Pediatric Intensive Care Unit Team Research Articles

Experiences of the Parents of Children Admitted to PICU.

A pediatric intensive care unit (PICU) is a highly technological and fast-paced setting in a hospital. To explore the experiences of the parents in the critical care area of a selected tertiary care facility. In a qualitative study, we interviewed 10 purposively selected parents of the children admitted to PICU using a pre-validated in-depth interview schedule. All parents, whose children were admitted to PICU for more than 5 days, who understood Hindi or English and were willing to participate in the study, were enrolled in the study. Parents of critically ill children having readmission to PICU or prolonged stay of more than 15 days and not accompanied by parents were excluded. Parents had unmet needs, such as the need for information, counseling and education from the healthcare team (HCT) members, having trusting relationship with the HCT, and expecting receiving orientation of the routines and the protocols of PICU, and empathy from the various levels of PICU team. The majority of subjects expressed the desire to talk to a dedicated person for their queries. The parents had multiple feelings of distress, hopelessness, helplessness, guilt, and the fear of losing the child and used various coping strategies. Parents of critically ill children in the PICU have unmet needs. Healthcare team members should take initiative in relieving parental distress and improving their coping abilities. Kichu S, Joshi P, Bhandari S, Lodha R, Jaykrishnan K. Experiences of the Parents of Children Admitted to PICU. Indian J Crit Care Med 2024;28(7):696-701.

Comfort and Coordination among Interprofessional Care Providers Involved in Intubations in the Pediatric Intensive Care Unit.

Successful execution of invasive procedures in acute care settings, including tracheal intubation, requires careful coordination of an interprofessional team. The stress inherent to the intensive care unit (ICU) environment may threaten the optimal communication and planning necessary for the safe execution of this complex procedure. The objective of this study is to characterize the perceptions of interprofessional team members surrounding tracheal intubations in the pediatric ICU (PICU). This is a single-center survey-based study of staff involved in the intubation of pediatric patients admitted to a tertiary level academic PICU. Physicians, nurses, and respiratory therapists (RT) involved in tracheal intubations were queried via standardized, discipline-specific electronic surveys regarding their involvement in procedural planning and overall awareness of and comfort with the intubation plan. Qualitative variables were assessed by both Likert scales and free-text comments that were grouped and analyzed thematically. One hundred and eleven intubation encounters were included during the study time period, of which 93 (84%) had survey responses from at least 2 professional teams. Among those included in the analysis, the survey was completed 244 times by members of the PICU teams including 86 responses from physicians, 76 from nurses, and 82 from RTs. Survey response rates were >80% from each provider team. There were significant differences in interprofessional team comfort with nurses feeling less well informed and comfortable with the intubation plan and process compared to physicians and RTs (p < 0.001 for both). Qualitative themes including clear communication, adequate planning and preparation prior to procedure initiation, and clear definition of roles emerged among both affirmative and constructive comments. Exploration of provider perceptions and emergence of constructive themes expose opportunities for teamwork improvement strategies involving intubations in the PICU. The use of a preintubation checklist may improve organization and communication amongst team members, increase provider morale, decrease team stress levels, and, ultimately, may improve patient outcomes during this high stakes, coordinated event.

A confirmed case of macrophage activation syndrome secondary to spotted fever rickettsiosis: Response to immunomodulation in a pediatric patient in northeastern, Mexico

An 8-year-old girl with a rash and high-grade fever for 6 days arrived at the emergency room. She had an erythematous macular rash on the face, trunk, arms, and legs. Further interrogation called attention to the presence of close contact with stray dogs. Her town had been recognized as a site of a rickettsiosis outbreak in the past year. Spotted fever rickettsiosis was suspected, and doxycycline treatment was initiated. Macrophage activation syndrome (MAS) secondary to Rickettsia rickettsii infection was diagnosed according to the Hemophagocytic lymphohistiocytosis and EULAR/PRINTO/PRES 2016 criteria. As there are no clear guidelines on the treatment of MAS secondary to R. rickettsii. the course of action taken by the pediatric intensive care unit team was to avoid disseminated intravascular coagulopathy and treat MAS, both life-threatening conditions. Directed therapy with high doses of methylprednisolone and intravenous immunoglobulin therapy was initiated. The patient recovered, regaining her functional state before the illness. Few articles have described the association between MAS and rickettsiosis, an illness with high mortality, which makes it paramount to detect and treat promptly.

