PICU Staff Research Articles

Supported Privacy: An Essential Principle for End-of-Life Care for Children and Families in the PICU.

Caring for children and their families at the end-of-life is an essential but challenging aspect of care in the PICU. During and following a child's death, families often report a simultaneous need for protected privacy and ongoing supportive presence from staff. Balancing these seemingly paradoxical needs can be difficult for PICU staff and can often lead to the family feeling intruded upon or abandoned during their end-of-life experience. In this "Pediatric Critical Care Medicine Perspectives" piece, we reframe provision of privacy at the end-of-life in the PICU and describe an essential principle that aims to help the interprofessional PICU team simultaneously meet these two opposing family needs: "Supported Privacy." In addition, we offer concrete recommendations to actualize "Supported Privacy" in the PICU, focusing on environmental considerations, practical needs, and emotional responses. By incorporating the principles of "Supported Privacy" into end-of-life care practices, clinicians can support the delivery of high-quality care that meets the needs of children and families navigating the challenges and supports of end-of-life in the PICU.

The Mediating Role of Anxiety in the Relationship between Job Satisfaction and Psychosocial Functions of Nurses and Pediatricians in PICUs.

Job satisfaction refers to an individual's overall attitude towards their job. It is influenced by various factors such as work environment, job role, work-life balance, compensation, anxiety, opportunities for growth and development. However, low levels of job satisfaction can have a significant impact on an individual's mental health and overall well-being. We contacted this study in order to assess the effect of PICU nurses' and pediatricians' job satisfaction on their psychosocial functioning and to examine the role of anxiety as a mediating factor in this relationship. A sample of 155 nurses and pediatricians at 7 University Hospitals in Greece has consented to participate in the study. Socio-demographic data, Hamilton Rating Scale for Anxiety, Minnesota Satisfaction Questionnaire -short form and a Brief Inventory of Psychosocial Functioning were used to evaluate anxiety, job satisfaction and psychosocial functions. According to our results, participants with moderate or severe levels of anxiety showed moderate or low job satisfaction, while moderate or severe anxiety was also associated with low levels of participants' psychosocial functioning. Job satisfaction is a dynamic situation that is affected by the levels of anxiety of each worker in PICU. The presence of anxiety may be related to comorbid mental health disorders since it affects the psychosocial functions of the worker. We propose a longer rest period, a change of department in case an employee wishes it or shows symptoms of increased stress or another mental health disorder, regular assessments by mental health experts for all PICU's staff and support after a diagnosis of a mental health problem.

Mental Health Provision in PICU: An Analysis of Referrals to an Embedded Psychologist Over 20 Years at a Single Center.

The main aim of this study was to illustrate the type of mental health provision possible on PICU by describing the nature of referrals of child patients and their parents to an embedded psychologist over a 20-year period, adding to the literature on intervention and service development. Retrospective evaluation of anonymized departmental database. Twelve-bed PICU at a teaching hospital in a major urban center. Five hundred forty-five consecutive referrals for support for parent and/or child by PICU staff between 1998 and 2017. None. Referrals increased from seven of 288 (2.4%) in 1998 to 85 of 643 (13.2%) in 2017. The majority were for parent support initially (456/545, 84%). Mean ( sd ) number of contacts was 4.5 (10.2), range 1 to 143, and mode was 1. Patient gender and age typical of the total PICU population, but referrals were more common where children had an oncology or trauma diagnosis ( p < 0.001). Comparisons with other inpatient referrals at the same hospital revealed a higher proportion of requests were made for parent support on PICU (456/545 [84%] vs 789/1,997 [40%]; p < 0.001) and that nurses were more likely to initiate referrals on PICU than on the other wards (437/543 [80%] vs 1,190/1,993 [60%]; p < 0.001). In other respects, the two groups were similar in terms of number of sessions, waiting times, and attendance rates. Growing appreciation of the psychological impact of a child's admission to PICU has been associated with increasing referral to an embedded psychologist over a 20-year period, at this center. Clinical and service implications are outlined in the context of the latest research on the mitigation of post-intensive care syndrome in this population.

