Critical Care Program Research Articles

Development of a Prioritized Anesthesiology Residency Critical Care Content Outline.

Critical care education is an important, mandatory component of residency training in anesthesiology. Currently, there is no accepted national standardized curriculum, and a prioritized critical care content outline would be beneficial to the creation of a pragmatic standardized residency curriculum. The modified Delphi method is a recognized method for establishing consensus in medical education. We developed a prioritized critical care content outline using the modified Delphi method. Topics were selected from critical care topics included in the Program Requirements for Graduate Medical Education in Anesthesiology and the American Board of Anesthesiology Content Outline. Panel members rated critical care topics on a 9-point Likert scale (1 = not important, 9 = mandatory). Consensus was defined as ≥75% rating the topic as very important to mandatory for inclusion (Likert scale 7-9). Topics with >80% consensus were removed from subsequent surveys and included in the final list, and topics with <50% were removed. Members were asked to select the ideal timing of topic delivery during residency (Foundational-Early Residency, Intermediate-Mid Residency, Advanced-Late Residency). A total of 158 panel members who were contacted using national anesthesiology organization email lists completed the initial round, 119 (75%) completed the second iteration, and 116 (73%) completed the third. Response rate on the first survey was (22/55) 40% for anesthesiology critical care program directors, (18/132) 14% for core anesthesiology residency program directors, and (77/1150) 7% for the remaining respondents. Trainees (n = 41) were not included in response rate calculations. Most participants (103/158, 65%) had completed both core anesthesiology and subspecialty critical care medicine training and most (87/158, 55%) had formal roles in medical education. Forty-one (26%) responders were currently in training. All panelists worked in institutions with graduate medical education (GME) learners. Fifty-eight of 136 (43%) topics met consensus for inclusion. Most consensus topics (50/58, 86%) were recommended to be delivered early during residency with the other 8 topics to be delivered in the middle of residency. We developed a prioritized critical care content outline for anesthesiology residents that includes highly recommended critical care topics with ideal timing for inclusion in residency. This outline provides the first step in developing a pragmatic standardized curriculum to guide faculty and programs in critical care education.

Multiple Goals Theory and Communication Quality Analysis for Fellows Communication Training.

End-of-life communication skills are vital to high-quality critical care. Patients and families often report deficiencies in end-of-life communication by providers. However, formalized training is difficult to implement and study on a large scale. Furthermore, curricula are often designed with early-stage clinical trainees in mind and are not tailored to advanced clinician learners. The goal of this pilot study was to explore educational and practical implications of using Multiple Goals Theory (MGT), Communication Quality Analysis (CQA), and communication logs as a three-pronged, reflective communication curriculum for advanced trainees. We describe design and qualitative evaluation of a novel, pilot, longitudinal curricular intervention for pulmonary and critical care fellows and program directors at a tertiary academic medical center. The 2-year longitudinal communication curriculum incorporates 1) a theoretical framework from communication science (MGT), with 2) a novel training modality of analyzing audio-recorded intensive care unit family meetings (CQA), and 3) written communication logs after an intensive care unit family meeting. The sample included 13 pulmonary and critical care medicine fellows and two program directors. Qualitative thematic analysis was conducted on seven fellow interviews and on 23 communication logs completed. Four themes emerged from interviews: 1) fellows incorporated the skills into real-life practice and found the curriculum useful and valuable; 2) a key takeaway from MGT was the deemphasis of task goals; 3) CQA was an engaging opportunity for self-reflection and learning; and 4) written communication logs were perceived as helpful in theory but too burdensome in practice. Findings from analyses of the communication logs included that most fellows' writing was brief and without substantial reflection. Many scholars have argued that communication theory can impact practice, but few have recognized the potential of theory and methods, such as MGT and CQA, as educational tools. Our findings demonstrate that MGT is a feasible and useful theoretical framework for improving communication skills among advanced trainees, and CQA fosters meaningful self-reflection about practice. Communication logs were not feasible or useful training tools in this context, but CQA workshops helped fulfill the goals of narrative reflection. Next steps are to implement this curriculum in more programs and measure changes in behavior acquisition and clinical care.

