Pediatric Critical Care Medicine Fellowship Research Articles

Survey of Pediatric Critical Care Fellows on Postresuscitation Debriefing.

Current guidelines recommend debriefing following medical resuscitations to improve patient outcomes. The goal of this study was to describe national trends in postresuscitation debriefing practices among pediatric critical care medicine (PCCM) fellows to identify potential gaps in fellow education. A 13-item survey was distributed to fellows in all 76 ACGME-accredited PCCM programs in the United States in the spring of 2021. The online survey addressed frequency and timing of debriefings following medical resuscitations, whether formal training is provided, which medical professionals are present, and providers' comfort level leading a debriefing. Results were analyzed using descriptive statistics. A total of 102 responses (out of a possible N of 536) were gathered from current PCCM fellows. All fellows (100%) reported participation in a medical resuscitation. Only 21% stated that debriefings occurred after every resuscitation event, and 44% did not follow a structured protocol for debriefing. While 66% reported feeling very or somewhat comfortable leading the debriefing, 19% felt either somewhat uncomfortable or very uncomfortable. A vast majority (92%) of participating fellows believed that debriefing would be helpful in improving team member performance during future resuscitations, and 92% expressed interest in learning more about debriefing. The majority of PCCM fellows do not receive formal training on how to lead a debriefing. Given that 74% of fellows in our study did not feel very comfortable leading a debriefing but almost universally expressed that this practice is useful for provider well-being and performance, there is a clear need for increased incorporation of debriefing training into PCCM curricula across the United States.

Central Venous Catheter Placement Skill Acquisition Through Apprenticeship Training in Clinical Context during Pediatric Critical Care Medicine Fellowship: A Longitudinal Study

AbstractPediatric critical care medicine (PCCM) fellows must develop competence in central venous catheter (CVC) placement. The impact of experiential learning opportunities in the clinical context on PCCM fellow CVC placement skill acquisition remains unknown. We sought to measure femoral CVC placement skill acquisition during fellowship and compare fellow to attending skill. We performed a prospective observational cohort study of PCCM fellows at the University of Colorado from 2019 to 2021. Femoral CVC placement skill was measured by attending evaluation of level of the supervision (LOS) required for the fellow, and hand motion analysis (HMA) on simulation task trainer. Competence in femoral CVC placement was defined as LOS ≥ 4 (can perform this skill independently) on a 5-point Likert scale. We compared fellow skill in femoral CVC placement to years of training and number of femoral CVCs placed. We also compared third-year fellow and attending HMA measurements. We recruited 13 fellows and 6 attendings. Fellows placed a median of 8 (interquartile range 7, 11) femoral CVCs during the study period. All fellows who reached third-year of fellowship during the study period achieved competence. Longitudinal analysis demonstrated improvement in CVC placement skill by both LOS and HMA as years of fellowship and number of femoral CVCs placed increased. Few third-year fellows achieved attending level skill in femoral CVC placement as measured by HMA. PCCM fellows acquired skill in CVC placement during fellowship and achieved competence in the procedure, but most did not reach attending level of skill.

End-of-Life Care Education in Pediatric Critical Care Medicine Fellowship Programs: Exploring Fellow and Program Director Perspectives.

Background/Objectives: The aim of this study is to describe the current state of end-of-life (EOL) care education within pediatric critical care medicine (PCCM) fellowship programs and explore potential differences in beliefs on EOL care education between program directors (PDs) and fellows. Design: A mixed-methods study based on data obtained through a nationally distributed, web-based cross-sectional survey of PCCM fellowship PDs and PCCM fellows was performed. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowships in the United States. Subjects: PCCM fellows and PDs participated in this study. Measurements and Results: The total number of survey respondents was 124 (94/654 fellows and 30/96 PDs), representing 39% of ACGME-accredited PCCM programs. Bedside teaching and lecture-based modalities were the most commonly used methods to teach EOL care. Most fellows and PDs reported a perceived need for additional EOL education within their respective training programs (fellows 91%, n = 86/94; PDs 67%, n = 20/30). A thematic analysis of curriculum structure questions revealed significant similarities between PDs and fellows, including the perceived need for education in communication, medical management, and cultural awareness. Dealing with uncertainty and resiliency were identified as themes among PDs only, and emotional/moral and legal issues were identified as themes solely by fellows. Conclusions: Our study describes the current state of EOL care education within a sample of PCCM fellowship programs. We highlight the perceived need for additional EOL education and identify areas within EOL care that deserve more focus by PCCM fellows and PDs. Future studies with focus on EOL curriculum development in PCCM EOL training are needed.

