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Adolescent females may undergo pregnancy screening while receiving critical care services, but the frequency and results are unknown. The objectives of this study are to evaluate patient characteristics, pregnancy screening frequency, and rate of positive pregnancy screens in adolescent females of childbearing age who require critical care services. We hypothesize that when adolescent pregnancy screening is performed in the critical care setting, it occurs in a higher frequency in older subjects.This is a multicenter retrospective observational cohort study utilizing TriNetX, an electronic health record database. The following electronic health record data were collected and evaluated in adolescent females aged 12-18 years and billed for critical care services: age, race, ethnicity, diagnostic codes, selected radiology and surgical procedure codes, number of deaths, pregnancy screening laboratory codes, and pregnancy screening results.A total of 5,241 subjects (2,242 [42.8%] subjects for whom pregnancy screen was noted and 2,999 [57.2%] subjects for whom it was not noted) were included in this study. Subjects aged 15-18 years (odds ratio = 1.56, 95% confidence interval = 1.38-1.77, p value.0001) and had Hispanic or Latina ethnicity (odds ratio = 1.46, 95% confidence interval = 1.28-1.66, p value.0001) had a higher association with pregnancy screening. A positive pregnancy screen was identified in 18 (0.8%) subjects.In our study, positive pregnancy screens were infrequent, not all subjects were screened, and there was an association between pregnancy screening and ethnicity. Because of the potential for screening bias, this study suggests that clinicians should strongly consider routine pregnancy screening for all females of childbearing age and that hospital policies should require this type of screening.

Background Preadmission discussions in the study institution’s pediatric intensive care unit are not standardized and admission plans were thought to be disjointed, leading to a perceived lack of organization and preparation for the arrival of a critically ill child. Objective To evaluate the impact of a new, formalized preadmission pediatric intensive care unit interdisciplinary huddle on clinician perceptions of interprofessional communication. The hypothesis was that preadmission huddles would improve unit clinicians’ perceptions of interprofessional communication. Methods Interprofessional pediatric intensive care unit clinicians (physicians, advanced practice providers, nurses, and respiratory therapists) completed surveys before and 7 months after preadmission interdisciplinary huddle implementation. Huddle compliance and perceptions of interprofessional communication in the unit were evaluated. Results Of 265 eligible pediatric intensive care unit admissions, 69 huddles (26.0%) occurred. The postintervention survey revealed increased odds (odds ratio [95% CI]) of responding “strongly agree” or “agree” to questions about the opportunity to “communicate effectively with health care team members” (2.42 [1.10-5.34]), “respond to feedback from health care team members” (2.54 [1.23-5.24]), and “convey knowledge to other health care team members” (2.71 [1.31-5.61]) before an admission. Discussion This study introduced a formalized huddle that improved pediatric intensive care unit clinicians’ perceived communication with other health care team members in the preadmission period. Conclusions Future studies are needed to determine if this perceived improvement in communication significantly affects health care outcomes of critically ill children or if these results are generalizable to other pediatric intensive care unit settings.

Objective Critically ill children may be transferred from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) for further critical care, but the frequency and outcomes of this patient population are unknown. The aims of this study are to describe the characteristics and outcomes in patients transferred from NICU to PICUs. We hypothesized that a higher-than-expected mortality would be present for patients with respiratory or cardiovascular diagnoses that underwent a NICU to PICU transition and that specific factors (timing of transfer, illness severity, and critical care interventions) are associated with a higher risk of mortality in the cardiovascular group. Study Design Retrospective analysis of Virtual Pediatric Systems, LLC (2011–2019) deidentified cardiovascular and respiratory NICU to PICU subject data. We evaluated demographics, PICU length of stay, procedures, disposition, and mortality scores. Pediatric Index of Mortality 2 (PIM2) score was utilized to determine the standardized mortality ratio (SMR). Results SMR of 4,547 included subjects (3,607 [79.3%] cardiovascular and 940 [20.7%] respiratory) was 1.795 (95% confidence interval: 1.62–1.97, p Conclusion In this present study, we found that NICU to PICU observed deaths were high and various factors, particularly transfer age, were associated with increased odds of mortality. While the type of patients evaluated in this study likely influenced mortality, further investigation is warranted to determine if transfer timing is also a factor. Key Points

Background: A guideline to determine pediatric brain death was updated in 2011. It is unknown how pediatric intensivists have accepted and adopted the revised guideline into clinical practice. Methods: We surveyed US pediatric critical care attending physicians July 2013 to September 2013 and February 2020 to May 2020. Brain death testing practices and utilization of the 2011 pediatric and neonatal brain death guideline were assessed. Results: The 2020 respondents found that the revised pediatric brain death guideline were useful in clinical practice (93.7% vs 83.3%, P = .0484) and provided more consistency and clarity (73.2% vs 63.1%, P = .0462) when compared to 2013 respondents. Conclusion: This study demonstrates that with defined criteria, survey participants reported increased clarity and consistency. Findings from our study indicate that in clinical practice there is no significant deviation from the minimum requirements to determine brain death in children as outlined in the 2011 guideline.

