Training in pediatric critical care medicine: A survey of pediatric residency training programs.

Numerous studies have shown that critically ill infants and toddlers admitted to paediatric intensive care units (PICUs) have a lower mortality than those admitted to adult ICUs. In 2014, there were only 23 registered PICUs in Italy, most of which were located in the north. For this reason, in Italy and elsewhere in Europe, some neonatal ICUs (NICUs) have begun managing critically ill infants and toddlers. Our proposal for healthcare organization is to establish “extended NICUs” in areas where paediatric intensive care beds are lacking. While some countries have opted for a strict division between neonatal and paediatric intensive care units, the model of “extended NICUs” has already been set up in Italy and in Europe. In this instance, the management of critically ill infants and toddlers undoubtedly falls upon neonatologists, who, however, must gain specific knowledge and technical skills in paediatric critical care medicine (PCCM). Postgraduate residencies in paediatrics need to include periods of specific training in neonatology and PCCM. The Italian Society of Neonatology’s Early Childhood Intensive Care Study Group is supporting certified training courses for its members involving both theory and practice.Conclusion: Scientific societies should promote awareness of the issues involved in the intensive management of infants and toddlers in NICUs and the training of all health workers involved. These societies include the Italian Society of Neonatology, the European Society of Paediatric and Neonatal Intensive Care, and the Union of European Neonatal and Perinatal Societies. They should also act in concert with the governmental institutional bodies to establish the standards for the “extended NICUs.”What is Known:• The mortality of critically ill infants and toddlers admitted to PICUs is lower than that for those admitted to adult ICUs.• In Italy, there are only a handful of PICUs, located mainly in the north.What is New:• Critically ill infants and small toddlers can be managed in “extended NICUs” in areas with a lack of paediatric intensive care beds.• “Extended NICUs” is our proposal for healthcare organization to compensate for the paucity of paediatric intensive care beds, but neonatologists must be trained to provide them with specific knowledge and technical skills in PCCM.

ObjectiveTo identify the neonatal, pediatric and mixed (neonatal and pediatric) intensive care units in Brazil that use cuffed tracheal tubes in clinical practice and to describe the characteristics related to the use of protocols and monitoring.MethodsTo identify the intensive care units in Brazil, the Ministry of Health’s National Registry of Health Facilities was accessed, and information was collected on 693 registered intensive care units. This was an analytical cross-sectional survey conducted through electronic questionnaires sent to 298 neonatal, pediatric and mixed intensive care units in Brazil.ResultsThis study analyzed 146 questionnaires (49.3% from neonatal intensive care units, 35.6% from pediatric intensive care units and 15.1% from mixed pediatric intensive care units). Most of the participating units (78/146) used cuffed tracheal tubes, with a predominance of use in pediatric intensive care units (52/78). Most of the units that used cuffed tracheal tubes applied a cuff pressure monitoring protocol (45/78). The use of cuff monitoring protocols was observed in intensive care units with a physical therapy service exclusive to the unit (38/61) and in those with a physical therapist present 24 hours/day (25/45). The most frequent cause of extubation failure related to the use of cuffed tracheal tubes in pediatric intensive care units was upper airway obstruction.ConclusionIn this survey, the use of cuffed tracheal tubes and the application of a cuff pressure monitoring protocol was predominant in pediatric intensive care units. The use of a monitoring protocol was more common in intensive care units that had a physical therapist who was exclusive to the unit and was present 24 hours/day.

