Pediatric Critical Care Services Research Articles

Social Disadvantage and Inequity in Access to Pediatric Critical Care Services for Children Living Remote from a Children's Hospital

AbstractRegionalization of health care has created geographical distance between pediatric specialty services and children, with the potential for disparities in access to care. We investigated the association of state-level area deprivation index (S-ADI), a measure of socioeconomic disadvantage, and characteristics and outcomes in a cohort of children requiring unplanned hospital transfer to a quaternary care pediatric intensive care unit (PICU). We conducted a single-center retrospective cohort study of children requiring unplanned hospital transfer to the PICU at the University of Virginia Children's Hospital from July 1, 2019 to December 31, 2020, excluding planned transfers, transfers from another intensive care unit, and patients whose address could not be associated with an S-ADI. We collected demographic and clinical data as well as the S-ADI, an ordinal variable ranging from 1 to 10 with 10 representing the most disadvantage. We observed no differences in S-ADI based on patient sex, age, history of chronic medical conditions, or need for a medical device (tracheostomy, home ventilator, surgical feeding tube, cerebrospinal fluid shunt). We also did not observe differences in PICU or hospital length of stay based on S-ADI. We did observe for every one-point increase in S-ADI there was an associated increase of 8.6 miles (p < 0.001) in patient travel distance. Among patients from a higher S-ADI area, we observed increased severity of illness on PICU admission (p = 0.02) and case fatality as compared with patients from a lower S-ADI area (11 vs. 1.9%, p = 0.038). Children traveling the farthest for subspeciality pediatric critical care at our hospital had higher measures of socioeconomic disadvantage and severity of illness.

Integration of Intraosseous Approach Method in Georgia.

In pediatric emergencies, as in case of shock, the use of intraosseous (IO) route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome. Nevertheless, the IO approach is not used at all and/or is limited because of lack of demand and lack of training on the issue of medical staff. The aim of the study was to test applicable and/or demand of IO in clinics providing pediatric critical care services and assess the opportunities to integrate IO access use in emergency care in Georgia. A quasi-experimental study was conducted, following a training of medical staff to perform IO access procedure. Our study involved 140 children admitted to emergency department, 114 of whom underwent venous access and 26 underwent IO access. Several parameters were monitored and reported. Outcomes were compared between the 2 procedures. Use of an IO catheter has significantly altered the clinical outcome of the patient's condition; 35% of the total number of patients needed to continue their treatment in the intensive care unit, whereas 65% of the patient's continued treatment in the various general wards (compared with 99% and 1%, respectively, in intravenous access patients). None of IO patients were transferred to other clinics because of the deterioration of their clinical condition. Complications in the form of local infection were not observed in any of the patients using the IO approach (which is interesting in terms of infection control). With proper training and in certain indications, the internationally approved method can be safely used in pediatric emergency management in Georgian and similar country health system contexts. Several urgent conditions with high rates of requiring hospitalization could benefit from the IO approach.

Home ventilation in low resource settings: Learning to do more, with less.

Long-term ventilation (LTV) in children at home, especially invasive ventilation, is not widely available nor practised in low-resource settings (LRS). Barriers to providing LTV include underdeveloped pediatric critical care services, limited expertise in pediatric LTV, limited capacity to screen for sleep-disordered breathing (SDB) and high cost of LTV equipment and consumables. Additional challenges encountered in LRS may be unreliable electricity supply and difficult socioeconomic conditions. Where LTV at home has been successfully implemented, caregivers and families in LRS must often take full responsibility for their child's care as professional home-based nursing care is scarce. Selecting suitable children and families to offer LTV in LRS may therefore face difficult ethical decisions when families are disempowered or incapable of providing 24-h care at home. Early caregiver participation and hands-on training in tracheostomy care and LTV equipment is key to success, irrespective of the caregiver's level of education. The use of overnight oximetry, mobile phone technology, spirometry, and clinical evaluation are simple tools that can aid recognition and monitoring of children needing LTV. As children survive longer supported by LTV, engaging with adult services at an early stage is important to ensure suitable pathways for transition to adult care are in place. Building capacity and expertise in pediatric LTV in LRS requires targeted training of health professionals in related disciplines and advocacy to policymakers and funders that LTV in appropriately selected circumstances is worthwhile, life-changing, and cost-saving.

Pediatric critical care services in resource-limited settings; a current state and approaches to improvement.

Pediatric critical care services in resource-limited settings; a current state and approaches to improvement.

Trends in Long-Term Ventilation Care in U.K. Children and Young People-Further Consideration Required for Pediatric Critical Care Services.