Background/Objectives Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be associated with febrile seizures, but the overall frequency and outcomes are unknown. The objectives of this study are to (1) determine the frequency of pediatric subjects diagnosed with febrile seizures and COVID-19, (2) evaluate patient characteristics, and (3) describe the treatments (medications and need for invasive mechanical ventilation) applied. Methods This was a retrospective study utilizing TriNetX electronic health record data. We included subjects ranging from 0 to 5 years of age with a diagnosis of febrile seizures (R56.00, R56.01) and COVID-19 (U07.1). We extracted the following data: age, race, ethnicity, diagnostic codes, medications, laboratory results, and procedures. Results During this study period, 8854 pediatric subjects aged 0-5 years were diagnosed with COVID-19 among 34 health care organizations and 44 (0.5%) were also diagnosed with febrile seizures (simple, 30 [68.2%]; complex, 14 [31.8%]). The median age was 1.5 years (1, 2), there were no reported epilepsy diagnoses, and a proportion required hospitalization (11; 25.0%) and critical care services (4; 9.1%). Conclusions COVID-19 infections in children can be associated with febrile seizures. In our study, 0.5% of COVID-19 subjects were diagnosed with febrile seizures and approximately 9% of subjects were reported to require critical care services. Febrile seizures, although serious, are not a commonly diagnosed neurologic manifestation of COVID-19.

STUDY OBJECTIVE The objective of this study was to determine the rate of incidental pregnancy, pregnancy screening frequency, and factors associated with pregnancy screening in the pediatric intensive care unit (PICU). DESIGN A cross-sectional, descriptive study. SETTING The research was conducted at Penn State Health Children's Hospital evaluating PICU admissions between January 1, 2011, and January 31, 2019. PARTICIPANTS Female adolescents 14-21 years of age who were admitted to the PICU. INTERVENTIONS The study population was divided into 2 groups (Presence and Non-Presence of Pregnancy Screening), and data were collected from the electronic health record. MAIN OUTCOME MEASURES We evaluated for patient characteristics and for presence and results of urine pregnancy screening. RESULTS A total of 431 patients were included in the study. Of these, 275 patients (63.8%) had a pregnancy screen performed. No patients with incidental pregnancy were found. There was a statistically significant relationship between pregnancy screening and patient age, type of admission, and origin of transfer (P < .01). Analysis of secondary diagnoses (co-morbidities) indicated lower screening rates in patients with developmental delay, cerebral palsy, and/or mental retardation (15, 5.5%) [p < 0.0001] and chromosomal abnormalities (9, 3.3%) [p =0.021]. CONCLUSION Incidental pregnancy is uncommon in female adolescents of childbearing age who are admitted to the PICU, but not all patients were screened, thus potentially jeopardizing maternal and fetal care. Clinicians should consider routine pregnancy screening of female patients of childbearing age admitted to the PICU and should be cognizant of individual factors that could preclude screening prior to or during their presentation.

Background and Purpose Febrile seizures are common in children and are associated with viral infection. Mitigation strategies implemented during the coronavirus disease 2019 (COVID-19) pandemic have slowed the spread of all viral illnesses potentially impacting febrile seizure frequency. The objective of this study is to assess the impact of COVID-19 mitigation strategies on the diagnostic frequency of febrile seizures. Methods This was a retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects aged 0 to 5 years of age reported to have a febrile seizure diagnosis. After the query, the study population was divided into 2 groups [pre-COVID-19 (April 1st, 2019 until March 31st, 2020) and COVID-19 (April 1st, 2020 until March 31st, 2021). We analyzed the following data: age, sex, race, diagnostic, medication, and procedural codes. Results During the pre-COVID time frame, emergency or inpatient encounters made up 688,704 subjects aged 0 to 5 years in the TriNetx database, while in the COVID-19 pandemic time frame, it made up of 368 627 subjects. Febrile seizure diagnosis frequency decreased by 36.1% [2696 during COVID-19 vs 7462 during the pre-COVID-19] and a higher proportion of status epilepticus was coded [72 (2.7%) vs 120 (1.6%)] ( P < .001) during the COVID-19 pandemic. Hospitalization, lumbar puncture, critical care services, mechanical ventilation procedural codes were similar between the 2 cohorts. Antimicrobial use was higher in the pre-COVID-19 pandemic group [424 (15.7%) vs 1603 (21.5%)] ( P < .001). Conclusions Less children were diagnosed with febrile seizures during the COVID-19 pandemic, but a higher proportion were coded to have the complex subtype. The medical interventions required with the exception of antimicrobial use was similar. Further study is needed regarding mitigation strategies and its impact on pediatric diseases associated with viruses.