Designing and maintaining a rescue extracorporeal life support program: A holistic simulation approach.

Rescue Extracorporeal Life Support Programs based at non-cardiac surgery centers have unique needs to be able to ensure successful outcomes despite low patient volumes. In this paper we describe the important role simulation had in each stage of development, implementation, and maintenance of our pediatric Rescue ECLS Program. Systems-focused simulations were used to develop robust workflows, processes, and bundles. Simulation-based education targeted the acquisition and maintenance of clinical skills for individual team members, bringing together a multidisciplinary team of local clinicians who do not routinely perform pediatric cannulation related tasks. Translational simulation ensured continued improvement by addressing adverse events or latent safety threats observed during system-focused or educational simulations. Realism of all simulations was our priority, and was achieved through in situ simulations, participation of multidisciplinary teams, use of real equipment and medical supplies, and use of a high-fidelity cannulation manikin. This holistic simulation approach allowed us to overcome the barriers to high quality care, and maintain outcomes comparable to high volume centers. A similar approach can help other centers design simulation for their own Rescue ECLS Program, and can be translated to other high-risk and high-acuity critical care programs.

A Model for Residency Training: The Small Animal Emergency and Critical Care Residency Program at Purdue University

Training residents in any specialty is a balancing act between ensuring high quality education, making certain the resident meets the requirements set forth by the specialty college to achieve credentials and be eligible to take the board certification examination, and fulfilling clinical duties at that institution. For programs such as this one, residents are integral members of the clinical team, working primary emergency receiving shifts in order to allow the service to function; this leads to a need to identify and protect learning time for the residents. Those involved in the Purdue Small Animal Emergency and Critical Care residency program believe that in the chaos that is emergency and critical care, a firm timeline with attainable checkpoints is crucial to resident success. Such a timeline follows goal setting theory and provides structure and guidance to candidates to navigate their three year program and ensure that they complete all requirements during the residency period. Candidates completing the Purdue program successfully finish their credentials, including at least one first author publication, and have at least one scientific presentation to improve their curriculum vitae. This paper serves to present the structure and timelines used by the Purdue Small Animal Emergency and Critical Care program to organize its residency program as an example of a successful program.

Survey of national practices for postgraduate year two critical care and emergency medicine pharmacy residency emergency response training

AbstractIntroductionMedical emergency response within the hospital involves an interdisciplinary team, including pharmacists. Pharmacist involvement in these teams has increased over time due to published benefits of their involvement. Development of emergency response skills may start during pharmacy residency, although limited data suggest how this is best implemented.ObjectivesLimited data evaluate post‐graduate year 2 (PGY2) pharmacy resident training for emergency response, as well as PGY2 program values for this in screening/ranking candidates, which may help post‐graduate year one (PGY1) pharmacy residents identify residency programs that are a good fit for their career goals.MethodsA list of PGY2 critical care (CC) and emergency medicine (EM) programs were identified. The questionnaire included program demographics, characteristics of PGY2 emergency response training, and PGY2 residency program values of PGY1 emergency response exposure for screening and ranking applicants for their programs. A Fisher's exact test was used to compare differences between CC and EM programs for these outcomes.ResultsA total of 85 complete responses were analyzed (response rate by all identified programs: CC = 36.4%; EM = 32.1%). Emergency response training was often with both core and longitudinal experiences (72.9%), although differed by type of program (p &lt; 0.001). Both CC and EM programs considered PGY1 pharmacy resident exposure to emergency response in screening candidates (33.9% and 57.7%, respectively), as well as ranking candidates (22% and 38.5%, respectively). For CC programs, both Advanced Cardiovascular Life Support certification and quantity of PGY1 emergency response ranked as the most important characteristics, while EM programs ranked quantity as the most important.ConclusionThe results of this survey indicate heterogeneity in PGY2 CC and EM emergency response training. PGY1 applicants for these programs should consider their experience with emergency response as a potential factor in identifying an appropriate program for their training.

Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department.

To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED). Single-center, retrospective cohort study using ED-visit data between 2015 and 2019. Tertiary academic medical center. Adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival. Dedicated bedside critical care for medical ICU patients by an ED-based intensivist following initial resuscitation by the ED team. Primary outcomes were inhospital mortality and the proportion of patients downgraded to non-ICU status while in the ED within 6 hours of the critical care admission order (ED downgrade <6 hr). A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015-2017) and the intervention period (2017-2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours). Adjustment for severity of illness was performed using the emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The primary cohort included 2,250 patients. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, -11.9 to -0.1) with largest difference in the intermediate illness severity group (DiD, -12.2%; 95% CI, -23.1 to -1.3). The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, -0.7 to 10.3%) except in the intermediate group (DiD, 8.8%; 95% CI, 0.2-17.4). The implementation of a novel ECCP was associated with a significant decrease in inhospital mortality among critically ill medical ED patients, with the greatest decrease observed in patients with intermediate severity of illness. Early ED downgrades also increased, but the difference was statistically significant only in the intermediate illness severity group.

Perception, perceived scope, and potential barriers towards developing nurse practitioners cadre among health care providers and beneficiaries: A pilot study from Northern India.

The role of nurse practitioner (NP) emerged in early 1965 when general practitioners began working with nurses. Evidence across the world highlights the benefits achieved by the NP role. The Indian Nursing Council (INC) implemented a country-wide NP in critical care (NPCC) program with the approval of the ministry of health and family welfare (MoHFW) in 2017. The NP role is in its infancy in India. Hence, there is a need to assess the perception among beneficiaries and healthcare personnel. This study was conducted to assess the perception, perceived scope, and potential barriers for developing the role of NPs in India among beneficiaries and healthcare providers. A descriptive, cross-sectional pilot study was conducted at AIIMS Rishikesh, Uttarakhand, India, among 205 participants (84 beneficiaries, 78 nurses, and 43 physicians) using a proportionate stratified random sampling technique. Likert scales and socio-demographic sheets were used to assess the perception, perceived scope of practice, and potential barriers in developing a NP cadre in India. Descriptive and inferential statistics were used for analyzing data. The mean age of beneficiaries was 37.98, nurses was 27.58, and physicians was 28.13 years, respectively. 121 (61%) of participants were highly favored, and 77 (38%) were in favor of developing NP cadre in India. They considered it to be necessary, feasible, and acceptable in India. The feasibility and necessity of the perception domain were highly significant (P < 0.001 and P < 0.003, respectively). Nurses (mean ± SD: 35.36 ± 3.55) considered that NPs could have a wide range of practice followed by beneficiaries (mean ± SD: 38.17 ± 3.68) than physicians (mean ± SD: 34.75 ± 5.95). Lack of awareness, the nonexistence of cadre structure, lack of acceptance of the role of physicians, and lack of clear policy were the key potential barriers to develop an NP cadre in India. In this study, participants had favorable views on employing NPs in India; thus, this role will improve healthcare access for beneficiaries. NPs can carry out a wide range of practices.However, a lack of awareness, no cadre structure, and a lack of a clear policy may hinder the development of the NP cadre in India.

Development of critical care medicine in post-war Republic of Srpska: Banja Luka region

Critical care medicine as relatively young discipline, started developing in mid1950s in response to epidemy of poliomyelitis. This branch of medicine evolved much faster in high-income countries (HIC) than in low resource settings (LRS) where the Republic of Srpska (Western Balkan) belongs. The experience of setting up a modern critical care program under the LRS constraints as a promising way forward to meet the increased demand for critical care worldwide is described. Main tool was systematic analysis of written documents related to the establishment of the first multidisciplinary MICU and its development to the present day. Successful development is contingent on formal education and continued mentorship from HIC, establishment of a multidisciplinary team, the support from local healthcare authorities, development of a formal subspecialty training, academic faculty development and research. Critical care medicine is a critical public health need in HIC and LRS alike.