Editor’s Choice Articles for April

Editor’s Choice Articles for April

Assessing PICU Staff Nurses’ Knowledge toward Delirium in Pediatric Patients

Background:Delirium is frequently under diagnosed and under treated in Pediatric Intensive Care Units (PICU). Both adult and pediatric literature have noted the significance of detecting and treating PICU delirium. Delirium lengthens hospital stays, the duration of mechanical ventilation, and the Intensive Care Unit (ICU) and PICU morbidity. Method: The goal of this study was to use a brief questionnaire to assess pediatric critical care nurses’ current understanding of delirium and its risk factors. Assuming that PICU nurses lack the necessary information to accurately screen for and diagnose delirium in critically ill children before a focused nursing educational intervention. To gauge current understanding regarding delirium in children, a 10-bed PICU distributed a 16-question online survey to all PICU nurses.Results: The response rate was 84% (26/31). Lack of knowledge was found that only two staff nurses (2/26; 8%) who properly responded when asked whether administering benzodiazepines is beneficial in treating delirium when asked about the use of these drugs to treat the condition. In addition, a family history of dementia predisposes a patient to delirium was another question that some participants correctly answered (4/26; 15%). Lastly, common incorrect answers when using the Glascoma Scale (GCS) as a diagnostic tool to identify delirium in pediatric patients, some staff nurses frequently give the incorrect response that delirium always manifests as a hyperactive, confused state, and those pediatric patients typically do not remember being delirious (5/26; 19%). Conclusion: The survey’s findings revealed knowledge gaps about the causes, symptoms, and treatments of pediatric delirium in critically ill children. Before the unit-wide adoption of a delirium screening and prevention program, PICU staff members urgently need to receive nursing education concerning pediatric delirium and associated risk factors, particularly regarding screening procedures and pharmacologic risk factors.

845: TRANSITION FROM DIRECT TO VIDEO LARYNGOSCOPY IN A PEDIATRIC ICU

Introduction: As an infection control measure for COVID-19, our PICU transitioned to near universal video laryngoscopy (VL). In 2019, 24% of intubations used VL; this increased to 96% in 2021. Comparing these two cohorts elucidates the effect of transitioning from direct laryngoscopy (DL) to VL on first time success rate (FTSR), Cormack-Lehane (C-L) grade view and successful trainee intubation. First time intubation success is associated with fewer complications and is therefore an important marker of intubation safety. Methods: Single Center retrospective case control. Data for 2019 were identified via chart review. Data from 2021 were obtained through a dedicated form introduced in the Fall of 2020. Each comparison group was limited to a full calendar year (Jan-Dec) to account for progression in trainee skill. A comparison was made between all patients in cohort groups with additional stratification of patients above and below the age of one. Included intubations were those in the PICU as well as those in the pediatric floor or ED performed by PICU staff. Statistics via Fischer Exact test. Results: 75 patients met criteria for 2019 and 73 in 2021. The age range in both groups was 2 days to 23 years. C-L view was documented in 72 of 75 patients in 2019 and all patients in 2021. 2019 had a 69.4% grade 1 C-L view rate, while 2021 had a 79.5% grade 1 C-L view rate (p=0.19). The overall FTSR in 2019 was 57.3% vs 65.7% in 2021 (p=0.31). 26 children under the age of one were intubated in both years, with a FTSR of 53.8% and 50% respectively. The FTSR in children above one year was 59.2% and 74.5% respectively (p=0.13). Additionally, an airway provider was documented in all but two cases in 2019. Of these, 75.3% were managed successfully by pediatric subspecialty fellows (PICU or rotating PEM). In 2021 this number increased to 84.9% (p=0.21). Conclusions: FTSR did not improve with transition to VL. In the 2021 cohort, children above age one had a 15.3% increased FTSR and trainees had a 9.6% increase in completed intubations. While not significant, these findings would benefit from reanalysis with a larger sample. First time success is an important marker for safe intubation practice, however there may be other benefits to either approach such as set up time and assistance from a second viewer.

Four-in-One: A Comprehensive Checklist for the Assessment of Pain, Undersedation, Iatrogenic Withdrawal and Delirium in the PICU: A Delphi Study.