Introduction/Objectives: Cerebral palsy (CP) patients may be at risk of obesity, but outcomes and risk factors are understudied. The objectives of this study are to evaluate the body mass index (BMI) types of CP patients and to evaluate the presence of cardiometabolic specific diseases and medications. We hypothesize CP subjects with an increased BMI have a higher frequency of cardiometabolic specific diseases and medications. Methods: This is a retrospective observational cohort study utilizing TriNetX ®, an electronic health record (EHR) database, in CP subjects aged 2 to 18 years who had a BMI value available. The study population was divided into 4 BMI percentile groups, underweight (th BMI percentile), healthy weight (≥5th to th percentile), overweight (≥85th to th percentile), and obese (≥95th percentile), and the following variables were evaluated: demographics, diagnostic codes, and medication codes. Results: A total of 5993 subjects were included [underweight (251, 4.2%), healthy weight (2390, 39.9%), overweight (943, 15.7%), and obese (2409, 40.2%)]. Obese subjects had a higher frequency of the following: asthma [811 (33.7%), p=0.0001], diabetes mellitus [102 (4.2%), p=0.0001], hypertension [213 (8.8%), p=0.0001], and sleep apnea [686 (28.5%), p=0.0001]. Overweight subjects had a higher frequency of spastic diplegic cerebral palsy [574 (60.9%), p=0.0001). Conclusions: This study found CP patients classified as obese had a higher frequency of cardiometabolic comorbidity and medication codes that influence weight. BMI measurements are limited in this population but may be used cautiously to evaluate the body type of CP children, and monitor the occurrence of cardiometabolic associated comorbidities.

Background Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. Methods AO was implemented across 14 pediatric intensive care units (ICUs) as a quality improvement intervention during 2016–2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO were as follows: 5 liters/minute for infants (2 p p p = 0.03) after adjusting for site clustering (primary analysis). However, after further adjusting for patient and provider characteristics (secondary analysis), AO utilization was not independently associated with the occurrence of adverse TIAEs: aOR 0.90, 95% CI 0.72–1.12, p = 0.33. The occurrence of hypoxemia was not different: AO 14.2% vs without AO 15.2%, p = 0.43. Conclusion AO utilization was associated with a lower occurrence of adverse TIAEs in patients undergoing TI in the pediatric ICU.

BACKGROUND/OBJECTIVES When a severe asthma exacerbation occurs in an obese pediatric patient, it is unknown if this body type persists in future encounters. Persistent obesity can lead to future asthma exacerbations. The main study objective is to evaluate the persistence of a BMI percentile ≥85th in children 5 years after the first reported diagnosis of status asthmaticus. We hypothesized that a hospital admission for status asthmaticus was associated with persistence of a BMI percentile ≥85th. METHODS This was a long-term retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects aged 2 to 18 years of age with a diagnosis of status asthmaticus. Study population was divided into two groups based on their admission body mass index percentile: (underweight/healthy weight [

Background When central or peripheral intravenous access cannot be achieved in a timely manner, intraosseous (IO) access is recommended as a safe and equally effective alternative for pediatric resuscitation. IO usage and its complications in the pediatric population have been primarily studied in the setting of cardiac arrest. However, population-based studies identifying noncardiac indications and complications associated with different age groups are sparse. Results This was a retrospective observational cohort study utilizing the TriNetX® electronic health record data. Thirty-seven hospitals were included in the data set with 1012 patients where an IO procedure code was reported in the emergency department or inpatient setting. The cohort was split into two groups, pediatric subjects < 1 year of age and those ≥ 1 year of age. A total incidence of IO line placement of 18 per 100,000 pediatric encounters was reported. Total mortality was 31.8%, with a higher rate of mortality seen in subjects < 1 year of age (39.2% vs 29.0%; p = 0.0028). A diagnosis of cardiac arrest was more frequent in subjects < 1 year of age (51.5% vs 38.0%; p = 0.002), and a diagnosis of convulsions was more frequent in those ≥ 1 of age (28.0% vs 13.8%; p Conclusions More IOs were placed in subjects ≥ 1 year of age, and a higher rate of mortality was seen in subjects < 1 year of age. Lower frequencies of noncardiac diagnoses at the time of IO placement were found in both groups, highlighting IO may be underutilized in noncardiac settings such as convulsions, shock, and respiratory failure. Given the low rate of complications seen in both groups of our study, IO use should be considered early on for urgent vascular access, especially for children less than 1 year of age.

