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1. Mixed-methods approach to understanding clinician macrocognition in the design of a clinical decision support tool: a study protocol

Author

Patricia Trbovich, Azadeh Assadi, and Peter Laussen

Subjects
Medicine
Abstract

IntroductionThe anatomic variants of congenital heart disease (CHD) are multiple. The increased survival of these patients and disposition into communities has led to an increase in their acute presentation to non-CHD experts in primary care clinics and emergency departments. Given the vulnerability and fragility of these patients in the face of acute illness, new clinical decision support systems (CDSS) are urgently needed to better translate the best practice recommendations for the care of these patients. This study aims to understand the perceived confidence and macrocognitive processes of non-CHD experts (emergency medicine physicians) and CHD experts (paediatric cardiac intensivists) when treating children with CHD during acute illness and apply this to optimise the design of a CDSS (MyHeartPass™) for these patients.Methods and analysisThe first phase of the study involves a survey of non-CHD experts and CHD experts to understand their perceived confidence as it relates to treating acutely ill patients with CHD. The second phase is a qualitative cognitive task analysis using critical decision method to characterise and compare the macrocognitive processes used by non-CHD experts and CHD experts during the critical decision making. In phases 3 and 4, heuristic evaluation and usability testing of the CDSS will be completed. These results will be used to inform design changes to the chosen CDSS (MyHeartPass™). In the final phase, a within-participant simulation design will be used to study the effect of the CDSS on clinical decision making compared with baseline (without use of CDSS).Ethics and disseminationEthics approval from The Hospital for Sick Children in Toronto, Ontario, Canada has been obtained for all phases. Results will be published in peer-reviewed journals and presented at relevant conferences. On successful completion of these studies, it is anticipated that there will be a controlled implementation of the redesigned CDSS.

Published
2020
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2. Usability of data integration and visualization software for multidisciplinary pediatric intensive care: a human factors approach to assessing technology

Author

Ying Ling Lin, Anne-Marie Guerguerian, Jessica Tomasi, Peter Laussen, and Patricia Trbovich

Subjects
Computer applications to medicine. Medical informatics, R858-859.7
Abstract

Abstract Background Intensive care clinicians use several sources of data in order to inform decision-making. We set out to evaluate a new interactive data integration platform called T3™ made available for pediatric intensive care. Three primary functions are supported: tracking of physiologic signals, displaying trajectory, and triggering decisions, by highlighting data or estimating risk of patient instability. We designed a human factors study to identify interface usability issues, to measure ease of use, and to describe interface features that may enable or hinder clinical tasks. Methods Twenty-two participants, consisting of bedside intensive care physicians, nurses, and respiratory therapists, tested the T3™ interface in a simulation laboratory setting. Twenty tasks were performed with a true-to-setting, fully functional, prototype, populated with physiological and therapeutic intervention patient data. Primary data visualization was time series and secondary visualizations were: 1) shading out-of-target values, 2) mini-trends with exaggerated maxima and minima (sparklines), and 3) bar graph of a 16-parameter indicator. Task completion was video recorded and assessed using a use error rating scale. Usability issues were classified in the context of task and type of clinician. A severity rating scale was used to rate potential clinical impact of usability issues. Results Time series supported tracking a single parameter but partially supported determining patient trajectory using multiple parameters. Visual pattern overload was observed with multiple parameter data streams. Automated data processing using shading and sparklines was often ignored but the 16-parameter data reduction algorithm, displayed as a persistent bar graph, was visually intuitive. However, by selecting or automatically processing data, triggering aids distorted the raw data that clinicians use regularly. Consequently, clinicians could not rely on new data representations because they did not know how they were established or derived. Conclusions Usability issues, observed through contextual use, provided directions for tangible design improvements of data integration software that may lessen use errors and promote safe use. Data-driven decision making can benefit from iterative interface redesign involving clinician-users in simulated environments. This study is a first step in understanding how software can support clinicians’ decision making with integrated continuous monitoring data. Importantly, testing of similar platforms by all the different disciplines who may become clinician users is a fundamental step necessary to understand the impact on clinical outcomes of decision aids.