ObjectivesChildren's pain, undersedation, iatrogenic withdrawal syndrome and delirium often have overlapping symptoms, which makes it difficult to decide why a child in the PICU is not comfortable. Validated assessment tools for these conditions are available, but regular assessment with multiple instruments may be too time-consuming. Therefore, we aimed to develop a new holistic instrument–the mosaIC checklist–that incorporates the assessment of the four conditions.Materials and MethodsWe conducted a two-rounds international Delphi study among experts working in PICUs worldwide to find cues that in combination or separately are relevant for the four conditions.ResultsIn the first Delphi round, 38 of the 48 enrolled participants (79%) completed a questionnaire; in the second round 32 of 48 (67%). Eventually, 46 cues in eight categories (e.g., facial, vocal/verbal, body movements, sleep /behavioral state, posture/muscle tone, agitation, physiological and contextual) were found relevant. Thirty-three (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for iatrogenic withdrawal syndrome (76%) and 28 (61%) for pediatric delirium. Thirteen cues (28%) were considered relevant for all four conditions; 11's (24%) for only one condition.ConclusionThis Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. Application of the mosaIC checklist could help determine what condition is most likely to cause a child's discomfort–and at the same time help reduce the PICU staff's registration burden.

Quality improvement intervention to stimulate early mobilisation of critically ill children.

Immobility during hospital stay is associated with muscle weakness, delirium, and delayed neurocognitive recovery. Early mobilisation of critically ill adults improves their physical functioning and shortens the duration of mechanical ventilation. However, comparable research in children is lacking. To determine the effects of the implementation of an early mobilisation (EM) program on mobility activities for critically ill children and to explore barriers and facilitators and clinical outcomes before and after implementation. A prospective single-centre before-and-after study. This study was conducted in a PICU of a large tertiary hospital. Children aged from 3months to 18 years, with an expected stay of ≥3 days were eligible to participate. In the "before" phase, participants received usual care; in the "after" phase we implemented a multicomponent, multidisciplinary EM protocol. The primary outcome was a change in the process outcome "mobilisation activities". Secondary outcomes were PICU staff opinions on mobilisation (survey), safety, process measures, involvement of parents and physical therapist, and clinical outcomes (sedative use and prevalence of delirium). A total of 113 children were included; 55 before and 58 after, with a median age of 31 months (IQR: 10-103) and 35 months (IQR: 7-152), respectively. The number of mobilisation activities (per patient per day) had significantly increased from 5 (IQR: 2-7) to 6 (IQR: 4-8) (U=272185.0; p < .001). PT consultations for mobilisation had significantly increased from 23.6% (13/55) to 46.5% (27/58) (X2 =6.48; p=.011). In both phases, no mobilisation-related adverse events were documented. The survey showed that PICU staff found EM of critically ill children useful and feasible. In the after phase, PICU staff rated the perceived benefit of the support of the physical therapist during mobilisation activities significantly higher than in the before phase (X2 =34.80; p < .001). Implementation of a structured EM program for critically ill children is feasible and safe. It is suggested to start the implementation of a structed EM program with the idendentification of local barriers and facilitators by an interdisciplinary PICU team. Further, an increased presence of physiotherapists on the PICU would improve mobilisation levels, and facilitate mobilisation in critically ill children. Also, they can support and advice PICU nurses and parents in mobilising children.

Implementation of a Delirium Bundle for Pediatric Intensive Care Patients.

Background and ObjectiveDelirium represents the most common form of acute cerebral dysfunction in critical illness. The prevention, recognition, and treatment of delirium must become the focus of modern pediatric intensive care, as delirium can lead to increased morbidity and mortality. The aim of this study is to evaluate the impact of a delirium bundle consisting of mainly non-pharmacological measures.Material and MethodsThis is a pre-/post-implementation study in an interdisciplinary pediatric intensive care unit of a tertiary care university hospital. In the pre-implementation period, pediatric intensive care delirium was monitored using the Sophia Observation withdrawal Symptoms and Pediatric Delirium scale. After introduction of a delirium bundle consisting of non-pharmacological prevention and treatment measures a period of 4 months was interposed to train the PICU staff and ensure that the delirium bundle was implemented consistently before evaluating the effects in the post-implementation period. Data collection included prevalence of delirium and withdrawal, length of PICU stay, duration of mechanical ventilation, and cumulative dose of sedatives and analgesics.ResultsA total of 792 critically ill children aged 0–18 years were included in this study. An overall delirium prevalence of 30% was recorded in the pre-implementation group and 26% in the post-implementation group (p = 0.13). A significant reduction in the prevalence of pediatric delirium from was achieved in the subgroup of patients under 5 years of age (27.9 vs. 35.8%, p = 0.04) and in patients after surgery for congenital heart disease (28.2 vs. 39.5%, p = 0.04). Young age, length of PICU stay, and iatrogenic withdrawal syndrome were found to be risk factors for developing delirium.ConclusionsBased on a validated delirium monitoring, our study gives new information regarding the prevalence of pediatric delirium and the characteristics of intensive care patients at risk for this significant complication. Especially young patients and patients after surgery for congenital heart disease seem to benefit from the implementation of non-pharmacological delirium bundles. Based on our findings, it is important to promote change in pediatric intensive care—toward a comprehensive approach to prevent delirium in critically ill children as best as possible.