858: THE IMPLEMENTATION OF A HEALTH EQUITY CURRICULUM IN A PEDIATRIC CRITICAL CARE FELLOWSHIP

Introduction: Bias and racism in medicine perpetuate health disparities. In response, the Accreditation Council for Graduate Medical Education has instituted program requirements to address diversity, equity, and inclusion (DEI) in training programs. Little guidance has been given regarding the structure and content of these curricula. As such, we aim to describe the structure and function of an integrated health equity curriculum at the pediatric critical care medicine (PCCM) fellowship program at the Children’s Hospital of Philadelphia (CHOP) and present our curriculum as a model for other training programs. Methods: Attendings, fellows, research assistants, and administrators serve on the Health Equity Committee (HEC). HEC is divided into three domains: education, research, and community engagement. Education topics include understanding institutional racism in medicine, mitigating bias and microaggressions, and local patterns of disparate outcomes (i.e. violence, asthma, etc). The research domain incorporates health equity into research and quality improvement projects. The community engagement domain is involved in patient education in Philadelphia and recruitment initiatives for medical students who are underrepresented in medicine. Results: Over the first 24 months, HEC has conducted nine lectures, four journal clubs, three health equity case conferences, and an interactive session regarding a structured response to microaggressions. Nationally, HEC directed a PCCM survey to assess diversity engagement across fellowship programs and identify areas for improvement; locally, HEC is working to improve the utilization of interpreters and partnering with CHOP’s Center for Health Equity to increase CPR teaching in Philadelphia. Most importantly, HEC activities are fully integrated into existing fellow education with high expectations for participation and accountability. Conclusions: The CHOP PCCM HEC is a feasible and generalizable model for implementing a DEI curriculum. HEC fosters an environment that integrates DEI into the education of pediatric critical care fellows. Integrating DEI-focused education, research, and community engagement sustainably modeled by HEC can contribute to the elimination of disparities and bias in the care of critically ill children.

Simulation-Based Training for Ultrasound-Guided Central Venous Catheter Placement in Pediatric Patients.

IntroductionCentral venous catheter (CVC) placement in pediatric patients is lifesaving but associated with complications. To standardize training and decrease complications, we developed a simulation-based ultrasound-guided CVC placement training program for pediatric critical care providers.MethodsWe implemented our CVC placement training program with several groups of learners, including pediatric critical care medicine (PCCM) fellows, pediatric emergency medicine fellows, and PCCM advanced practice providers. Learners completed prework assignments and a knowledge test before participation. The session started with group activities including a learner-led CVC site-selection debate and a team-based competition to list the steps in CVC placement. Next, the learners rotated between four stations for deliberate practice on separate components of CVC placement. Finally, they performed CVC placement on a task trainer. Evaluation included assessment of learner confidence, a knowledge test, and measurement of procedure time before and after training.ResultsTwenty-seven learners participated in the training. Learner confidence in CVC placement increased significantly after participation (median confidence level: 1.5 vs. 4.0, p < .001). Learner CVC knowledge also increased significantly after participation (median test score: 68% vs. 88%, p < .001). CVC placement procedure time, a marker for skill in CVC placement, decreased significantly after participation (median procedure time: 264 seconds vs. 146 seconds, p < .001).DiscussionOur simulation-based training program effectively increased knowledge, skill, and confidence in CVC placement for a variety of learners. Future work should evaluate the optimal frequency and structure of maintenance training and the impact of training on clinical outcomes.

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.