Specialized laboratory evaluation of supraventricular tachycardia in children may occur, but the utility is unknown. The study objectives are to assess the type, frequency, and results of specialized laboratory testing performed in pediatric patients presenting with new-onset supraventricular tachycardia. We hypothesized that when specialized laboratory testing occurs (particularly for cardiac failure, toxicologic, inflammatory, and thyroid diseases), the results are generally within normal limits.This is a retrospective descriptive study using an electronic health record database (TriNetX, Inc). We collected and evaluated the following data of subjects aged younger than 18 years with a first-time supraventricular tachycardia diagnosis: demographics, diagnostic codes, deaths, and laboratory codes/results (natriuretic peptide B, natriuretic peptide B prohormone N-terminal, troponin I, toxicology testing, inflammatory markers, and thyroid studies).A total of 621 subjects (524 [84.4%] without laboratory testing, 97 [15.6%] with laboratory testing) were included. Thyroid studies (65 [10.5%]) were the most frequent laboratory study performed followed by cardiovascular specific studies (35 [5.6%]), inflammatory markers (21 [3.4%]), and toxicology tests (10 [1.6%]) (P = .002). Obtained laboratory testing was more frequent with older subjects, females, and need for emergency, hospital, and critical care services.Cardiac-specific and noncardiac laboratory testing is frequently ordered for pediatric patients who present with supraventricular tachycardia. Thyroid studies were the most common laboratory testing ordered, but abnormal results only occurred in less than a quarter of subjects. These findings may highlight a quality improvement opportunity for emergency nurses and practitioners in the practice of obtaining laboratory tests to better reflect high-value evidence-based care for this vulnerable population.

When unrecognized and antibiotic delay occurs, Lyme disease, Rocky Mountain–spotted fever, babesiosis, and human ehrlichiosis and anaplasmosis can result in multiorgan system dysfunction and potentially death. This review focuses on the early recognition, evaluation, and stabilization of the rare life-threatening sequelae seen in tick-borne illnesses that require admission in the pediatric intensive care unit.

OBJECTIVES Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients. DESIGN A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018. SETTING Forty-six international PICUs. PATIENTS Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001). CONCLUSIONS Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.

Objectives Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. Design We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. Setting Forty international PICUs participating in the National Emergency Airway Registry for Children. Patients Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. Interventions None. Measurements and main results The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. Conclusions Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.

Video conference software has been increasingly used during the COVID-19 pandemic, but it is unknown if pediatric critical care providers would participate in culinary training via video conference in an effort to improve their wellness. The study aims were to (1) assess the feasibility of implementing a video-based culinary training wellness intervention; and (2) understand the barriers and motivators to attaining wellness from the perspective of pediatric critical care clinicians. We conducted, transcribed, and analyzed pre- and post-intervention semi-structured interviews using a directed content analysis approach. Four participants were included in this study. Pre-intervention qualitative analysis identified 3 themes: (1) Job-specific constraints contributed to poorer eating habits; (2) Poor nutrition was related to anxiety levels and job stress; (3) Meal preparation improved healthy eating. Post-intervention analysis identified 3 themes: (1) Wellness intervention was enhanced by involving loved ones; (2) Course improvement suggestions focused on more participants; (3) Major impacts from the course focused on cooking higher quality meals, obtaining new cooking tools, and applying new techniques. By providing pediatric critical care clinicians an opportunity to participate in virtual interactive culinary training experiences, we found that participants reported increased motivation to prepare quick and nutritious meals to improve their overall wellness.