1057: PROCESS MAPPING POSTOPERATIVE PICU ADMISSIONS

Introduction: The lack of a standard communication process around anticipated postoperative destination for patients leads to inefficiencies and staffing challenges in the pediatric intensive care unit (PICU). Many PICU admissions are unanticipated; however, many of the complex or prolonged surgical cases can be anticipated. We aim to identify opportunities in perioperative scheduling communications to facilitate optimization of staffing and efficiency for planned post-operative admissions to the PICU. Methods: Over 45 days, a daily REDCap survey was administered to PICU charge nurses aiming to identify new admissions from the operating room, whether they were considered planned, how the team learned about the new patient admission (overnight OR list, bed reservation email, call from perioperative team day of admission, etc.), and if the intended destination was posted on Epic. The perioperative team can use more than one way to notify the PICU team of an admission for one patient. There were 67 total OR admissions, but 17 of these survey submissions were removed because they were previously admitted to the PICU (n=11), they had an unforeseen surgical complication (n=3), or they were scheduled to go to the PICU and did not show up (n=3). 50 surveys were processed for their data. Results: Of the 50 survey submissions, 35% were considered unplanned by the PICU charge nurse. These unanticipated admissions resulted in one less nurse requested for the shift during which they were admitted. Of unplanned admissions, 11% were posted on the overnight OR list, 53% were called in by a perioperative team member the day of admission, and 29% appeared to the PICU without any type of communication to the team. 85% of planned admissions were posted to the overnight OR list. They also utilized bed reservation email (6%), surgery call the day of admission (3%) and the bed reservation book (21%). Conclusions: Unplanned admissions from the OR indicate scheduling communication gaps across surgical disciplines. This is likely due to the lack of standardization in communicating PICU admissions from the operating room. Since a majority of planned admissions utilized Epic and the overnight OR list for communication, we propose to make the postoperative destination field a required field within the posting process in the EHR.

Up to the Challenge: Adapting Pediatric Intensive Care During a Global Pandemic.

BackgroundThe COVID-19 pandemic has strained health systems world wide. In our region, surging numbers of critically ill adult patients demanded urgent system-wide responses. During the peak of the pandemic, our Pediatric Intensive Care Unit (PICU) team redesigned the existing educational resources and processes of care to ensure for adult patients for the first time in the hospital’s history.AimDescribe the experiences and impacts of the rapidly initiated Adult COVID-19 Program on health care providers (HCP) and family members. Havelock’s Theory of Change framed the examination of Adult COVID-19 Program participant experiences and surfaced lessons learned.Materials and MethodsA quality improvement review was employed to collect feedback about the program experience from the health care team and patient’s family members. HCP completed a questionnaire 10 months following the implementation of the program and feedback from family members was provided during the program was obtained. Havelock’s Theory of Change was used to explore trends and frame participants’ experiences.ResultsPediatric Intensive Care Unit bedside team members and clinical leaders (n = 17), adult hospital partners (n = 3), and family members (n = 8) participated. HCP describe; motivation and readiness; concern for personal safety and uncertainty experienced in the early program phases; the importance of supports and resources; use of relationships and collaboration to facilitate change; the emotional impacts of this unique experience; and opportunities for individual and team growth. An overarching theme of ‘doing our part to help’ emerged. Family members described the positive impacts of family-centered interventions offered, individualized care, and shock at their family member’s illness.ConclusionThe PICU team rapidly adapted to provide care for adults at the peak of the pandemic. Family members expressed feeling grateful for the care their loved ones received in the pediatric setting. The experience of caring for adult patients with COVID-19 was a source of tension, personal growth, and meaning for the pediatric intensive care team.

The State of the Do-Not-Resuscitate Order in a Pediatric Intensive Care Unit in the Middle East: A Retrospective Study.

Objectives: The Do-Not-Resuscitate (DNR) order is part of most hospitals' policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family. Methods: This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017. Results: Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested "soft" resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician. Conclusions: The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for "soft" resuscitations like administering epinephrine without chest compressions.

Simulation-based Training of Pediatric Intensive Care Unit Teams in Endotracheal Intubation of Patients with Suspected or Confirmed COVID-19: Response to a Letter to the Editor.