Comparison of severity and diagnosis-adjusted mortality rates from pediatric intensive care units (ICUs) staffed by physicians training in pediatric critical care, as well as pediatric residents, with mortality rates from pediatric ICUs staffed with only pediatric residents. Cohort study. Sixteen volunteer pediatric ICUs, eight with critical care fellowships, and eight without such programs. Consecutive admissions until at least 14 deaths occurred at each site. None. Descriptive data and Pediatric Risk of Mortality scores were collected. Severity and diagnosis-adjusted mortality risk for each patient was computed by a predictor developed in an independent sample. The effect of fellowship programs was analyzed at the institution level by ranking the pediatric ICUs in terms of observed/predicted mortality rates, and, at the patient level, by including a training factor into the predictor model. The use of monitoring and therapeutic modalities was compared in the two types of pediatric ICUs by severity-adjusted odds ratios. There were 2,744 admissions (145 deaths) to the eight fellowship pediatric ICUs and 3,006 admissions (150 deaths) to the eight nonfellowship pediatric ICUs. Institutional characteristics were not different between the two pediatric ICU sets. The raw mortality rates were similar (fellowship 5.28%; nonfellowship 4.99%, p = .714). Institution-level analyses indicated that fellowship pediatric ICUs performed better than nonfellowship pediatric ICUs; fellowship pediatric ICUs ranked better than pediatric ICUs without such programs (Wilcoxon rank-sum test, p = .020). However, both the best and the worst ranked pediatric ICUs had fellowships. Patient-level analyses also indicated that outcome was significantly influenced by the fellowship status of the pediatric ICU. Using two different patient-level analytic approaches, the odds of dying in a fellowship pediatric ICU vs. a nonfellowship pediatric ICU were 0.592 (95% confidence interval 0.468 to 0.749, p = .0001) and 0.714 (95% confidence interval 0.529 to 0.964, p = .028). Pediatric ICUs with fellowship programs performed more (p < .05) invasive monitoring, including intra-arterial catheters and central venous pressure catheters, and more technological therapies such as mechanical ventilation. Pediatric ICUs with critical care fellowship programs are generally associated with better risk-adjusted mortality rates than pediatric ICUs without such fellowship training programs. The cause for this effect requires a more in-depth study. The presence or absence of such training programs does not guarantee superior or inferior performance.

Successful Integration of Advanced Practice Providers Into a Pediatric Academic Community Intensive Care Unit

Enhancing communication between family members and health care team members within the pediatric intensive care unit (PICU) is a national clinical and research priority. Poor communication can increase patients’ length of stay, hospital costs, and the likelihood of delivering value-discordant care. Family members of PICU patients report numerous communication barriers, such as poor access to members of the health care team, inadequate care coordination, and infrequent clinician-initiated discussions. Despite these rec-ognized barriers, there is a salient lack of interventions to support communication between PICU family members and members of the health care team.To address this issue, the investigators studied the feasibility of implementing a navigator-based communication intervention called PICU Supports and assessed the responses of family members and clinicians to that intervention. PICU Supports comprises specific intervention components for the navigator, patients’ family members, and health care providers. The navigator’s intervention components included a rigorous navigator- training protocol; a standardized meeting-frequency protocol for the navigators, the family members, and the health care team members; tailored PICU-transition support for the family members; and a post-PICU discharge check-in. Family members’ intervention components included a parent-developed PICU information handbook, a bedside communication log, and bereavement packets for family members of decedents. Each week, members of the health care team reviewed a navigator-prepared document that included relevant psychosocial information and identified family needs. The investigators conducted this study at a university-based, tertiary-care children’s hospital with 76 PICU beds.Family members completed the same survey at enrollment, discharge, and 3 to 5 weeks after discharge. Some family members participated in an optional 1-on-1 semistructured audio interview at discharge. Thirty-five family members enrolled in the study. Family members reported that PICU Supports improved communication with members of the health care team, although no family members requested a family meeting. Opinions on the PICU handbook were mixed, as some family members were too overwhelmed to read the material. Family members and health care team members rarely used the bedside communication log. Overall, the health care team members found PICU Supports to be valuable, but they recommended improving the navigator’s integration with members of the health care team. The investigators concluded that PICU Supports was feasible to implement and research and that further refinement and testing of the intervention are warranted.Kelly N. Michelson, MD, MPH, lead author of the study, cites her prior research and personal clinical experiences as the motivation for the study. Originally, Dr Michelson had planned to develop a standardized approach to address end-of-life decision-making in the PICU. However, her preliminary work “highlighted the individual nuances and contextual issues that often influence decision-making” in the PICU. So rather than creating a standardized intervention, Dr Michelson concluded that critical care providers may benefit from “a malleable approach to decision-making that can easily be adapted to the individual needs of each family, patient, and situation.” She adds, “given the successful implementation of navigators in other settings, introducing a navigator into the PICU setting to individualize decision-making and psychosocial supports seems like the next natural step.”To assemble the team necessary to develop PICU Supports, Dr Michelson used “stakeholder-engaged comparative effectiveness research” as a guiding framework. “We identified 3 groups of stakeholders: parents of previously critically ill children, clinicians who care for and administrators who oversee the care of critically ill children, and clinical trials research experts.” The clinician stakeholder group included representatives from various medical specialties, nursing, social work, palliative care, spiritual care, and administration. Together, these 3 stakeholder groups developed the PICU Supports intervention and helped design the study.Dr Michelson contends that the “value of having such a large, multifaceted group is reflected in the comprehensive nature of the PICU Supports intervention,” and encourages “investigators to make that extra effort to engage” multidisciplinary groups during research. However, she admits that “coordinating such a large group presented some challenges.” Dr Michelson recalls difficulty scheduling meetings and “finding ways to keep the larger team engaged when there were no direct activities for them to comment on or participate in.” Nevertheless, she concludes: “I feel incredibly privileged to have had the opportunity to work with such a diverse and dedicated group of people.”Dr Michelson believes that although “we are still trying to determine the best way to support parents and families of critically ill children … the best approaches will ultimately require a team effort,” as many disciplines and professions influence the family experience within the PICU. She anticipates that “this work will help pediatric critical care teams develop strategies for bringing those group efforts together.” Dr Michelson humbly acknowledges that PICU Supports is “only one approach” that can be used to support families and clinicians and “the impact of this approach is still yet to be determined. But the idea that we need to find better, more efficient ways to individualize care for families, knowing the complexity of the care team and clinical challenges facing those in the PICU, is fundamental.”As clinicians and scientists conduct more research, prominent questions may arise. For example, Dr Michelson shares, “we were surprised to see so few parents interested in having family meetings because many experts tout their value.” She further acknowledges that research within the PICU can be difficult because “it serves a very heterogeneous population with different support needs.” As such, studies may focus on “very specific populations,” which “limits generalizability.” Alternatively, investigators may “create an option that could be adapted to different populations to maximize generalizability and scalability…. Perhaps, the best approach lies somewhere between those two extremes.”This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Kelly N. Michelson, MD, MPH, has been a pediatric critical care specialist for more than 15 years. However, another of her life’s passions is dance: “Dancing and the human body were always my passions.” In fact, she focused on dance between completing her undergraduate degree and entering medical school. “My dance career allowed me to travel nationally and internationally and to fulfill one of my childhood dreams. But I never let go of my dream to become a physician.”During her pediatric and critical care training, Dr Michelson “was drawn to the interesting pathophysiology and fast pace in the PICU.” She “was also amazed by the intense relationships that clinicians develop with parents of critically ill patients … [who are] facing their worst nightmare.” She says that these formative experiences “drove me to do the research that I do now.” Even today, Dr Michelson’s experiences as a pediatric intensivist remain central: “[they] shape how I think about supporting families of critically ill children and about the questions I try to address in my research.”

Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.

Computed radiography in neonatal and pediatric intensive care units: A comparison of 2.5 K × 2 H soft copy images vs digital hard-copy film

Critical Care Rotation Impact on Pediatric Resident Mental Health and Burnout

Introduction: Although preventive medicine and primary care are priorities in developing countries, they must be supported by appropriate care of sick and extremely sick children in the medical facilities. Lack of resources and absence of skilled physicians and nurses may lead to poor outcomes in critically ill patients. Intensive care of newborns and children is thought to be very expensive with a low cost-benefit ratio. This presentation discusses the critical factors that facilitated the establishment of PICU and NICU in an urban public hospital in Nepal, where a good standard of Level 2 care was already provided. Aims and objectives: A cooperative model of creation and transfer of technology from the West to a resource-poor country was envisaged. PICU and NICU with six beds each were established. Design and setting: The Nick Simons Foundation, USA provided financial support for design, building and furnishing of a new Mother and Child Wing at Patan Hospital. A generous grant of $300,000 again by the Nick Simons Foundation helped equip the units. Donated equipments also included procedures, medication and storage carts. Methodology: A total of 22 volunteers, 21 from USA and one from Netherlands, were recruited to complete the three months of training. An extensive curriculum was prepared. The trainer team had monthly teleconferences and regular communications with the Chief of Paediatric Services and Nursing Director of Patan Hospital via e-mails and telephone. Responsibilities of volunteers and the host hospital were identified. Results: After 3 years of preparation, the project started in June 2009. All day lectures on topics in critical care, mock case scenarios, practical equipment training and simulated procedures led to the graduation of 60 nurses. Twenty five physicians were trained for three months. The expert team worked with the locals in preparing the units, arranging furniture and equipment, stocking carts, making inventory and preparing protocols. A protocol handbook was developed on topics such as mechanical ventilation, sedation, admission/discharge criteria, procedures and management of different disease states. Various charts such as nurse observation charts, notes by residents, procedure hand offs at change of shifts were designed and printed. Infection control practices and methods of sterilizing non disposable articles were identified and protocols written. At the end of three months the units were functioning with trained local manpower and reasonable modern equipment. Conclusion: Developing nations may not have enough resources to establish much needed critical care facilities. Developed countries can help by funding basic infrastructure and providing expertise in order to transfer knowledge and technology. Involvement in planning from the beginning and training at the host site is a preferred model of transfer of technology. Key words: Paediatric Intensive Care Unit (PICU); Neonatal Intensive Care Unit (NICU); Patan Hospital DOI: 10.3126/jnps.v31i1.4161J Nep Paedtr Soc 2010;31(1):49-56