Contributions of Surgical Critical Care Program Directors Society to the training of surgeons.

In 1986, Surgical Critical Care (SCC) was formally recognized as a specialty by the American Board of Surgery (ABS), however it took another two decades to develop a formal national training structure in SCC. In 2003, the program directors of SCC fellowships began to meet and the Surgical Critical Care Program Directors Society (SCCPDS) was officially formed in 2004, with recognition of the SCCPDS as a non-profit organization in 2008. Over the next several years, and in conjunction with other interested groups, such as the American Association for the Surgery of Trauma (AAST) and the Society of Critical Care Medicine (SCCM), SCCPDS created a formal curriculum, developed a unified system for the fellowship application process, and increased recruitment and match such that now approximately 1 in 6 general surgery graduates are pursuing training in SCC. In discussion with past and present leadership of SCCPDS, there are several ongoing initiatives to further improve the educational opportunities of the fellows and increase inclusion of other organizations and other specialties interested in SCC. The purpose of this article is to discuss the role of SCCPDS in the development and evolution of SCC and Acute Care Surgery (ACS) training. Expert Opinion; Level V.

666: POST-PICU SLEEP EFFICIENCY AND QUALITY OF LIFE IN INFANTS AND TODDLERS WITH ACQUIRED BRAIN INJURY

Introduction: Young children are high risk for long-term morbidity after critical care for acquired brain injury (ABI), including sleep disturbances. Poor sleep in children after ABI is associated with worse developmental outcomes. Sleep efficiency (SE) is a mainstay of the evaluation of sleep disorders and response to sleep interventions in adults, but is infrequently measured in pediatric populations, especially infants and toddlers. This study investigated SE after ABI in an at-risk cohort, and associations with quality of life and family impact outcomes. Based on prior work demonstrating the importance of sleep in healing after ABI, we hypothesized that there would be a positive correlation between SE and quality of life outcomes. Methods: This retrospective cohort study examined 98 children aged 0-3 years who survived critical care hospitalization for ABI and received outpatient follow-up care through the Pediatric Critical Care and Neurotrauma Recovery Program one to three months post-discharge. We derived SE from the Brief Infant Sleep Questionnaire as the ratio of nighttime sleep to total time in bed, which accounts for sleep latency and duration of nighttime awakenings. Poor SE defined as < 80%. Pediatric Quality of Life Inventory Core Total Score (QOL) and Family Impact Module Total Score (FIM) evaluated outcomes. Spearman’s correlation (rs) quantified associations between SE and outcomes. Multivariable linear regression evaluated association between SE and QOL controlling for significant covariates (age, comorbidities, worsening functional status scale score). Significance defined as p<.05. Results: Following ABI, we found a median SE of 91.4 (IQR= 83.1, 95.5). Nineteen (19.4%) children had poor SE. There was a significant positive correlation between SE and QOL (rs= .331) and FIM scores (rs= .321; both p<.01). When controlling for covariates, worse SE remained significantly associated with worse QOL (β-coefficient= -9.7; 95% Confidence Interval= -15.2, -4.1; p<.001). Conclusions: Young children with ABI are at an increased risk of poor SE and subsequent negative impacts on a variety of child and family health outcomes. Our study underscores the importance of identifying early sleep interventions following ABI in order to optimize recovery.