Background Inappropriate triage of critically ill pediatric patients can lead to poor outcomes and suboptimal resource utilization. This study aimed to determine and describe the demographic characteristics, diagnostic categories, and timing of unplanned upgrades to the pediatric intensive care unit (PICU) that required short (< 24 hours of care) and extended (≥ 24 hours of care) stays. In this article, we hypothesized that we will identify demographic characteristics, diagnostic categories, and frequent upgrade timing periods in both of these groups that may justify more optimal triage strategies. Methods This was a single-institution retrospective study of unplanned PICU upgrades between 2012 and 2018. The cohort was divided into two groups (short and extended PICU stay). We reviewed the electronic health record and evaluated for: demographics, mortality scores, upgrade timing (7a-3p, 3p-11p, 11p-7a), lead-in time (time spent on clinical service before upgrade), patient origin, and diagnostic category. Results Four hundred and ninety-eight patients' unplanned PICU upgrades were included. One hundred and nine patients (21.9%) required a short and 389 (78.1%) required an extended PICU stay. Lead-in time (mean, standard deviation) was significantly lower in the short group (0.65 ± 0.66 vs. 0.91 ± 0.82) (p = 0.0006). A higher proportion of short group patients (59, 46.1%) were upgraded during the 3p-11p shift (p = 0.0077). Conclusion We found that approximately one-fifth of PICU upgrades required less than 24 hours of critical care services, were more likely to be transferred between 3p-11p, and had lower lead-in times. In institutions where ill pediatric patients can be admitted to either a PICU or a monitored step-down unit, this study highlights quality improvement opportunities, particularly in recognizing which pediatric patients truly need critical care.

Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets.Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpOA total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs.While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.

Mitigation strategies were implemented during the coronavirus disease 2019 (COVID-19) pandemic that slowed the spread of this virus and other respiratory viruses. The objective of this study is to assess the impact of COVID-19 mitigation strategies on the medical services that children less than 1 year of age with acute bronchiolitis required (emergency department services, hospitalization, critical care services, and mechanical ventilation).This was a retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects less than 1 year of age with a diagnosis of acute bronchiolitis. After the query, the study population was divided into two groups [pre-COVID-19 (March 1st, 2019 until February 29th, 2020) and COVID-19 (March 1st, 2020 until February 1th, 2021)]. We analyzed the following data: age, sex, race, diagnostic codes, common terminology procedures (CPT), and antimicrobials administered.A total of 5063 subjects (n,%) were included [4378 (86.5%) pre-COVID-19 and 685 (13.5%) during the COVID-19 pandemic]. More subjects were diagnosed with acute bronchiolitis in the pre-COVID time frame (4378, 1.8% of all hospitalizations) when compared to the COVID-19 pandemic time frame (685, 0.5%). When diagnosed with acute bronchiolitis, the frequency of emergency department services, critical care services, hospitalization, and mechanical ventilationwere similar between the two cohorts.During the COVID-19 pandemic, less infants were diagnosed with acute bronchiolitis but the frequency of emergency department services, hospitalization, and mechanical ventilation, reportedly required was similar. Longer-term studies are needed to evaluate the benefits of COVID-19 mitigation strategies on common viruses that require critical care.

BACKGROUND: Wellness initiatives implemented by graduate medical education programs can help mitigate burnout in resident physicians. OBJECTIVE: This systematic review seeks to identify factors that impact the effectiveness of resident wellness interventions and to provide a conceptual framework to guide future interventions. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 6 electronic databases were searched in November 2019 using variations of the keywords “resident physicians,” “wellness,” and “intervention.” Peer-reviewed full-text English-language articles on controlled studies were considered for inclusion. The quality of the studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. RESULTS: The initial search disclosed 1196 articles, of which 18 studies enrolling 666 resident physicians met inclusion criteria for qualitative review. Interventions using peer support and individual meditation enhanced well-being. Effective wellness interventions also used educational theory to guide program development, surveyed participants to guide intervention design, incorporated programming into existing didactic curricula, and recruited voluntary participants. The quality of most of the included studies was poor (13 of 18, 72%) and could be improved by using standardized wellness assessments supported by validity evidence. CONCLUSIONS: This systematic review suggests that future resident wellness initiatives should focus on grounding interventions in educational theory, forging consensus on wellness instruments with validity evidence, and examining the impact of initiatives on patient outcomes. A logic model can provide a framework for designing and implementing effective wellness interventions.

This study aimed to evaluate the efficacy of a newly implemented Child Protection Alert System (CPAS) that utilizes triggering diagnoses to identify children who have been confirmed/strongly suspected as maltreated. We retrospectively reviewed electronic health records (EHRs) of 666 patients evaluated by our institution’s child protection team between 2009 and 2014. We examined each EHR for the presence of a pop-up alert, a persistent text-based visual alert, and diagnoses denoting child maltreatment. Diagnostic accuracy of the CPAS for child maltreatment identification was assessed. Of 323 patients for whom child maltreatment was confirmed/strongly suspected, 21.7% (70/323) had a qualifying longitudinal diagnosis listed. The pop-up alert fired in 14% of cases (45/323) with a sensitivity and specificity of 13.9% (95% CI [10.4%, 18.2%]) and 100% (95% CI [98.9%, 100.0%]), respectively. The text-based visual alert displayed in 44 of 45 cases. The CPAS is a novel simple way to support clinical decision-making to identify and protect children at risk of (re)abuse. This study highlights multiple barriers that must be overcome to effectively design and implement a CPAS to protect at-risk children.