P0318 / #2073: DEVELOPING A DEBRIEFING FRAMEWORK IN A PICU

Aims & Objectives: To evaluate perspectives on current debriefing practice and to develop a debriefing framework in PICU. Methods: A survey was conducted of all PICU staff to determine their views on current debriefing practice and their preferences on what type of debriefing they would like to access. A review of literature on debriefing practices in healthcare was also undertaken. The results of survey and literature were combined to create a debriefing framework. Results: from the survey found that 50% of staff felt debriefing wasn’t adequate, however there was a significant variation in the types of debriefing requested with some staff requesting right-away debriefing and others debriefing at a later stage. A debriefing framework was developed with medical, nursing and PICU psychology team to provide a formalized and consistent approach in providing staff with support. The framework addresses debriefing at the time of an incident and a system for follow up support and accounts for both clinical and psychological support. The most common type of support identified in the survey was support from colleagues as a result peer support was also included in this framework. Conclusions: Debriefing in critical care can be difficult due to competing demands however creating a system that can provide staff with consistent support will increase staff resilience and well-being. Further evaluation of this framework is required to assess the longitudinal impact of consistent debriefing in PICU. Acknowledgement: Funding support from Dr. Miriam Weisz , the Giving Circle and RCH Foundation Auxiliaries

Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!

To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU. A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts. Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD. Interprofessional PICU staff. None. Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement. Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.

53: PICU Staff Knowledge and Perceptions of Pediatric Delirium and Impact of an Educational Curriculum

53: PICU Staff Knowledge and Perceptions of Pediatric Delirium and Impact of an Educational Curriculum

Rapid Transition of a PICU Space and Staff to Adult Coronavirus Disease 2019 ICU Care.

We describe the process by which a PICU and a PICU care team were incorporated into a hospital-wide ICU care model during the coronavirus disease 2019 pandemic. A descriptive, retrospective report from a single-center PICU. Twenty-three bed, quaternary PICU, within an 862-bed hospital. Critically ill adults, with coronavirus disease 2019-related disease. ICU care provided by pediatric intensivists with training and support from medical intensivists. Within the context of the institution's comprehensive effort to centralize and systematize care for adults with severe coronavirus disease 2019 disease, the PICU was transitioned to an adult coronavirus disease 2019 critical care unit. Nurses and physicians underwent just-in-time training over 3 days and 2 weeks, respectively. Medical ICU physicians and nurses provided oversight for care and designated hospital-based teams were available for procedures and common adult emergencies. Over a 7-week period, the PICU cared for 60 adults with coronavirus disease 2019-related critical illness. Fifty-three required intubation and mechanical ventilation for a median of 18 days. Eighteen required renal replacement therapy and 17 died. During the current and potentially in future pandemics, where critical care resources are limited, pediatric intensivists and staff can be readily utilized to meaningfully contribute to the care of critically ill adults.

A Hybrid Model of Pediatric and Adult Critical Care During the Coronavirus Disease 2019 Surge: The Experience of Two Tertiary Hospitals in London and New York.

The current novel severe acute respiratory syndrome coronavirus 2 outbreak has caused an unprecedented demand on global adult critical care services. As adult patients have been disproportionately affected by the coronavirus disease 2019 pandemic, pediatric practitioners world-wide have stepped forward to support their adult colleagues. In general, standalone pediatric hospitals expanded their capacity to centralize pediatric critical care, decanting patients from other institutions. There are few units that ran a hybrid model, managing both adult and pediatric patients with the same PICU staff. In this report, we describe the hybrid model implemented at our respective institutions with shared experiences, pitfalls, challenges, and adjustments required in caring for both young and older patients. Retrospective cohort study. Two PICUs in urban tertiary hospitals in London and New York. Adult and pediatric patients admitted to the PICU in roughly a 6-week period during the coronavirus disease 2019 surge. None. The PICU at King's College Hospital admitted 23 non-coronavirus disease adult patients, while whereas the PICU at Morgan Stanley's Children Hospital in New York admitted 46 adults, 30 of whom were coronavirus disease positive. The median age of adult patients at King's College Hospital was higher than those admitted in New York, 53 years (19-77 yr) and 24.4 years (18-52 yr), respectively. Catering to the different physical, emotional, and social needs of both children and adults by the same PICU team was challenging. One important consideration in both locations was the continued care of patients with severe non-coronavirus disease-related illnesses such as neurosurgical emergencies, trauma, and septic shock. Furthermore, retention of critical specialists such as transplant services allowed for nine and four solid organ transplants to occur in London and New York, respectively. This hybrid model successfully allowed for the expansion into adult critical care while maintaining essential services for critically ill children. Simultaneous care of adults and children in the ICU can be sustained if healthcare professionals work collaboratively, show proactive insight into anticipated issues, and exhibit clear leadership.