Published
2017
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3. Bedside functional brain imaging in critically-ill children using high-density EEG source modeling and multi-modal sensory stimulation

Author

Danny Eytan, Elizabeth W. Pang, Sam M. Doesburg, Vera Nenadovic, Bojan Gavrilovic, Peter Laussen, and Anne-Marie Guerguerian

Subjects
Bedside cerebral function, Children, Brain injury, Electroencephalography (EEG), Evoked potentials, Neuroimaging, Pediatrics, Computer applications to medicine. Medical informatics, R858-859.7, Neurology. Diseases of the nervous system, RC346-429
Abstract

Acute brain injury is a common cause of death and critical illness in children and young adults. Fundamental management focuses on early characterization of the extent of injury and optimizing recovery by preventing secondary damage during the days following the primary injury. Currently, bedside technology for measuring neurological function is mainly limited to using electroencephalography (EEG) for detection of seizures and encephalopathic features, and evoked potentials. We present a proof of concept study in patients with acute brain injury in the intensive care setting, featuring a bedside functional imaging set-up designed to map cortical brain activation patterns by combining high density EEG recordings, multi-modal sensory stimulation (auditory, visual, and somatosensory), and EEG source modeling. Use of source-modeling allows for examination of spatiotemporal activation patterns at the cortical region level as opposed to the traditional scalp potential maps. The application of this system in both healthy and brain-injured participants is demonstrated with modality-specific source-reconstructed cortical activation patterns. By combining stimulation obtained with different modalities, most of the cortical surface can be monitored for changes in functional activation without having to physically transport the subject to an imaging suite. The results in patients in an intensive care setting with anatomically well-defined brain lesions suggest a topographic association between their injuries and activation patterns. Moreover, we report the reproducible application of a protocol examining a higher-level cortical processing with an auditory oddball paradigm involving presentation of the patient's own name. This study reports the first successful application of a bedside functional brain mapping tool in the intensive care setting. This application has the potential to provide clinicians with an additional dimension of information to manage critically-ill children and adults, and potentially patients not suited for magnetic resonance imaging technologies.

Published
2016
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7. Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary

Author

Melania M. Bembea, Michael Agus, Ayse Akcan-Arikan, Peta Alexander, Rajit Basu, Tellen D. Bennett, Desmond Bohn, Leonardo R. Brandão, Ann-Marie Brown, Joseph A. Carcillo, Paul Checchia, Jill Cholette, Ira M. Cheifetz, Timothy Cornell, Allan Doctor, Michelle Eckerle, Simon Erickson, Reid W.D. Farris, E. Vincent S. Faustino, Julie C. Fitzgerald, Dana Y. Fuhrman, John S. Giuliano, Kristin Guilliams, Michael Gaies, Stephen M. Gorga, Mark Hall, Sheila J. Hanson, Mary Hartman, Amanda B. Hassinger, Sharon Y. Irving, Howard Jeffries, Philippe Jouvet, Sujatha Kannan, Oliver Karam, Robinder G. Khemani, Niranjan Kissoon, Jacques Lacroix, Peter Laussen, Francis Leclerc, Jan Hau Lee, Stephane Leteurtre, Katie Lobner, Patrick J. McKiernan, Kusum Menon, Paul Monagle, Jennifer A. Muszynski, Folafoluwa Odetola, Robert Parker, Nazima Pathan, Richard W. Pierce, Jose Pineda, Jose M. Prince, Karen A. Robinson, Courtney M. Rowan, Lindsay M. Ryerson, L. Nelson Sanchez-Pinto, Luregn J. Schlapbach, David T. Selewski, Lara S. Shekerdemian, Dennis Simon, Lincoln S. Smith, James E. Squires, Robert H. Squires, Scott M. Sutherland, Yves Ouellette, Michael C. Spaeder, Vijay Srinivasan, Marie E. Steiner, Robert C. Tasker, Ravi Thiagarajan, Neal Thomas, Pierre Tissieres, Chani Traube, Marisa Tucci, Katri V. Typpo, Mark S. Wainwright, Shan L. Ward, R. Scott Watson, Scott Weiss, Jane Whitney, Doug Willson, James L. Wynn, Nadir Yeyha, and Jerry J. Zimmerman

Subjects
Evidence-Based Medicine, Critical Care, Organ Dysfunction Scores, Critical Illness, Multiple Organ Failure, Pediatrics, Perinatology and Child Health, Humans, Child, Article
Abstract

Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.