Objective Electronic health records (EHR) have largely replaced paper-based medical records. Academic institutions have adapted EHR successfully and technological innovations now allow remote access. Thus, self-reported resident duty hours may not accurately reflect the actual time that is spent on patient care-related activities. Methods This retrospective observational study quantified vascular surgery resident EHR activities between January 2016 and June 2016 at a tertiary care hospital. Use time was tracked from user login to logout, divided by day of the week, and separated by EHR tasks performed. Each 24-hour time period was further divided into on-duty (6:00 am to 6:00 pm ) and off-duty (6:00 pm to 6:00 am ) hours. On-call weekdays and rotations that occurred off campus were excluded. The following EHR activity data were requested: total time, chart review time, documentation time, electronic order entry, patient discovery, and electronic messages. Results A total of 11,812 charts were accessed: 80.5% on weekdays and 19.5% on weekends. Total time spent (hours:minutes:seconds, weekday percentage, weekend percentage) on EHR during this time period was 634:33:36 (81.2%, 18.8%). On weekdays, 79% of the EHR time was during the work hours and 21% after hours. On weekends, 78% of the EHR time was during work hours and 22% after hours. Time spent on different EHR tasks was as follows: chart review 278:58:34, documentation 66:33:07, electronic order entry 120:50:24, electronic messaging 2:16:48, problem list modification 1:49:26, electronic messages 4:30:43, patient discovery 151:14:53, and other 164:05:17. Overall, postgraduate year 1 residents spent the most number of hours on EHRs and during the weekdays. There was serial decrease in the total number of EHR hours and the number of weekday hours with the seniority of the residents, with postgraduate year 5 residents spending the least number of overall hours and weekday hours on the EHR. When EHR access was compared with self-reported duty hours, resident compliance was 58% on average. Conclusions EHR use after hours constituted one-fifth of a vascular surgical trainee's total EHR time. Despite self-reported duty-hour compliance, a good proportion of their daily time is still spent on patient care. This pilot study sets the stage for larger studies to be conducted in future to address this issue.

BACKGROUND AND OBJECTIVES: Coronavirus disease 2019 (COVID-19) is associated with pulmonary embolism in adults, but the clinical circumstances surrounding its presence are unknown in children. The objectives of this study are to determine the prevalence of pulmonary embolism in pediatric subjects with COVID-19, evaluate patient characteristics, and describe treatments applied. METHODS: We performed a retrospective cohort study using TriNetX electronic health record data of subjects aged RESULTS: During the study period, 24 723 pediatric subjects were reported to have a COVID-19 infection diagnosis among 41 health care organizations, of which 693 (2.8%) were hospitalized. Eight subjects (0.03% overall and 1.2% of hospitalized patients) were diagnosed with pulmonary embolism. The median age (25th to 75th percentile) of patients diagnosed with pulmonary embolism was 16.5 years, and median (25th to 75th percentile) BMI was 22.1 (19.6–47.9). Three (37.5%) received critical care services, and 1 (12.5%) underwent mechanical ventilation. Five (62.5%) subjects had potentially significant risk factors (obesity, malignancy, recent surgery, and oral contraceptive use). All patients received anticoagulation, but none underwent thrombolysis. There were no reported deaths. CONCLUSIONS: Although pulmonary embolism is diagnosed less commonly in children than in adults, its occurrence appears to be more frequent in children hospitalized with COVID-19, as compared with previous reports in hospitalized children in general. All patients survived, with only 1 requiring mechanical ventilation.

Objectives To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. Design Multicenter time-series study. Setting PICUs in the United States. Patients All patients received tracheal intubations in ICUs. Interventions We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. Measurements and main results The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). Conclusions Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has resulted in the suspension of our pediatric clerkship, which may result in medical student skill erosion due to lack of patient contact. Our clerkship has developed and assessed the feasibility of implementing a video-recorded oral presentation assignment and formative assessment centered on virtual case-based modules. Methods This retrospective study examined the feasibility of providing a remote formative assessment of third-year medical student video-recorded oral presentation submissions centered on virtual case-based modules over a one-week time period after pediatric clerkship suspension (March 16th to 20th, 2020). Descriptive statistics were used to assess the video length and assessment scores of the oral presentations. Results Twelve subjects were included in this study. Overall median assessment score [median score, (25th, 75th percentile)] was 5 (4,6), described as “mostly on target” per the patient presentation rating tool. Conclusion Patient-related activities during the pediatric clerkship were halted during the COVID-19 pandemic. This study demonstrated the possibility of remotely assessing oral presentation skills centered on virtual case-based modules using a patient presentation tool intended for non-virtual patients. This may prepare students for their clinical experiences when COVID-19 restrictions are lifted. Future studies are needed to determine if suspended clerkships should consider this approach.