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

A 2011 study evaluating oral health training in pediatric medical residency programs highlighted opportunities to improve residents' oral health competence. The aim of this 2017 follow-up study was to assess progress since 2011 in promoting development of pediatric residents' oral health competence. A survey was sent to all 281 pediatric and med-peds medical residency program directors to assess the structure and determinants of oral health training in their programs. A total of 110 program directors responded to the 2017 survey (response rate 40%). Just over half (54%) of the respondents reported that their residents received one to two hours of oral health education during residency, while 38% received ≥3 hours (compared to 47% and 48%, respectively, in 2011). There was improvement in the proportion of respondents reporting that their residents integrated fluoride varnish application training in 2017 vs. 2011 (83% vs. 43%; p<0.001). Departmental support for integrating oral health and having an oral health elective were significantly associated with satisfaction with residents' oral health competence. These findings suggest that pediatric and med-peds medical residency programs have improved their residents' oral health awareness and training through integration of at least one hour of oral health education and fluoride varnish training. However, given deficiencies in program structure and uneven perceptions of residents' oral health competence found in this study, opportunities remain to improve pediatric residency programs' oral health curricula.

Antibiotic consumption (AC) is a key component of antimicrobial stewardship programs to recognize local patterns of antibiotic use. Our aim was to measure AC in neonatal units, including neonatal (NICU)/paediatric (PICU) intensive care units in different countries. We conducted a multicenter, retrospective, cohort study in three NICUs, one neonatal ward, and three PICUs with a total of 84 beds. Global and individual AC in days of therapy (DOT) and DOT per 1000 patient-days were assessed. During the study period, 2567 patients were admitted, corresponding to 4961 patient-days in neonatal units and 9243 patient-days in PICUs. Multidrug-resistant Gram-negative bacteria and methicillin-resistant Staphylococcus aureus were more frequent in Brazil than in Germany. Average AC was 386.5 and 1335.5 DOT/1000PD in German and Brazilian neonatal units, respectively. Aminopenicillins plus 3rd generation cephalosporins were the most commonly prescribed antibiotics in German neonatal units, while aminopenicillins plus aminoglycosides were the class most commonly used in Brazilian NICU. Average AC was 888.1 and 1440.7 DOT/1000PD in German and Brazilian PICUs, respectively. Antipseudomonal penicillins were most commonly used in the German PICU, and glycopeptides were the most frequently prescribed in Brazilian PICUs. Carbapenems represented 2.3-14% of total DOTs in German neonatal units and 4% in the Brazilian NICU and 13.0% in the German PICU and 6-12.2% in Brazilian PICUs. We concluded that different patterns of most commonly prescribed antibiotics were observed in neonatal units and PICUs in these two countries, probably related to different local patterns of antibiotic resistance, with a higher antibiotic consumption in Brazilian study units.

Ventilator-associated Pneumonia (VAP) is a lung infection that occurs in patients who use mechanical ventilation for breathing. Neonates and children with respiratory distress who require mechanical ventilation have a higher risk of developing VAP. Neonates and children using breathing apparatus in the Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) are prone to Ventilator Associated Pneumonia (VAP). Therefore, VAP prevention should be considered one of the most important issues in NICU and PICU care. This study aims to identify VAP prevention efforts in the NICU and PICU. The research design used in this study was descriptive qualitative. This study's sampling technique used the Focus Group Discussion (FGD) with six nurse participants who worked in the NICU and PICU of a regional public hospital in Bandung using a semi structured interview format. Data were analyzed using thematic analysis. Three main themes describe implementing VAP prevention efforts in the NICU and PICU. The first theme concerns VAP prevention efforts that are still not optimal. Some VAP prevention measures implemented include hand washing, gloves usage, sterile suctioning techniques, head up 30-45 degrees, and oral hygiene. At the same time, other actions have not been routinely carried out. The second theme is the existence of barriers to implementing VAP prevention, and the third theme is related to the need to increase the capacity of nurses and support facilities. Based on the study's results, nurses revealed that the implementation of the VAP prevention program in the NICU and PICU had not run optimally, one of which could be caused by limited infrastructure and nurses' competence. Thus, it is necessary to increase the knowledge and skills of nurses related to VAP and provide adequate infrastructure.

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

“The curriculum brings equity to the forefront”: Pediatric residents’ perspectives and experiences in a longitudinal EDI curriculum