Pediatric Interfacility Transport Curriculum: Its Impact on the Pediatric Intensive Care and Emergency Medicine Fellows’ Performance and Confidence

ObjectivePediatric interfacility transports are frequent. Despite the absence of a formal pediatric transport curriculum in eastern Canada, directly managing patients during transport and medical direction of the referring center and transport team are part of the pediatric critical care medicine (PCCM) and pediatric emergency medicine (PEM) program requirements. The authors developed a pediatric interfacility transport curriculum and measured its impact on fellows’ confidence and performance. MethodsThis was a pilot interventional prospective study in Montreal, Canada. Postcurriculum surveys were used to measure confidence, and high-fidelity simulations were used to measure performance. A target threshold for confidence was defined before implementation, and pre- and post values were compared. The simulation scenario and assessment checklist were locally developed. ResultsThe participants were 11 PCCM and 3 PEM fellows. The content of the curriculum and educational methods were selected based on the literature and a needs assessment survey. All participants rated themselves as confident at the end of the curriculum. Eighty-three percent of the participants were deemed proficient with a perfect interrater agreement. ConclusionThe pediatric transport curriculum had a positive impact on PEM and PCCM fellows’ confidence and performance in transport. Further studies should look at the impact of such a curriculum on participants’ real-life performance and patient care.

Core Components of a Pediatric Critical Care Transport Communication Curriculum: A Modified Delphi Approach

ObjectiveInterfacility transport of critically ill infants and children is an essential part of the care of children in the United States. However, there is tremendous variation in how transports are coordinated and performed. Pediatric critical care medicine (PCCM) fellows have differing experiences in their fellowships, and there is no standardized way of training medical command for the transport process. The aim of this study was to use a consensus-building process to establish core components of a PCCM transport curriculum focused on communication. MethodsA national group of experts in transport medicine rated 51 total possible topics for their importance to include in a fellowship curriculum. Three rounds of surveys were completed. ResultsFifty-two of 372 invitees (14%) participated in round 1. Consensus was reached to include 15 items in a PCCM curriculum. Twenty of 52 (38%) experts completed round 2, reaching consensus on 2 additional items. Seventeen of 20 (85%) experts completed round 3. No additional items reached consensus. ConclusionExperts reached consensus on 17 core components to include in a PCCM fellowship transport communication curriculum. This curriculum could likely be adapted to train providers from different disciplines in the transport process.

The Effect of the Coronavirus-2019 Pandemic on Pediatric Critical Care Fellowship Training.

Objective: To assess the impact of the coronavirus-2019 (COVID-19) pandemic on pediatric critical care medicine (PCCM) fellowship training through a cross-sectional survey of both program directors (PDs) and fellows. Design: Cross-sectional internet-based survey. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowship programs in the United States. Subjects: PCCM PDs and fellows. Results: A total of 34 PDs and 92 fellows responded to the national survey (rate of 47% and 17%, respectively). The majority (69%) of respondents agreed that medical education has been negatively impacted by the COVID-19 pandemic. When PDs were surveyed, 91% noted a significant decrease in the patient census since March 2020, with 59% citing a >15% decrease. Further, 65% reported trainees had less procedural experience. All respondents reported that education was at least in part provided through virtual learning platforms, with nearly half having exclusive remote learning without in-person sessions. Fifty percent of PDs and 62% of fellows reported decreased learner engagement during virtual didactics when compared to in-person education. The majority of PDs reported specific decreases in simulation, procedural skills training, and ultrasound training. Few PDs (15%) and fellows (13-16%) reported redeployment to adult patient care, with northeastern programs having the highest rates. In univariate analyses, decreased PDs confidence in trainee procedural skills was associated with reported decreases in number of procedures performed (P = .0006) and number of procedural skills didactic sessions (P = .0245). Change in the unit census was associated with less PDs confidence in fellows' medical knowledge (P = .0004), fellows' management skills (P = .0232), and fellows' procedural skills (P = .0003), with larger decreases in patient census correlating with larger decreases in confidence. Conclusions: The COVID-19 pandemic has significantly impacted the education and clinical training of PCCM fellows. More knowledge on this topic can assist PDs in curriculum changes for the future to address any gaps in learning that have occurred.