Background The cause of a pediatric out-of-hospital cardiac arrest (OHCA) may go unexplained in the emergency department setting but can be secondary to a toxicologic etiology. It is unclear how toxicologic screens are used in the postarrest period after a pediatric OHCA. Objectives The primary objectives are to describe 1) when the toxicology screen (urine and serum) is used, 2) patient characteristics, and 3) toxicology screen results. We hypothesized that toxicology screens are frequently used but that positive results are uncommon. Methods This was a retrospective study of pediatric OHCA patients admitted to the Penn State Health Children's Hospital pediatric intensive care unit as transfers from the emergency department between January 1, 2011 and May 31, 2018. We reviewed the electronic health record and evaluated for toxicology screen completion, patient characteristics, and toxicology screen results. Results One hundred forty-one patients had a pediatric OHCA. Sixty-three (44.7%) patients did not have a toxicology screen completed. A toxicology screen had a higher completion rate for children >11 years of age (n = 26 [78.8%]; p = 0.0024), and in unwitnessed arrests (n = 48 [66.7%]; p = 0.0052). Four cases (5.1%) revealed the presence of substances that were not administered by a medical provider or were illicit. Conclusion Our study found that in pediatric OHCA, toxicologic screens were completed but were not routinely sent in our institution. There may be factors such as clinician bias or the severity of a patient's illness that impact the approach to toxicologic screening in pediatric OHCA. In addition to the history and physical examination, emergency physician and pediatric intensivists should consider routinely sending toxicologic screens to assist in uncovering any accidental or malicious explanation for the event.

Purpose: Pediatric clerkships that utilize off-campus clinical sites ensure clinical comparability by requiring completion of patient-focused tasks. Some tasks may not be attainable (especially off-campus); thus, they are not assigned. The objective of this study was to evaluate the feasibility of providing a voluntary assignment list to third-year medical students in their pediatric clerkship.Methods: This is a retrospective single-center cross-sectional analysis of voluntary assignment completion during the 2019–2020 academic year. Third-year medical students were provided a voluntary assignment list (observe a procedure, use an interpreter phone to obtain a pediatric history, ask a preceptor to critique a clinical note, and follow-up on a patient after the rotation ends). Descriptive statistics were used to assess the timing and distribution of voluntary assignment completion.Results: In total, 132 subjects (77 on the main campus, 55 off-campus) were included. Eighteen (13.6%) main-campus and 16 (12.1%) off-campus students completed at least 1 voluntary assignment. The following voluntary assignments were completed: observe a procedure (15, 11.4%), use an interpreter phone (26, 19.7%), ask a preceptor to critique a clinical note (12, 9.1%), and follow-up on a patient after the rotation ends (7, 5.3%). Off-campus students completed the assignments more often (29.1%) than on-campus students (23.4%)Conclusion: Our clerkship values specific patient-focused tasks that may enhance student development, but are not attainable at all clinical sites. When provided a voluntary assignment list, 34 out of 132 students (25.8%) completed them. Clerkships that utilize off-campus sites should consider this approach to optimize the pediatric educational experience.

During residency training, one of the tools residents learn to use is the electronic health record (EHR). The EHR contains up-to-date medical data that are crucial to the care of the patient; thus the provider must know what is pertinent, where to locate it, and how to efficiently document the data for ongoing communication of patient care. Because institutions may have different EHR vendors, EHR workflow study data are often obtained in single institutions, with a limited number of participants and specialties. Increasing our understanding of the subtleties of residents' EHR usage not only can help educators understand how residents use the EHR but also may provide information on another cognitive factor to assess residents' performance. This, however, will only occur when EHR skills are considered an important part of residency training and we ask our EHR vendors to help us develop validated electronic tools to assess EHR performance.