Simulation-based Training of Pediatric Intensive Care Unit Teams in Endotracheal Intubation of Patients with Suspected or Confirmed COVID-19: Response to a Letter to the Editor.

Staff Family Day in the Pediatric Intensive Care Unit

Staff Family Day in the Pediatric Intensive Care Unit

P0235 / #981: EXTRACORPOREAL MEMBRANE OXYGENATION AS A TREATMENT FOR REFRACTORY LACTIC ACIDOSIS DUE TO GLYCOGEN STORAGE DISEASE TYPE 1A: A CASE REPORT

Aims & Objectives: Glycogen storage disease (GSD) type Ia (Von Gierke’s Disease) is an infrequent metabolic disease characterized by the deficient activity of glucose-6-phosphate-a. This deficiency causes the accumulation of glycogen in the body leading to hypoglycemia, lactic acidosis, failure to thrive, hepatomegaly, hepatic adenomas, renal failure and inflammatory bowel disease. The aim of this study is to describe a case of GSD type Ia and to evaluate the utility of Extracorporeal Membrane Oxygenation (ECMO) to treat this condition. Methods: We present a 7-year-old male patient with a history of GSD type 1a. The patient arrived at the hospital due to diarrhea and emesis. Patient is treated with intravenous fluids and glucose infusion, however, clinical stabilization is not met after 24-hours. Patient develops hemodynamic instability secondary to lactic and metabolic acidosis and is transferred to the pediatric intensive care unit (PICU). At the fifth day of admission at the PICU hemodynamic and respiratory status worsens. Results: Mechanical ventilation and vasopressor therapy are initiated. Patient is placed into hemodialysis (PRISMA FLEX®) to treat refractory lactic acidosis, fluid overload, and acute kidney injury. 48-hours later the PICU team emergently cannulated for veno-arterial (VA) ECMO support. During the following days patient’s hemodynamic and metabolic status improves. Patient ECMO support was stopped 7 days after initiation. PRISMAFLEX® management continued for 9 days until renal function normalized. Patient was discharged 58 days after hospital admission with no neurological complications. Conclusions: This case emphasizes the efficacy of ECMO as a therapy to stabilize pediatric patients with metabolic diseases such as GSD Type 1a

P0676 / #912: RAPID CYCLE DELIBERATE PRACTICE FOR INTER PROFESSIONAL EDUCATION IN A NON TRAINEE STAFFED PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: Rapid Cycle Deliberate Practice (RCDP) is a simulation debriefing methodology that has been compared to post simulation debriefing (PsD) in simulation based medical education (SBME) studies, mostly focused on resuscitations and procedure skills. The aim of this study is to compare the RCDP versus PsD training as methods for experiential learning in the pediatric intensive care unit (PICU) interprofessional SBME sessions. We also measure PICU team workload perception during the simulation scenario using the National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaire. We hypothesize the RCDP will be more effective than PsD in improving team performance and minimizing cognitive load of learners and facilitators. Methods: Pediatric Critical Care attending physicians, Nurses, Pharmacists and Respiratory Therapists will participate in a 3-hour simulation workshop. Workshops are being conducted from October 2019 - March 2020, and include 5 workshops covering two medical sepsis scenarios. Each session will schedule 1 physician, 2-3 nurses, 1 pharmacist and 1 RT. The first part of the SBME workshop will be PsD and the second half will be RCDP with hard stops and soft stops. The learners complete pre and post-test crew resource knowledge assessments and cognitive load assessments (NASA Task Load Index). Facilitators complete the validated teamwork assessment tool (TEAM Assessment) andNASA Task Index. Results: Raw scores of crew resource knowledge test, TEAM Assessment and NASA Task Load Index between the two studies will be examined. Conclusions: RCDP during interporfessional SBME is feasible and needs to be designed differently in a trainee versus non trainee environment.

Rapid Cycle Deliberate Practice to Facilitate "Nano" In Situ Simulation: An Interprofessional Approach to Just-in-Time Training.