Transport Medical Control Education for Pediatric Critical Care Fellows: A National Needs Assessment Study.

Characterize transport medical control education in Pediatric Critical Care Medicine fellowship. Cross-sectional survey study. Pediatric Critical Care Medicine fellowship programs in the United States. Pediatric Critical Care Medicine fellowship program directors. None. We achieved a 74% (53/72) response rate. A majority of programs (85%) require fellows to serve as transport medical control, usually while carrying out other clinical responsibilities and sometimes without supervision. Fellows at most programs (80%) also accompany the transport team on patient retrievals. Most respondents (72%) reported formalized transport medical control teaching, primarily in a didactic format (76%). Few programs (25%) use a standardized assessment tool. Transport medical control was identified as requiring all six Accreditation Council for Graduate Medical Education competencies, with emphasis on professionalism and interpersonal and communication skills. Transport medical control responsibilities are common for Pediatric Critical Care Medicine fellows, but training is inconsistent, assessment is not standardized, and supervision may be lacking. Fellow performance in transport medical control may help inform assessment in multiple domains of competencies. Further study is needed to identify effective methods for transport medical control education.

Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit?

Endotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.

P0675 / #906: PEDIATRIC CRITICAL CARE FELLOW ENGAGEMENT WITH AN OPEN-ACCESS E-LEARNING RESOURCE

Aims & Objectives: Pediatric critical care medicine (PCCM) fellows must provide acute, complex clinical care while addressing numerous knowledge gaps, and so may particularly benefit from online educational support. Limited data illustrate the e-learning behaviors or interests of PCCM fellows specifically. Such information may help guide design and targeting of educational interventions. To explore this, we characterized PCCM fellow usage of OPENPediatrics, a worldwide open-access e-learning resource, from June 2018 through June 2019. Methods: IRB-approved retrospective analysis of automatically collected activity log data from users who self-identified as PCCM fellows. The most popular resources (based on percent of fellows who accessed the resource) are reported. Timestamps were used to calculate the duration of time spent by individual users on the website. Results: 299 fellows from 39 countries were included. The distribution of time spent on the site was bimodal, with 105/299 (35%) of users logging <=60 minutes on the site in the analyzed interval, and 100/299 (33%) logging >=240 minutes (Figure 1). These users accessed an average of 9 resources on the site (range 1-89). Table 1 reports the most frequently accessed resources by this cohort of users.Conclusions: The majority of PCCM fellows spent at least 30 minutes on the site. Over 33% of included fellows spent >=4 hours using the site in one year. Courses and simulators were especially popular. Specific popular items included PCCM fellowship-specific curricula, materials for cardiology and congenital heart disease, and interactive online simulators teaching mechanical ventilation and hemodialysis. Our findings can help shape educational interventions and strategies for PCCM fellows.

Abstract to publication conversion in pediatric critical care medicine in Pakistan.

BackgroundTo determine the rate of conversion of abstracts presented at conferences into full-text articles published in peer-reviewed journals in the field of pediatric critical care medicine (PCCM) in a developing country.MethodsWe retrospectively reviewed PCCM abstracts from Pakistan presented at national and international pediatric and critical care conferences over 10 years (January 2010 to March 2020). Data included abstract characteristics, such as presentation (poster/oral), presenter (fellow/resident), time of meeting (month and year), type of meeting, study design and topic; and publication characteristics, such as journal name, time (month and year) and first author. The primary outcome was publication rate of PCCM abstracts presented in meetings and time (months) from presentation to publication.ResultsA total of 79 PCCM abstracts were presented in 20 meetings during the study period. There were 65 poster presentations (82.28%), of which 63 (79.74%) were presented at international critical care conferences and all presenters were PCCM fellows. In total, 64 (81%) abstracts were descriptive observational studies (retrospective: 50, 63.29%) and prospective (14, 17.72%). Only one was an interventional randomized controlled trial. The publication rate of PCCM abstracts was 63.3% (50/79) and the mean time to publication was 12.39±13.61 months. The publication rate was significantly correlated to the year of publication (P<0.001).ConclusionsThe PCCM abstract publication rate and mean time from presentation to publication was 63.3% and 12.39±13.61 months, respectively, in a developing country.

