objective assessment and implementation of CUS requires the standardization of ultrasound image acquisition and the need to establish a CUS procedure. At the same time, the standardized training for CUS accepted by critical care medicine physicians requires the application of technical specifications, and the establishment of technical specifications is the basis for the quality control and continuous improvement of CUS. Chinese Critical Ultrasound Study Group and Critical Hemodynamic Therapy Collabration Group, based on the rich experience of clinical practice in critical care and research, combined with the essence of CUS, to learn the traditional ultrasonic essence, established the clinical application technical specifications of CUS, including in five parts: basic view and relevant indicators to obtain in CUS; basic norms for viscera organ assessment and special assessment; standardized processes and systematic inspection programs; examples of CUS applications; CUS training and the application of qualification certification. The establishment of applied technology standard is helpful for standardized training and clinical correct implementation. It is helpful for clinical evaluation and correct guidance treatment, and is also helpful for quality control and continuous improvement of CUS application.