287: ASSOCIATION BETWEEN AN EMERGENCY CRITICAL CARE PROGRAM AND DKA CRITICAL CARE UTILIZATION IN THE ED

Introduction: The Stanford Emergency Critical Care Program (ECCP), in which a dual-boarded EM/CCM physician serves as an embedded consultant during hours of peak ED census, was initiated in 2017. We investigated the association between the ECCP intervention and critical care utilization in ED patients with Diabetic Ketoacidosis (DKA). Methods: This is a retrospective cohort analysis of adult DKA patients in the ED who were admitted to critical care between 2017-2019. Duration of critical care and ICU bed utilization by patients admitted during ECCP hours were compared to patients admitted during non-ECCP hours. Stata was used for all analyses. Results: Of 71 patients identified, 16 (23%) were in the ECCP cohort, and 55 (77%) were admitted outside ECCP hours. No demographic or baseline clinical differences were noted between groups, although ECCP patients had significantly lower initial glucose (419 vs 602, p=0.014). On univariable analysis, there was no significant difference in mortality or length of hospital stay. In terms of critical care utilization, however, ECCP patients were more likely to be downgraded to non-ICU level of care directly from the ED (93.8% vs 45.5%, p=0.001), and also specifically to be downgraded within 6 hours (62.5% vs 12.7%, p< 0.0001). Finally, total critical care duration was reduced during ECCP hours (5.4h vs 14.4h, p=0.0001). These findings remained significant upon multivariable analyses controlling for demographics and baseline clinical characteristics. Conclusions: DKA patients admitted to the ICU during ECCP hours were found to have decreased critical care duration and increased likelihood of downgrade to non-ICU level of care while still in the ED. These results suggest that early care by an embedded intensivist is associated with decreased critical care utilization among DKA patients in the ED. Future research should focus on prospective validation of these findings in a larger cohort, and identifying specific aspects of ECCP care that could be adapted for general ED use.

Being and Becoming: Narrative Records of Pediatric Critical Care Clinicians.

Medical humanities initiatives have been integrated in our Pediatric Critical Care program to help clinicians make meaning of key experiences in their professional and personal journeys. In particular, narrative medicine and clinicians' writings illuminate and commemorate these journeys and increase our understanding of our profession in its full complexity. In this piece, we provide an example of a medical humanities curriculum and a selection of pieces written by several participants in it. These pieces form a collective narrative, portraying aspects of our individual and collective biography.

Implementation of a unique mass casualty and emergency preparedness longitudinal learning experience for postgraduate year 2 pharmacy residents

Background and purposeThe American Society of Health-System Pharmacists (ASHP) postgraduate year 2 (PGY2) critical care pharmacy residency program offers an elective competency area, E3: Mass Casualty. Similar elective competencies are also available for PGY2 emergency medicine and postgraduate year 1/2 pharmacotherapy programs. Because of the COVID-19 pandemic, pharmacist proficiency in the management of disasters is even more urgent. However, few residency programs require or include a specific learning experience to achieve this competency. This article provides examples of opportunities that residency programs can implement to offer an Emergency Preparedness/Mass Casualty (EP/MC) learning experience. Educational activity and settingA longitudinal EP/MC learning experience was integrated into a PGY2 critical care program. FindingsA longitudinal EP/MC learning experience within the PGY2 critical care, emergency medicine, and pharmacotherapy residency program curricula is achievable and promotes resident development. Learning experience components included topic discussions, participation on local and state-level emergency preparedness (EP) committees, completion of certification programs, projects, and participation on statewide emergency response teams. SummaryImplementation of a longitudinal EP/MC learning experience formalizes topics and activities that support achievement of the ASHP elective competency area of Mass Casualty for PGY2 residency programs. EP/MC goals and objectives should be a requirement for critical care, emergency medicine, pharmacotherapy, and health-system pharmacy administration and leadership PGY2 programs. By formalizing training, pharmacists can be better prepared for EP and more integrated into multidisciplinary disaster response teams.

Reimagining Critical Care Education During COVID-19 With High-Level Technology.

Methods of critical care (CC) education were quickly challenged when faced with the COVID-19 pandemic requiring social distancing and limited group sizes. A new delivery model was designed-one that included a smart video conferencing and recording system and an online platform to access education. Over the course of 4 weeks, the CC program was revamped to meet the immediate needs of CC new hires coming to this tertiary and quaternary medical center.