Background/Objective Pediatric brain death determination (BDD) can be subject to interprovider variability of documentation, resulting in diagnosis credibility. The aim of this study was to describe our approach to assessing pediatric BDD documentation and documentation variation in the electronic health record (EHR). Methods This was a single institution cross-sectional review of pediatric patients younger than 18 years determined to meet brain death criteria. We assessed electronic documentation and evaluated for the presence of contributing factors that can interfere with the brain death documentation based on our institutional brain death evaluation policy (core body temperature, systolic blood pressure within an acceptable range, sedative/analgesic drug effects, and neuromuscular blockade). Results In total, 33 pediatric brain death patients were identified. This review revealed pediatric BDD documentation consistency (n, %) as follows: performance of the first pediatric brain death clinical examination with temperature above 36°C (27, 81.8%), systolic blood pressure above the defined range (29, 87.9%), more than 24 hours following admission (28, 84.8%); performance of the second pediatric brain death clinical examination with temperature above 36°C (32, 97%), more than 12 hours following the first examination (26, 89.7%); and ensuring sedative infusions were discontinued within the recommended cutoff period prior to pediatric BDD (28, 84.8%). Clinical neurologic examinations were fully documented. Conclusions Pediatric BDD is a rare process subject to documentation omissions and error. Our findings highlight the variability of pediatric BDD electronic documentation among different providers and specialties at our institution. An approach to improving pediatric BDD documentation may start with completing a standardized electronic brain death document.

As of July 2013, pediatric resident trainee guidelines in the United States no longer require proficiency in nonneonatal tracheal intubation. We hypothesized that laryngoscopy by pediatric residents has decreased over time, with a more pronounced decrease after this guideline change.Prospective cohort study.Twenty-five PICUs at various children's hospitals across the United States.Tracheal intubations performed in PICUs from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children).None.Prospective cohort study in which all primary tracheal intubations occurring in the United States from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children) were analyzed. Participating PICU leaders were also asked to describe their local airway management training for residents. Resident participation trends over time, stratified by presence of a Pediatric Critical Care Medicine fellowship and airway training curriculum for residents, were described. A total of 9,203 tracheal intubations from 25 PICUs were reported. Pediatric residents participated in 16% of tracheal intubations as first laryngoscopists: 14% in PICUs with a Pediatric Critical Care Medicine fellowship and 34% in PICUs without one (p0.001). Resident participation decreased significantly over time (3.4% per year; p0.001). The decrease was significant in ICUs with a Pediatric Critical Care Medicine fellowship (p0.001) but not in ICUs without one (p = 0.73). After adjusting for site-level clustering, patient characteristics, and Pediatric Critical Care Medicine fellowship presence, the Accreditation Council for Graduate Medical Education guideline change was not associated with lower participation by residents (odds ratio, 0.86; 95% CI, 0.59-1.24; p = 0.43). The downward trend of resident participation was similar regardless of the presence of an airway curriculum for residents.Laryngoscopy by pediatric residents has substantially decreased over time. This downward trend was not associated with the 2013 Accreditation Council for Graduate Medical Education change in residency requirements.

OBJECTIVES Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. DESIGN Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). SETTING Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. PATIENTS Children with medical or surgical cardiac disease who underwent intubation in an ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002). CONCLUSIONS In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.A multicenter retrospective cohort study.Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.Primary tracheal intubation in children younger than 18 years.None.Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p0.001), whereas colorimetry use decreased (0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.International PICUs.Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p0.001).In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

Objective:Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs.Design:Retrospective

Atwo-month-old female presented to the local emergency department with respiratory distress in the setting of a three-day history of febrile illness with symptoms of an upper respiratory infection. During initial evaluation, she was noted to be lethargic, tachycardic, and tachypneic.

Purpose Residents collect information from the electronic health record (EHR) to present during rounds, but this crucial process is understudied. The purpose of this paper is to examine the feasibility of utilizing an EHR embedded time-tracking software to quantify resident pre-round EHR activity and how patient acuity impacts this activity. Design/methodology/approach This was a retrospective observational study that quantified resident EHR activities (total time spent, tasks performed and patient encounters accessed) during pre-rounds on their pediatric intensive care unit rotation between May 2016 and December 2016. Patient encounters were reviewed to determine resident ownership and critical care resources provided. Findings Allo 21 eligible participants were included. In total, 907 patient encounters were included to evaluate patient acuity impact. EHR usage per patient encounter (median in minutes (25th, 75th percentile)) was significantly affected by the critical care resources utilized. Total EHR time: both ventilator and vasoactive support (10.54 (6.68, 17.19)); neither ventilator nor vasoactive support (8.23 (5.07, 12.72)); invasive/noninvasive ventilator support (8.74 (5.69, 13.2)); and vasoactive support (10.37 (7.72, 11.65)), p Practical implications Residents spend more time utilizing the EHR to collect data on patients who require significant critical care resources. This information can be useful to determine optimal resident to patient workload. Future research is required to assess this EHR tool’s ability to contribute to physician workflow study. Originality/value EHR embedded time-tracking software can offer insights into resident workflow.