The Association of Pediatric Critical Care Medicine Training Programs with Research Publication Productivity and Employment Outcomes of Their Graduates.

Our objective was to associate characteristics of pediatric critical care medicine (PCCM) fellowship training programs with career outcomes of PCCM physicians, including research publication productivity and employment characteristics. This is a descriptive study using publicly available data from 2557 PCCM physicians from the National Provider Index registry. We analyzed data on a systematic sample of 690 PCCM physicians representing 62 fellowship programs. There was substantial diversity in the characteristics of fellowship training programs in terms of fellowship size, intensive care unit (ICU) bed numbers, age of program, location, research rank of affiliated medical school, and academic metrics based on publication productivity of their graduates standardized over time. The clinical and academic attributes of fellowship training programs were associated with publication success and characteristics of their graduates' employment hospital. Programs with greater publication rate per graduate had more ICU beds and were associated with higher ranked medical schools. At the physician level, training program attributes including larger size, older program, and higher academic metrics were associated with graduates with greater publication productivity. There were varied characteristics of current employment hospitals, with graduates from larger, more academic fellowship training programs more likely to work in larger pediatric intensive care units (24 [interquartile range, IQR: 16-35] vs. 19 [IQR: 12-24] beds; p < 0.001), freestanding children's hospitals (52.6 vs. 26.3%; p < 0.001), hospitals with fellowship programs (57.3 vs. 40.3%; p = 0.01), and higher affiliated medical school research ranks (35.5 [IQR: 14-72] vs. 62 [IQR: 32, unranked]; p < 0.001). Large programs with higher academic metrics train physicians with greater publication success (H index 3 [IQR: 1-7] vs. 2 [IQR: 0-6]; p < 0.001) and greater likelihood of working in large academic centers. These associations may guide prospective trainees as they choose training programs that may foster their career values.

Virtual Reality Simulation for Pediatric Airway Intubation Readiness Education.

BackgroundThe objective of this study was to provide education to inexperienced trainees regarding preparation for airway intubation using virtual reality (VR) tutorial and comparison of performance with that of experienced trainees without VR training. We hypothesized that after the VR tutorial, junior fellows and residents will have comparable recall of the proper steps as experienced trainees.MethodsThis project was initiated in the pediatric intensive care unit from July 1, 2019, to July 30, 2019. Volunteer residents and pediatric critical care medicine fellows participated. The VR group completed a 19-minute immersive tutorial and then demonstrated learned skills with a traditional manikin. Non-VR group fellows listed steps to prepare for airway intubation from memory with scoring on a 24-point timed checklist.ResultsSeventeen subjects participated; two residents were excluded. The VR group had seven trainees (47%) and scored similarly to the other group based on checklist items (50.5% vs 50.8%, P=1).ConclusionVR technologies can be used for education in preparation for pediatric airway intubation. There was no difference in the performance accuracy between the two groups. Larger studies are essential to study benefits of VR in preparation and performance of airway intubation.

956: Out of Sight: Transport Medical Control Education in Pediatric Critical Care Medicine Fellowship

956: Out of Sight: Transport Medical Control Education in Pediatric Critical Care Medicine Fellowship

Practice Variability in Screening and Treating Pediatric Critical Illness Delirium: Survey.

The best practice in pediatric delirium (PD) screening and treatment is still unknown. Current recommendations come from small studies and adult data. In this article, we surveyed the Pediatric Critical Care Medicine fellowship directors on PD screening and treatment practices in their centers. We reported high variability in the screening and treatment practices for PD in large academic medical centers in the United States. The Cornell Assessment of Pediatric Delirium tool is the most commonly used tool for screening, and quetiapine is the most commonly used pharmacologic agent. A national guideline on PD screening, prevention, and treatment is needed to standardize practice and provide guidance.