The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning. A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets. Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings. Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018. None. When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%). The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services.

Centralization of Pediatric Critical Care Services-It Seems to Work in Australia and New Zealand. Is It Right for All?

Centralization of Pediatric Critical Care Services-It Seems to Work in Australia and New Zealand. Is It Right for All?

Editor’s Choice Articles for December

For December 2021 I draw your attention to three articles as my Editor’s Choices: long-term mental health disorder diagnoses after mechanical ventilation for severe respiratory disease (1); left heart decompression on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for dilated cardiomyopathy and myocarditis (2); and socioeconomic disadvantage and distance to pediatric critical care services in the United States (3). All three research reports have accompanying articles (4−7), and all items will be openly available for the next few months. WHAT IS THE RELATIONSHIP BETWEEN INVASIVE MECHANICAL VENTILATION FOR SEVERE RESPIRATORY DISEASE AND LONG-TERM “MENTAL DISORDER” DIAGNOSES? Geneslaw AS, Lu Y, Miles CH, et al: Long-Term Increase in Mental Disorder Diagnoses After Invasive Mechanical Ventilation for Severe Childhood Respiratory Disease: A Propensity Matched Observational Cohort Study (1). A propensity matching study to learn so much from: the dataset, Texas Medicaid (1999 to 2012); the outcome measure, long-term mental disorder diagnoses; and the comparisons, 1,351 invasively ventilated children matched to 6,755 general inpatients and 7,780 children in the PICU matched to 38,900 general inpatients. For the answer, please read the authors’ transparent analysis of this complex material and their important observations. We all need to understand these data, research this field, and not allow any distortion of fact. Here, we are first helped by an insightful editorial on causal inference from observational data (4). Second, we have an accompanying article in the “PCCM Notes, Methods, and Statistics” section about learning from an association analysis using propensity scores (5). For many reasons, all three of these items are a benchmark for such work in PCCM. WHAT ABOUT LEFT HEART DECOMPRESSION ON VA-ECMO? Choudhury TA, Ofori-Amanfo G, Choi J, et al: Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review (2). This database study used the Extracorporeal Life Support Organization (ELSO) registry (2000 to 2016) to review two cohorts of patients supported with VA-ECMO: 532 with myocarditis and 906 with dilated cardiomyopathy. In all, 274 patients had left heart decompression and the authors present an analysis of associated outcomes. There is no editorial with this article. Instead, I am pleased to announce that the accompanying material is the first item in a new section called “PCCM Concise Clinical Physiology Review”. The purpose of this material is to provide an update on some aspect of clinical physiology that applies to pediatric critical illness. This month, Puri and Adachi not only discuss the new ELSO report in the context of other studies, but also treat us to an update of left heart physiology and simulated left ventricle pressure-volume loops on VA-ECMO and cardiopulmonary bypass (6). WHAT IS THE RELATIONSHIP BETWEEN POVERTY AND DISTANCE TO PEDIATRIC CRITICAL CARE SERVICES ACROSS THE UNITED STATES? Brown LE, Franca UL, McManus ML: Socioeconomic Disadvantage and Distance to Pediatric Critical Care (3). My third highlighted article is an epidemiological study using the 2016 American Community Survey that examines access to 319 PICUs within 170 metropolitan statistical areas across the continental United States. Our editorialists provide helpful discussion of the findings and challenge us with their discourse as they argue that unequal access to pediatric critical care services constitutes injustice (7). “PCCM CONNECTIONS” FOR READERS Perhaps you will consider December 2021 as the time to review what is new on the topic of overall health outcomes following pediatric critical illness, which is certainly pertinent given the discussion above about mechanical ventilation and long-term mental disorder diagnoses (1,4,5). Regular readers of PCCM will be able to cross reference to another article in the December 2021 issue, a scoping review of post-PICU discharge methods and instruments used to measure overall health (8). Also consider our other research articles looking at early- to long-term functional outcome and/or quality-of-life of PICU patients reported in the January (9,10), May (11), and October (12) issues of PCCM. Please use all eight articles as a means of quick topic review on how and what others have used in assessing PICU patient outcomes.

Socioeconomic Disadvantage and Distance to Pediatric Critical Care.

To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States. Retrospective, cross-sectional study. Contiguous United States. Children less than 18 years as represented in the 2016 American Community Survey. None. Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p < 0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p < 0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas. In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.

Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation?