The End of life care tab: A Quality improvement intervention

Background: Two sentinel cases prompted an evaluation of our EOL care practice for children in our pediatric intensive care unit. Lack of clear guidelines for end of life care in the PICU and physician variability in practice resulted in communication breakdowns triggering significant moral distress amongst PICU staff. Problem Analysis: A more detailed evaluation of the problem was performed using two measures: quantitative data collection with a PICU staff needs assessment survey as well as qualitative data from staff debriefings. The survey included a self-assessment on EOL clinical skills, an assessment of inter- and intra-team communication, an assessment of communication with patients/families, and …

Using Quality Improvement to Reduce IV Acetaminophen Use in a PICU.

Improve medication-related variable ICU costs by increasing value related to a locally identified high-frequency/high-cost medication, IV acetaminophen. Structured quality improvement initiative using the Institute for Healthcare Improvement's Model for Improvement. Twenty-three-bed tertiary PICU. All patients admitted to the PICU receiving IV acetaminophen during the study period of 2015-2018. PICU staff survey, education to close nurse/provider knowledge gap, optimization of order sets and electronic health record order entry, improving oral/enteral medication transition, and optimization of pharmacy dispensing. The primary outcome of interest was IV acetaminophen doses per patient day reported as a 12-month rolling average. Baseline IV acetaminophen prescribing prior to the study period was initially 0.55 doses per patient day, and in 2014, there were 3,042 doses administered. IV acetaminophen is $43 per dose. The rolling 12-month average post intervention was 0.33 doses per patient day. Enteral and rectal doses increased from 0.42 to 0.58 doses per patient day. Opioid utilization varied throughout the study. A 40% reduction in IV acetaminophen equated to a $35,507 cost savings in a single year. IV acetaminophen is prescribed with high frequency and impacts variable PICU costs. Value can be improved by optimizing IV acetaminophen prescribing.

Barriers to Communication in a PICU: A Qualitative Investigation of Family and Provider Perceptions.

Family and medical provider perceptions of communication barriers within the PICU are poorly understood. We designed a qualitative study to characterize the perspective of families and medical providers of critically ill children regarding communication barriers. The identified barriers may be used to direct efforts to improve communication. Semi-structured interviews were conducted from August 2017 to January 2018. Interviews were audio recorded and professionally transcribed verbatim. A PICU at a tertiary care academic center. Forty-two families whose children were admitted to the PICU (excluding patients receiving end-of-life care or with protective services involvement) and 12 PICU staff members, including nurses, residents, fellows, and attending's. None. An interprofessional team of a physician, nurse manager, and medical student coded the transcripts. Interviewing continued until thematic saturation was reached. Codes were organized into common themes using a modified constant comparative method. The families interviewed represented 16 previously healthy children, and 26 children with a chronic health condition. Staff interviewed included three residents, three fellows, three attending intensivists, and three nurses. Participants' perceptions and experiences of barriers to communication included the following: 1) Communication breakdowns related to coordination of care among several services, 2) Family-centered rounds are insufficient for effective communication, 3) Undervaluing the knowledge of families of children with chronic health conditions or special needs, and 4) Communication breakdowns occur across provider hand-offs. Theme 3 was identified by families, but not by providers. Families and medical providers both identified several barriers to communication. However, only families identified the barrier "Undervaluing the knowledge of families with chronically ill children." Future work should explore these barriers and the discrepancy in perception between providers and families to determine if there are interventions that improve both family satisfaction and patient care.

Are Pediatric Critical Personnel Satisfied With Their Lives? Prediction of Satisfaction With Life From Burnout, Posttraumatic Stress, and Posttraumatic Growth, and Comparison With Noncritical Pediatric Staff.