76. PICU FELLOW ENTRUSTMENT: HOW DO FACULTY MAKE SUPERVISION DECISIONS?

Introduction Academic faculty make supervision decisions which balance the goals of trainee competency with patient safety. Previous work shows significant variability and potential bias in these entrustment decisions. Given the high stakes, understanding how these decisions are made is vital. Qualitative studies established traits that influence entrustment decisions, but the relative contribution of each has not been described. We aim to characterize the influence of these traits on entrustment decisions for Pediatric Critical Care Medicine (PCCM) fellows. Methods We surveyed faculty who supervise PCCM trainees at three PCCM departments. Based on 8 vignettes, faculty chose the level of supervision for a fellow performing an endotracheal intubation- direct or indirect supervision with the attending, direct or indirect supervision of a fellow supervising a junior trainee, or unsupervised. Each vignette varied by 3 traits: 1) patient condition 2) trainee-supervisor relationship and 3) trainee experience. There was a 72% response rate (n=51/70). We created a logistic regression model using the 3 traits and faculty attributes (gender, primary unit, education role) as predictors of direct supervision. We also compared faculty attributes for those selecting direct supervision for e4 cases and Results The majority of vignettes (78%, 311/396) were rated direct supervision. Of vignettes with a 3rd year fellow, 59% (118/199) were rated direct supervision compared with 97% (193/197) for a 1st year. Trainee-supervisor relationship, patient status and primary unit were significant predictors of direct supervision in the regression model. Compared with cardiac ICU faculty, the odds ratio for pediatric ICU faculty to entrust fellows was 2.27 (95% CI 1.07-4.81) and 4.68 (95% CI 1.54-14.19) for mixed cardiac/pediatric ICU faculty. Odds ratios were 2.14 (95% CI 1.47-3.12) for 1 week on service with the fellow (ref: never worked together) and 0.09 (95% CI 0.04-0.17) for a rapidly deteriorating patient (ref: stable patient). Faculty selecting direct supervision for e or Conclusion PCCM entrustment decisions are influenced by the patient's condition, supervisor's relationship with the trainee and supervisor's primary unit.

Current State of Nutrition Education in Pediatric Critical Care Medicine Fellowship Programs in the United States and Canada.

To assess the current state of nutrition education provided during pediatric critical care medicine fellowship. Cross-sectional survey. Program directors and fellows from pediatric critical care medicine fellowship programs in America and Canada. Seventy current pediatric critical care medicine fellows and twenty-five pediatric critical care medicine fellowship program directors were invited to participate. Participants were asked demographic questions related to their fellowship programs, currently utilized teaching methods, perceptions regarding adequacy and effectiveness of current nutrition education, and levels of fellow independence, comfort, confidence, and expectations in caring for the nutritional needs of patients. Surveys were sent to randomly selected program directors and fellows enrolled in pediatric critical care medicine fellowship programs in America and Canada. Twenty program directors (80%) and 60 fellows (86%) responded. Ninety-five percent of programs (19/20) delivered a formal nutrition curriculum; no curriculum was longer than 5 hours per academic year. Self-reported fellow comfort with nutrition topics did not improve over the course of fellowship (p = 0.03), with the exception of nutritional aspects of special diets. Sixty-five percent of programs did not hold fellows responsible for writing daily parenteral nutrition prescriptions. There was an inverse relationship between total number of fellows in a pediatric critical care medicine program and levels of comfort in ability to provide parenteral nutrition support (p = 0.01). Program directors perceived their nutritional curriculum to be more effective than did their fellows (p ≤ 0.001). Nutrition education was reported as highly underrepresented in pediatric critical care medicine fellowship curricula. The majority of programs rely on allied health care professionals to prescribe parenteral nutrition, which may influence trainee independence in the provision of nutritional therapies. Improving the format of current nutrition curriculums, by relying on more active teaching methods, may improve the delivery and efficacy of nutrition education. The impact of novel training interventions on improving the competency and safety of enteral and parenteral nutrition delivery in the PICU must be further examined.

The New Trainee Effect in Tracheal Intubation Procedural Safety Across PICUs in North America: A Report From National Emergency Airway Registry for Children*

Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship. Retrospective cohort study. Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children. All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017. None. The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14). The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.