IntroductionWith the advancement of pediatric critical care services across India, many children require prolonged mechanical ventilation (MV), and tracheostomy is recommended to them. However, many pediatric intensivists have concerns regarding the safety, feasibility, and outcome of tracheostomy.We aimed to analyze clinical characteristics, indication, duration, and outcome of tracheostomized children with respect to timing of tracheostomy.Materials and methodsWe conducted a retrospective study from the hospital clinical database of consecutive patients below 12 years who had undergone tracheostomy after admission into the pediatric intensive care unit (PICU) for prolonged ventilation (≥96 hours) from January 2015 to December 2019. The study was approved by the Institutional Ethics Committee. Patients were divided into two groups: tracheostomies done within 14 days of MV (early tracheostomy) and patients with tracheostomies performed after 14 days (late tracheostomy). Patients’ age, sex, indications, complications, decannulation rate, length of MV, PICU, and hospital stay were analyzed.ResultsOf the 1,425 patients on invasive MV, 87 (6.1%) patients required tracheostomy after a mean 13.37 days of MV. The most common indication was encephalopathy 32 (36.7%) followed by acute respiratory distress syndrome 20 (22.9%). Factors like higher pediatric logistic organ dysfunction score, vasoactive inotrop score, incidence of pretracheostomy ventilator-associated pneumonia, and difficulty in obtaining parental consent were associated with late tracheostomy. The early tracheostomy group had a higher decannulation rate (odds ratio, 5.17; p, 0.01) and weaning rate (odds ratio, 5.94; p, 0.032). The late tracheostomy group needed a longer duration of MV, PICU, and hospital stay. Complications of tracheostomy were less in the early tracheostomy patients (odds ratio, 2.95; p, 0.03).ConclusionEarly tracheostomy was associated with lower complications, higher successful weaning rates, and less utilization of intensive care facilities in patients receiving prolonged MV.Clinical significanceIn the context of scarcity of data on the timing of tracheostomy in children with prolonged ventilation (≥96 hours) the study shows that early (<14 days) tracheostomy is associated with a better outcome.How to cite this articleSarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation? Indian J Crit Care Med 2021;25(4):435–440.

A study of medication errors during the prescription stage in the pediatric critical care services of a secondary-tertiary level public hospital

BackgroundMedication Errors (MEs) are considered the most common type of error in pediatric critical care services. Moreover, the ME rate in pediatric patients is up to three times higher than the rate for adults. Nevertheless, information in pediatric population is still limited, particularly in emergency/critical care practice. The purpose of this study was to describe and analyze MEs in the pediatric critical care services during the prescription stage in a Mexican secondary-tertiary level public hospital.MethodsA cross-sectional study to detect MEs was performed in all pediatric critical care services [pediatric emergency care (PEC), pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and neonatal intermediate care unit (NIMCU)] of a public teaching hospital. A pharmacist identified MEs by direct observation as the error detection method and MEs were classified according to the updated classification for medication errors by the Ruíz-Jarabo 2000 working group. Thereafter, these were subclassified in clinically relevant MEs.ResultsIn 2347 prescriptions from 301 patients from all critical care services, a total of 1252 potential MEs (72%) were identified, and of these 379 were considered as clinically relevant due to their potential harm. The area with the highest number of MEs was PICU (n = 867). The ME rate was > 50% in all pediatric critical care services and PICU had the highest ME/patient index (13.1). The most frequent MEs were use of abbreviations (50.9%) and wrong speed rate of administration (11.4%), and only 11.7% of the total drugs were considered as ideal medication orders.ConclusionClinically relevant medication errors can range from mild skin reactions to severe conditions that place the patient’s life at risk. The role of pharmacists through the detection and timely intervention during the prescription and other stages of the medication use process can improve drug safety in pediatric critical care services.

Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus.

BackgroundHospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients.MethodsA comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys.ResultsPROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care.ConclusionsPROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement.

Advances in Pediatric Critical Care Research in India.

Over last 2 decades, there has been a significant progress made in the field of pediatric critical care in India. There has been complementary and parallel growth in the pediatric critical care services in India and the number of pediatric critical care providers who are either formally trained in India or who have returned to India after their formal training abroad. The pediatric critical care community in India has recognized obvious differences in profiles of critical illnesses and patients between Indian subcontinent and the West. Therefore there is a growing interest in generating scientific evidence through local research which would be applicable to critically ill children in Indian subcontinent. This article focuses on advances in pediatric critical care research in India and its future directions.

Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned.

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.

Pediatric Critical Care Medicine Training in India: Past, Present, and Future.