Staff in PICUs shows high burnout, posttraumatic stress disorder symptoms, and posttraumatic growth levels. However, their levels of satisfaction with life and how positive and negative posttrauma outcomes relate to each other and contribute to predict satisfaction with life remain unknown. Thus, we attempted to explore these aspects and to compare the findings with data from pediatric professionals working in noncritical units. This is an observational multicentric, cross-sectional study. The PICU of nine hospitals in Spain, and other pediatric units in the same hospitals. Two hundred ninety-eight PICU workers (57 physicians, 177 nurses, and 64 nursing assistants) and 189 professionals working in noncritical pediatric units (53 physicians, 104 nurses, and 32 nursing assistants). Participants completed the Maslach Burnout Inventory, the Trauma Screening Questionnaire, the Posttraumatic Growth Inventory, and the Satisfaction With Life Scale. Of PICU staff, 16.4% were very satisfied with their lives, 34.2% were satisfied, 34.6% showed average satisfaction with life, and 14.8% were below average. No differences were found between PICU and non-PICU workers. Women reported lower satisfaction with life than men, and physicians reported higher satisfaction with life than other professional groups. The correlation between posttraumatic stress disorder and posttraumatic growth was low, but significant and positive. According to the path analysis with latent variables, 20% of the variance satisfaction with life could be predicted from burnout, posttraumatic stress disorder symptoms, and posttraumatic growth. Higher distress was inversely associated to satisfaction with life, whereas posttraumatic growth contributed to higher satisfaction with life. Posttraumatic growth can moderate the negative effect of traumatic work-related experiences in satisfaction with life. PICU and non-PICU workers were equally satisfied with their lives. Positive and negative impact of work-related potentially traumatic events can coexist in the same person. Interventions aimed at reducing distress and fostering posttraumatic growth could impact in an improvement in pediatric health professionals' satisfaction with life.

Caring for Parents After the Death of a Child.

To describe the health outcomes of bereaved parents and identify practical strategies for critical care providers as they support and provide anticipatory guidance to bereaved parents. PubMed and PsycInfo databases with search terms of bereavement, grief, with parent and pediatric or child complimented by personal experience and knowledge. We sought studies describing parental health outcomes and needs of bereaved parents after the death of their child. A narrative literature review was performed and framed from the perspective of PICU providers who care for bereaved parents. We aimed to describe experiences of grief and short- and long-term consequences and approaches to the care of parents and families in the immediate period and in the months after the death of a child. The death of a child is a traumatic experience that can put parents at risk for adverse mental and physical health during bereavement. Health professionals working in PICUs can benefit from knowing these risks to best support bereaved parents, both during their child's hospitalization and in the early postdeath period. The bereavement experience of parents is an adaptive process, and ongoing professional support may be required for vulnerable families. After the child's hospitalization and death, a bereavement follow-up meeting with PICU physician(s) and staff may allow parents to gain additional information, emotional support, and provide an opportunity for parents to give feedback on their experiences.

Care for Dying Children and Their Families in the PICU: Promoting Clinician Education, Support, and Resilience.

To describe the consequences of workplace stressors on healthcare clinicians in PICU, and strategies for personal well-being, and professional effectiveness in providing high-quality end-of-life care. Literature review, clinical experience, and expert opinion. A sampling of foundational and current evidence was accessed. Narrative review and experiential reflection. The well-being of healthcare clinicians in the PICU influences the day-to-day quality and effectiveness of patient care, team functioning, and the retention of skilled individuals in the PICU workforce. End-of-life care, including decision making, can be complicated. Both are major stressors for PICU staff that can lead to adverse personal and professional consequences. Overresponsiveness to routine stressors may be seen in those with moral distress, and underresponsiveness may be seen in those with compassion fatigue or burnout. Ideally, all healthcare professionals in PICU can rise to the day-to-day workplace challenges-responding in an adaptive, effective manner. Strategies to proactively increase resilience and well-being include self-awareness, self-care, situational awareness, and education to increase confidence and skills for providing end-of-life care. Reactive strategies include case conferences, prebriefings in ongoing preidentified situations, debriefings, and other postevent meetings. Nurturing a culture of practice that acknowledges the emotional impacts of pediatric critical care work and celebrates the shared experiences of families and clinicians to build resilient, effective, and professionally fulfilled healthcare professionals thus enabling the provision of high-quality end-of-life care for children and their families.