Published
2022
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8. Advancing Health Equity and Inclusion in an Academic Pediatric Medical Center: Priorities Addressed and Lessons Learned

Author

Valerie L. Ward, Michele M. Garvin, Ashley B. Tartarilla, Melicia Whitley, Amanda Grice, Patrice Melvin, Snehal N. Shah, Sabra Katz-Wise, Lois K. Lee, Paul A. Rufo, Ravi R. Thiagarajan, Peter Laussen, Sandra L. Fenwick, and Kevin B. Churchwell

Abstract

To provide optimal, equitable care to patients, hospital systems must have intentional efforts to advance health equity. We present both intentional and actionable steps that our senior executive leadership prioritized to improve the health equity of the children and families we serve and to create a more inclusive working and learning environment for our employees, staff, faculty and trainees in our academic pediatric medical center. The four key concepts or lessons learned that we found essential to successfully advancing and sustaining equity, diversity, and inclusion (EDI) in our academic pediatric medical center were to: 1) Prioritize the strategy for EDI at the levels of the Board of Trustees and senior executive hospital leadership, 2) Collaborate with multi-disciplinary departments, offices, programs, and subject matter experts, 3) Take an Academic Approach by creating educational initiatives and scholarship in EDI, and (4) Commit to intentionality and accountability in the work by developing and tracking metrics for EDI and health equity safety disparities. Our hospital’s approach to its EDI goals and initiatives can serve as a roadmap for other academic medical centers and healthcare organizations in their efforts to improve health equity for all patients, families, and communities.

Published
2023
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10. Cardiovascular Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

Author

Peta M.A. Alexander, Paul A. Checchia, Lindsay M. Ryerson, Desmond Bohn, Michelle Eckerle, Michael Gaies, Peter Laussen, Howard Jeffries, Ravi R. Thiagarajan, Lara Shekerdemian, Melania M. Bembea, Jerry J. Zimmerman, Niranjan Kissoon, University of Zurich, and Alexander, Peta M A

Subjects
10036 Medical Clinic, Cardiovascular Diseases, Organ Dysfunction Scores, Critical Illness, Multiple Organ Failure, Pediatrics, Perinatology and Child Health, Humans, 610 Medicine & health, 2735 Pediatrics, Perinatology and Child Health, Child, Cardiovascular System, Article
Abstract

CONTEXT Cardiovascular dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE We aim to derive an evidence-informed, consensus-based definition of cardiovascular dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 using medical subject heading terms and text words to define concepts of cardiovascular dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if they evaluated critically ill children with cardiovascular dysfunction and assessment and/or scoring tools to screen for cardiovascular dysfunction and assessed mortality, functional status, organ-specific, or other patient-centered outcomes. Studies of adults, premature infants (≤36 weeks gestational age), animals, reviews and/or commentaries, case series (sample size ≤10), and non–English-language studies were excluded. Studies of children with cyanotic congenital heart disease or cardiovascular dysfunction after cardiopulmonary bypass were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form, along with risk-of-bias assessment by a task force member. RESULTS Cardiovascular dysfunction was defined by 9 elements, including 4 which indicate severe cardiovascular dysfunction. Cardiopulmonary arrest (>5 minutes) or mechanical circulatory support independently define severe cardiovascular dysfunction, whereas tachycardia, hypotension, vasoactive-inotropic score, lactate, troponin I, central venous oxygen saturation, and echocardiographic estimation of left ventricular ejection fraction were included in any combination. There was expert agreement (>80%) on the definition. LIMITATIONS All included studies were observational and many were retrospective. CONCLUSIONS The Pediatric Organ Dysfunction Information Update Mandate panel propose this evidence-informed definition of cardiovascular dysfunction.

Published
2022

11. Risk factors for hospital morbidity and mortality after the Norwood procedure: A report from the Pediatric Heart Network Single Ventricle Reconstruction trial

Author

Sarah, Tabbutt, Nancy, Ghanayem, Chitra, Ravishankar, Lynn A, Sleeper, David S, Cooper, Deborah U, Frank, Minmin, Lu, Christian, Pizarro, Peter, Frommelt, Caren S, Goldberg, Eric M, Graham, Catherine Dent, Krawczeski, Wyman W, Lai, Alan, Lewis, Joel A, Kirsh, Lynn, Mahony, Richard G, Ohye, Janet, Simsic, Andrew J, Lodge, Ellen, Spurrier, Mario, Stylianou, Peter, Laussen, and Catherine L, Webb