Simulation is increasingly used to identify latent threats to patient safety, such as delays in recognition and management of time-sensitive conditions. The Rapid Cycle Deliberate Practice teaching method may facilitate "nano" (brief) in situ simulation training in a critical care setting to improve multidisciplinary team performance of time-sensitive clinical tasks. To determine whether nano-in situ simulation training with Rapid Cycle Deliberate Practice can improve pediatric intensive care unit team proficiency in identifying and managing postoperative shock in a pediatric cardiac patient. A quality improvement educational project was conducted involving nano-in situ simulation sessions in a combined pediatric and pediatric cardiac intensive care unit. The Rapid Cycle Deliberate Practice method was used with an expert-driven checklist for 30-minute simulation scenarios. A total of 23 critical care providers participated. The proportion of time-sensitive tasks completed within 5 minutes increased significantly from before to after training (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Using a 5-point Likert scale, with higher scores indicating higher levels, the participants reported high degrees of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the simulation experience (mean, 4.96; SD, 0.12). The Rapid Cycle Deliberate Practice method was used to facilitate nano-in situ simulation training and identify areas requiring additional education to improve patient safety. In situ simulation can educate providers in a cost-effective and timely manner.

Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.

We conducted a quality improvement study in a tertiary referral PICU. After developing stakeholder-driven guidelines for modified intubation in this population, we implemented a structured simulation program to train PICU physicians, nurses, and respiratory therapists. We directly observed PICU teams' adherence to the modified intubation process before and after simulation sessions and compared participants' confidence using the Simulation Effectiveness Tool-Modified (SET-M, Likert scale range 0: do not agree to 2: strongly agree regarding statements of confidence). Fifty unique PICU staff members participated in 9 simulation sessions. Observed intubation performance improved, with teams executing a mean of 7.3-8.4 out of 9 recommended practices between simulation attempts (P = 0.024). Before undergoing simulation, PICU staff indicated that overall they did not feel prepared to intubate patients with suspected or confirmed SARS-CoV-2 (mean SET-M score 0.9). After the simulation program, PICU staff confidence improved (mean SET-M score increased from 0.9 to 2, P < 0.001). PICU teams' performance and confidence in safely executing a modified endotracheal intubation process for children with suspected or confirmed SARS-CoV-2 infection improved using a rapidly deployed structured simulation education program.

Friend or Foe: Perceptions of Infectious Disease Specialists as Stewards and Social Determinants of Antimicrobial Prescribing

Background: Inappropriate prescribing behavior can be associated with higher rates of antibiotic resistance, calling for detailed studies on how physicians make prescribing decisions. We conducted a mixed-methods study to investigate physician antibiotic prescribing behavior in a 141-bed pediatric hospital. Methods: We applied a mixed-methods research design. The quantitative phase was conducted over a 6-month period to identify cases of inappropriate prescribing. The qualitative phase comprised 22 qualitative interviews with clinical teaching units (CTU) and pediatric intensive care unit (PICU) team members (physicians and pharmacists). Two coders analyzed the data deductively using the theoretical domain framework (TDF), as well as the social determinants of antimicrobial prescribing (SDAP). Results: In 52.9% of the 36 identified cases in the CTU and 31.4% of the 37 cases in the PICU, an infectious diseases (ID) consultation occurred. Compliance rates with ID recommendations were 79% and 91% in the CTU and PICU, respectively. The CTU and PICU expressed appreciation for ID involvement when ID supported their de-escalation choices in complex cases and in cases in which less commonly known antibiotics were used. However, the ID service involvement was perceived as detrimental to antimicrobial prescribing decisions for CTU and PICU across 3 of the 4 SDAP domains (Fig. 1, qualitative research quotes). Relationship between clinicians: CTU physicians and pharmacists perceived ID involvement as negatively impacting the relationship of the team. Antimicrobial decisions were automatically defaulted to ID, whereas pharmacy involvement was disregarded and the decisions were delayed. Risk, fear, and emotion: These were experienced across all respondents’ groups that identified ID specialists’ egos and personalities as contrary to open collaborative discussion on antimicrobial decisions. (Mis)perception of the problem: ID physicians were identified as more conservative in their antimicrobial choices, leading to prolonged duration of treatment, broader choices, and longer hospitalizations. The CTU and pharmacy respondents felt that ID recommendations were inconsistent among physicians and deviated from guidelines with little justification. Conclusions: Although CTU and PICU teams tend to comply with ID prescribing recommendations and ID involvement with complicated cases, pharmacists, CTU physicians, and PICU physicians perceived ID consultations to negatively affect collaborative efforts for stewardship. These findings offer novel insights into how an ID service can improve its role to positively affect appropriate prescribing. CTU and PICU respondents called for a supportive and trusting relationship with the ID service as a major driver for behavioral change and enhanced stewardship.Funding: NoneDisclosures: None

Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography.