Comparison of Master of Science in Critical Care Nursing Curriculum in Iran and Master of Science in Critical Care in the University of Glasgow: A Comparative Study

Background: The main purpose of a health system is to provide quality care services, and providing orderly, high-quality, safe, and economic services requires skillful and knowledgeable nurses. Critical Care M.Sc. curriculum in Iran was revised in June 2010. Studies show that, since specialized associations such as the World Health Organization have demanded the improvement of educational standards for the graduates of this major, educational planner have tried to design a successful and efficient curriculum through examining other successful educational systems in the world. By comparing different educational systems, quality of educational programs can be improved. In addition, comparative studies are one of the most dynamic scientific approaches adopted by educational planners in various countries, such that it is considered a prerequisite for designing modern educational systems. In light of this, the present study tried to compare Critical Care M.Sc. curriculum in Iran with that of the university of Glasgow. It is one of the oldest universities in the UK, the fourth oldest and of the top 100 universities in the world.&#x0D; Methods: This was a comparative and descriptive study conducted in 2020 to compare the Critical Care M.Sc. curriculum in Iran with a corresponding one in the university of Glasgow through Beredy model.&#x0D; Results: Although Critical Care M.Sc. Curriculum in Iran is in an acceptable position compared to the university of Glasgow's evidence-based education approach, the focus on academic writing skills for improving the graduates’ skill of writing research papers, and the availability of a part time program were of the advantages of Critical Clinical Care curriculum at the university of Glasgow. On the other hand, lack of a specific and strategic programing, and ambiguities about missions of the graduates were the weaknesses. The curriculum in Iran was clear about the philosophy, mission, and perspective, while job opportunities of the graduates in clinical settings were not clear. This was one of the reasons for the reluctance of the graduates to enter clinical environment, which was a disadvantage of the program in Iran.&#x0D; Conclusion: Although Critical Care M.S Curriculum in Iran is in an acceptable position compared to the one in the University of Glasgow's evidence-based approach, Focus on the academic writing skills for improving the graduates’ skills of writing research papers, and availability of a part time program were of the advantages of the critical clinical care program at the University of Glasgow. On the other hand, lack of a strategic programing and the ambiguities about missions of the graduates were the weaknesses. The curriculum in Iran was clear about the philosophy, mission, and perspective, while the job opportunities of the graduates in clinical setting were not clear. This is one of the reasons for the reluctance of graduates to enter clinical environment, which is a disadvantage of the program in Iran.

Survey of surgical critical care applicant and program director views on virtual interviews for fellowship training: a Surgical Critical Care Program Directors Society sponsored study

BackgroundThe COVID-19 pandemic forced postgraduate interview processes to move to a virtual platform. There are no studies on the opinions of faculty and applicants regarding this format. The aim of...

Gender Distribution of Current Surgical Critical Care Fellows, Faculty, and Program Directors.

As women surgeons continue to represent a minority within the surgical field while also holding lower ranked positions, gaining a sub-specialized set of clinical skills through surgical fellowships, like surgical critical care (SCC), is one approach to advance within the surgical field. A cross-sectional analysis was performed investigating the websites of all 106 US-based SCC fellowships. A total of 116 SCC fellows were included in this analysis, comprising 67 (59.3%) men and 46 (40.7%) women. There were 977 SCC fellowship faculty were evaluated, comprising 619 (67.9%) men and 292 (32.1%) women. Additionally, 103 SCC fellowship program directors were analyzed, consisting of 77 (74.8%) men and 26 (25.2%) women. There is a significantly lower proportion of women fellows and faculty members (P < .001) compared to men. SCC programs with female program directors on average have higher proportions of female fellows and faculty compared to programs with male program directors (52% and 36% vs 31% and 29%, respectively). There is a stable yet unbalanced gender distribution throughout all positions in SCC fellowship programs. Actively supporting women surgeons pursuing SCC fellowship and removing barriers to their advancement through effective interventions can disrupt the persistently low prevalence of women SCC fellows, faculty, and program directors.

Successfulimplementationof modern critical care in the low-resources country Bosnia and Herzegovina : Single-center experience.