Pediatric critical care services in India have grown with leaps and bounds. There has been a growing need of physicians specially trained in pediatric critical care medicine (PCCM) in India. Physicians returning to India after their formal training in PCCM abroad have partly supported this growing need. Development of formal PCCM training programs in India has been a huge step toward supporting the growing clinical needs. This article focuses on advances in pediatric critical care training in India and its future directions.

Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults.

Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications, and doses in neonates and children are different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. Although PBM programs are well recognized and appreciated in the adult setting, they are quite far from standard of care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children, and there currently is significant variation in transfusion practices. Because transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program, systematically explores various possible pediatric specific blood conservation strategies and the current available literature supporting them, and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance, and the hospital information technology personnel. These programs also expand the scope for high-quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest that restrictive transfusion strategies should be used for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold, and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease, and cyanotic cardiac disease. Perioperative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, antifibrinolytic agents, and using point-of-care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis-stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be used to investigate pediatric transfusion, and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.

A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions.

Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.

Technical Correction to Critical Care Codes (99468–99476)

CPT errata correcting prefatory language for neonatal and pediatric critical care services regarding same day or same stay

ABSTRACT 921

Background and aims: Ethiopia is demonstrating marked declines in child mortality. The advancement of primary and emergency care has improved the survival of acutely ill children but created a need for pediatric critical care services. Aims: To develop pediatric critical care services at TASH. Methods: TASH, a university hospital with 197 pediatric inpatient beds and 4 PICU beds, formed a twinning partnership with the University of Wisconsin (UW) in 2010. The initial emphasis was on development of emergency medicine services. A program that addressed the development of needed critical care services was added in 2012. Results: The partnership fostered the development of a curriculum consisting of lectures, bedside learning, and skills training to meet TASH needs. Training of pediatric nurses, residents, and faculty concentrated on critical care specific topics. We developed guidelines for the PICU, defined responsibilities of staff, designed a bedside patient chart, and created an emergency cart. As a result, providers working in the PICU are more confident in caring for critically ill children. Conclusions: The partnership increased the capabilities and confidence of health care providers at TASH to provide care for critically ill children. The next objective is to formalize the training in pediatric critical care, further modifying the curriculum to meet the needs of TASH, and create a combined pediatric emergency medicine/critical care program. This partnership was made possible through the generous support of the American people with funding from the US President's Emergency Plan for AIDS Relief (PEPFAR) and The U.S. Centers for Disease Control and Prevention (CDC/Ethiopia).

Distribution of Specialized Care Centers in the United States

As a recommended strategy for optimally managing critical illness, regionalization of care involves matching the needs of the target population with available hospital resources. The national supply and characteristics of hospitals providing specialized critical care services is currently unknown. We seek to characterize the current distribution of specialized care centers in the United States. Using public data linked with the American Hospital Association directory and US Census, we identified US general acute hospitals providing specialized care for ST-segment elevation myocardial infarction (STEMI) (≥40 annual primary percutaneous coronary interventions reported in Medicare Hospital Compare), stroke (The Joint Commission certified stroke centers), trauma (American College of Surgeons or state-designated, adult or pediatric, level I or II), and pediatric critical care (presence of a pediatric ICU) services. We determined the characteristics and state-level distribution and density of specialized care centers (centers per state and centers per state population). Among 4,931 acute care hospitals in the United States, 1,325 (26.9%) provided one of the 4 defined specialized care services, including 574 STEMI, 763 stroke, 508 trauma, and 457 pediatric critical care centers. Approximately half of the 1,325 hospitals provided 2 or more specialized services, and one fifth provided 3 or 4 specialized services. There was variation in the number of each type of specialized care center in each state: STEMI median 7 interquartile range (IQR 2 to 14), stroke 8 (IQR 3 to 17), trauma 6 (IQR 3 to 11), pediatric specialized care 6 (IQR 3 to 11). Similarly, there was variation in the number of each type of specialized care center per population: STEMI median 1 center per 585,135 persons (IQR 418,729 to 696,143), stroke 1 center per 412,188 persons (IQR 321,604 to 572,387), trauma 1 center per 610,589 persons (IQR 406,192 to 917,588), and pediatric critical care 1 center per 665,282 persons (IQR 441,525 to 942,254). The national distribution patterns differed for each type of specialized care center. The distribution of specialized care centers varies across the United States. These observations highlight unanswered questions about the regional organization of specialized care in the United States.

The Dilemma: Split/Shared Neonatal and Pediatric Critical Care Services

Interpretation of the physician directing inpatient care for codes 99468-99476 and 99478-99480