The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children. We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge. Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication. Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.

Bedside Rounds in Intensive Care Units during the COVID-19 Pandemic and Beyond.

A survey-based pilot study was performed to examine the feasibility of videoconferencing to facilitate multidisciplinary rounds following the initiation of strict isolation and social distancing policies in a pediatric intensive care unit (PICU). The use of a mobile workstation was implemented as the central hub for rounding at the bedside by the attending physicians, while other members of the multidisciplinary and multispecialty team joined rounds from other locations with maintaining appropriate social distance. Fifty-eight staff members who participated in videoconferencing rounds completed the postimplementation survey. Eighty-eight per cent of staff agreed that the use of videoconferencing to facilitate rounds was an effective strategy to maintain social distancing between team members during the pandemic. Sixty-four percent of staff agreed that the use of videoconferencing improved participation of the PICU team and consultants by increasing access to rounds. Over 50% of staff agreed that the use of videoconferencing improved the efficiency of rounds and team productivity. Only 4% of staff responded that videoconferencing increased the duration of rounds and 37% responded that it decreased resident and team education. Fifty-five percent of staff agreed that videoconferencing was used to promote parental participation during this pandemic month. Videoconferencing was found to be a feasible solution to safely conduct multidisciplinary rounds while maintaining social distancing, and participants found it effective without interfering with normal workflow. Incorporating videoconferencing into traditional rounding practices may be advantageous following the pandemic to improve team and family access to rounds and workflow efficiency and rounding structure.

13. PREPARING FOR THE PICU: A QUALITATIVE STUDY OF RESIDENTS FIRST TIME

Background Learning in the pediatric intensive care unit (PICU) can be stressful and complex. While theoretical models and innovative resources have been developed with the trainee in mind, few studies seek to characterize their voices and experiences. In this study, we aim to describe the resident learner as they prepare for their first pediatric critical care rotation. Methods Using a grounded-theory approach, pediatric (PM) and emergency medicine residents (EM) were interviewed before and after their rotation. The interviews were audio-recorded and transcribed. Two researchers independently coded the pre-rotation transcripts and discussed the coding system until agreement. The transcripts were then analyzed for emerging themes. Results 6 EM and 8 PM participated and emergent themes were: i) Emotions (see fig. 1): Residents feel anxious (some have yet to witness a patient death), but excited for a “really good learning experience”. ii) Preparation: Residents admit to scant formal preparation. They rely on ad-hoc methods, with the intensity of their efforts often motivated by fear from past experiences. When prompted, they report great efforts to ready significant others, clean, and plan ahead for meals. Linguistically, they prepare as one deploying for war (e.g. “put on armor”). iii) Learning goals: EM anticipate specific disease processes they may face in their career, while PM focus more on acquiring skills for future rotations. Both gravitate towards topics based on perceived commonality, chronology, and enigmatic quality. iv) Survival: Residents’ main “wellness strategy” is to sleep and eat when able. Afterthoughts include exercise, meditation, spending time with friends or pets, and mental health appointments. v) Information gaps and myths: Residents begin their rotation disoriented to PICU protocols and team roles. They also harbor conflated beliefs, for instance about their expected entrustability and being alone overnight. Conclusions Residents enter their PICU rotation with intense emotions, myths, and a survival approach in common, although they vary in their preparation methods and development of learning goals.

Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support.