BackgroundCritical care medicine is a relatively young discipline, developed in the mid-1950s in response to the outbreak of poliomyelitis. The mass application of mechanical ventilation and its subsequent technical advancement helped manage large numbers of patients with respiratory failure. This branch of medicine evolved much faster in high-income (HIC) than low- and middle-income countries (LMIC). Seventy years later, mankind’s encounter with coronavirus disease 2019 (COVID-19) represents another major challenge for critical care medicine especially in LMIC countries where over two thirds of the world population live.MethodsSystematic analysis of written documents related to the establishment of the first multidisciplinary medical intensive care unit (MICU) in Bosnia and Herzegovina and its development to the present day.ResultsWe describe the experience of setting up a modern critical care program under LMIC constraints as a promising way forward to meet the increased worldwide demand for critical care. Successful development is contingent on formal education and continued mentorship from HIC, establishment of a multidisciplinary team, the support from local health care authorities, development of a formal subspecialty training, academic faculty development, and research. Novel technologies including tele-education provide additional opportunities for rapid development and dissemination of critical care medicine programs in LMIC.ConclusionCritical care medicine is a critical public health need in HIC and LMIC alike. The challenges associated with the coronavirus pandemic should serve as a wakeup call for rapid development of critical care programs around the world.

An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19.

Background:UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals – one in the US, two in Mexico – as high volumes of severely ill patients overwhelmed hospitals.Objective:We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border.Methods:We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery.Findings:In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital.Conclusion:A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.

Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Guidelines for Management of Acute Kidney Injury in Children.

Purpose:This article provides guidance on managing acute kidney injury (AKI) and kidney replacement therapy (KRT) in pediatrics during the COVID-19 pandemic in the Canadian context. It is adapted from recently published rapid guidelines on the management of AKI and KRT in adults, from the Canadian Society of Nephrology (CSN). The goal is to provide the best possible care for pediatric patients with kidney disease during the pandemic and ensure the health care team’s safety.Information sources:The Canadian Association of Paediatric Nephrologists (CAPN) COVID-19 Rapid Response team derived these rapid guidelines from the CSN consensus recommendations for adult patients with AKI. We have also consulted specific documents from other national and international agencies focused on pediatric kidney health. We identified additional information by reviewing the published academic literature relevant to pediatric AKI and KRT, including recent journal articles and preprints related to COVID-19 in children. Finally, our group also sought expert opinions from pediatric nephrologists across Canada.Methods:The leadership of the CAPN, which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric AKI and acute KRT. The goal was to adapt the guidelines recently adopted for Canadian adult patients for pediatric-specific settings. These included specific COVID-19-related themes relevant to AKI and KRT in a Canadian setting, as determined by a group of kidney disease experts and leaders. An expert group of clinicians in pediatric AKI and acute KRT reviewed the revised pediatric guidelines.Key findings:(1) Current Canadian data do not suggest an imminent threat of an increase in acute KRT needs in children because of COVID-19; however, close coordination between nephrology programs and critical care programs is crucial as the pandemic continues to evolve. (2) Pediatric centers should prepare to reallocate resources to adult centers as needed based on broader health care needs during the COVID-19 pandemic. (3) Specific suggestions pertinent to the optimal management of AKI and KRT in COVID-19 patients are provided. These suggestions include but are not limited to aspects of fluid management, KRT vascular access, and KRT modality choice. (4) Considerations to ensure adequate provision of KRT if resources become scarce during the COVID-19 pandemic.Limitations:We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. The local context, including how the provision of care for AKI and acute KRT is organized, may impede the implementation of many suggestions. As knowledge is advancing rapidly in the area of COVID-19, suggestions may become outdated quickly. Finally, most of the literature for AKI and KRT in COVID-19 comes from adult data, and there are few pediatric-specific studies.Implications:Given that most acute KRT related to COVID-19 is likely to be required in the pediatric intensive care unit initial setting, close collaboration and planning between critical care and pediatric nephrology programs are needed. Our group will update these suggestions with a supplement if necessary as newer evidence becomes available that may change or add to the recommendations provided.