Sepsis is an uncontrolled inflammatory reaction caused by infection. Clinicians in the pediatric intensive care unit (PICU) developed a paper-based tool to identify patients at risk of sepsis. To improve the utilization of the tool, the PICU team integrated the paper-based tool as a real-time clinical decision support (CDS) intervention in the electronic health record (EHR). This study aimed to improve identification of PICU patients with sepsis through an automated EHR-based CDS intervention. A prospective cohort study of all patients admitted to the PICU from May 2017 to May 2019. A CDS intervention was implemented in May 2018. The CDS intervention screened patients for nonspecific sepsis criteria, temperature dysregulation and a blood culture within 6 hours. Following the screening, an interruptive alert prompted nursing staff to complete a perfusion screen to assess for clinical signs of sepsis. The primary alert performance outcomes included sensitivity, specificity, and positive and negative predictive value. The secondary clinical outcome was completion of sepsis management tasks. During the 1-year post implementation period, there were 45.0 sepsis events per 1,000 patient days over 10,805 patient days. The sepsis alert identified 392 of the 436 sepsis episodes accurately with sensitivity of 92.5%, specificity of 95.6%, positive predictive value of 46.0%, and negative predictive value of 99.7%. Examining only patients with severe sepsis confirmed by chart review, test characteristics fell to a sensitivity of 73.3%, a specificity of 92.5%. Prior to the initiation of the alert, 18.6% (13/70) of severe sepsis patients received recommended sepsis interventions. Following the implementation, 34% (27/80) received these interventions in the time recommended, p = 0.04. An EHR CDS intervention demonstrated strong performance characteristics and improved completion of recommended sepsis interventions.

A New Algorithm for Preventing Morbidity and Mortality Associated with Inflammation and Third Spacing in Pediatric HSCT Patients

Introduction Many HSCT patients experience severe vital sign changes during their hospital stay often requiring a higher level of service. Treatment historically uses fluid boluses, antibiotics, and vasopressors. However, inflammation places HSCT patients at risk of third spacing and fluid overload, prompting the need for targeted resuscitative efforts dependent on the etiology of the patientOs vital sign abnormalities. Objective We propose a novel treatment algorithm for patients receiving HSCT created in collaboration with the pediatric intensive care unit (PICU) at Texas ChildrenOs Hospital to provide targeted resuscitation for HSCT patients. The overarching goal is to limit morbidities associated with resuscitation and minimize differences in management across PICU and HSCT teams. Methods Our center is employing a grading system from 1 to 4 based on hemodynamics at various phases of HSCT (Figure A). This system will identify what we are characterizing as cytokine shock syndrome (CSS). Once they reach a grade of 1, they will receive antibiotics, albumin, hydrocortisone, and blood products as needed. There will be a maximum of 20 ml/kg of colloids given before starting pressors to avoid further fluid overload. Blood transfusions and albumin will be used as the fluids of choice. For worsening scores, they will receive additional targeted cardiac and respiratory interventions (Figure B). Echocardiogram and central venous pressure will provide additional resources for targeted management. Results Four patients to date have been managed according to this algorithm. All patients responded to therapy and received antibiotics, albumin, hydrocortisone, and TNF antibody without the need of further escalation of care. Conclusions We demonstrate that providing targeted therapy to HSCT patients has the potential to identify and treat HSCT patients early and prevent morbidity and mortality due to aggressive nonspecific treatment efforts when rapidly deteriorating. With further validation, this poses a promising alternative to existing supportive care measures.

Effects of Medical Transport on Outcomes in Children Requiring Intensive Care.

The need to centralize patients for specialty care in the setting of regionalization may delay access to specialist services and compromise outcomes, particularly in a large geographic area. The aim of this study was to explore the effects of interhospital transferring of children requiring intensive care in a Canadian regionalization model. A retrospective cohort design with a matched pair analysis was adopted to compare the outcomes in children younger than 17 years admitted to a pediatric intensive care unit (PICU) of a Canadian children's hospital by a specialized transport team (pediatric critical care transported [PCCT] group) and those children admitted directly to PICU from its pediatric emergency department (PED group). The outcomes of interest included mortality 72 hours from initial contact with the critical care team (ie, either PICU transport team or intrahospital PICU team). In total, 680 (27%) transports met our inclusion criteria, whereas 866 (7%) cases of 11 570 total PICU admissions were admitted directly from the emergency department. A total of 493 pairs were formed for the matched analyses. Odds of mortality within 72 hours in the PCCT group were significantly higher than in the PED group (odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.07-4.45; P = .032). When excluding cases who had at least one episode of cardiac arrest before involvement of the pediatric critical care (PCC) transport team, the OR dropped to 1.66 (95% CI: 0.77-3.46). Children transported from nonpediatric hospitals had a higher 72-hour mortality when compared to those children admitted directly to a children's hospital PICU from its own PED in a Canadian regionalized health-care model.

Nurse Practitioners and Interdisciplinary Teams in Pediatric Critical Care.

To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners. A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used. Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners. Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.