Subjects
Time Factors, medicine.medical_treatment, Respiratory System, Kaplan-Meier Estimate, Cardiorespiratory Medicine and Haematology, Cardiovascular, Hypoplastic left heart syndrome, law.invention, Pediatric Heart Network Investigators, Congenital, Postoperative Complications, law, Risk Factors, Hypoplastic Left Heart Syndrome, Infant Mortality, Ventricular Function, Hospital Mortality, Prospective Studies, Prospective cohort study, Heart Defects, Pediatric, Heart Disease, Treatment Outcome, Patient Safety, Risk assessment, Cardiology and Cardiovascular Medicine, 6.4 Surgery, Pulmonary and Respiratory Medicine, Heart Defects, Congenital, medicine.medical_specialty, Heart Ventricles, Clinical Sciences, Norwood Procedures, Risk Assessment, Disease-Free Survival, Article, Clinical Research, medicine, Cardiopulmonary bypass, Extracorporeal membrane oxygenation, Humans, Cardiopulmonary resuscitation, Risk factor, Blalock-Taussig Procedure, Proportional Hazards Models, business.industry, Prevention, Hemodynamics, Infant, Newborn, Infant, Evaluation of treatments and therapeutic interventions, Perinatal Period - Conditions Originating in Perinatal Period, Length of Stay, Newborn, medicine.disease, Surgery, Good Health and Well Being, Multivariate Analysis, North America, Norwood procedure, business
Abstract

ObjectivesWe sought to identify risk factors for mortality and morbidity during the Norwood hospitalization in newborn infants with hypoplastic left heart syndrome and other single right ventricle anomalies enrolled in the Single Ventricle Reconstruction trial.MethodsPotential predictors for outcome included patient- and procedure-related variables and center volume and surgeon volume. Outcome variables occurring during the Norwood procedure and before hospital discharge or stage II procedure included mortality, end-organ complications, length of ventilation, and hospital length of stay. Univariate and multivariable Cox regression analyses were performed with bootstrapping to estimate reliability for mortality.ResultsAnalysis included 549 subjects prospectively enrolled from 15 centers; 30-day and hospital mortality were 11.5% (63/549) and 16.0% (88/549), respectively. Independent risk factors for both 30-day and hospital mortality included lower birth weight, genetic abnormality, extracorporeal membrane oxygenation (ECMO) and open sternum on the day of the Norwood procedure. In addition, longer duration of deep hypothermic circulatory arrest was a risk factor for 30-day mortality. Shunt type at the end of the Norwood procedure was not a significant risk factor for 30-day or hospital mortality. Independent risk factors for postoperative renal failure (n=46), sepsis (n=93), increased length of ventilation, and hospital length of stay among survivors included genetic abnormality, lower center/surgeon volume, open sternum, and post-Norwood operations.ConclusionsInnate patient factors, ECMO, open sternum, and lower center/surgeon volume are important risk factors for postoperative mortality and/or morbidity during the Norwood hospitalization.

Published
2011

12. Cardiac Intensive Care

Author

M.P.H. Medical Stephen J. Roth M.D. and C Peter Laussen M.B.B.S.

Subjects
medicine.medical_specialty, business.industry, Intensive care, Medicine, business, Intensive care medicine
Published
2009
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13. Contributors

Author

P. David Adelson, David B. Allen, Estella M. Alonso, Gülay Pinar Alper, Derek C. Angus, Sidney Anthone, Andrew Argent, John H. Arnold, Barbara Bambach, Hülya Bayir, Pierre Beaulieu, Laurie O. Beitz, Jorge R. Beltrán, Wade W. Benton, Robert A. Berg, Ira Bergman, Julie Blatt, Douglas L. Blowey, Jeffrey L. Blumer, John S. Bradley, Barbara W. Brandom, Martin L. Brecher, Richard J. Brilli, Guy F. Brisseau, Thomas V. Brogan, Timothy E. Bunchman, Sean P. Bush, Joseph Carcillo, Aaron L. Carrel, Hector Carrillo-Lopez, Victoria Cartwright, Hugo F. Carvajal, Leticia Castillo, Michael G. Caty, Pelin Cengiz, Anthony C. Chang, John R. Charpie, Adrián Chávez, Russell W. Chesney, Michael A. Cimino, Robert S.B. Clark, Jacqueline J. Coalson, D. Ryan Cook, Craig M. Coopersmith, Christopher P. Coppola, Seth J. Corey, Peter N. Cox, Kathleen Culver, James J. Cummings, Martha A.Q. Curley, Marek Czosnyka, Heidi J. Dalton, Stéphane Dauger, Peter J. Davis, Jenina Deshler, Sonny Dhanani, Rhonda M. Dick, Emily L. Dobyns, Elizabeth J. Donner, Didier Dreyfuss, Philippe Durand, Susan Duthie, Richard G. Ellenbogen, Jacqueline Evans, James C. Fackler, Kathryn Felmet, Jeffrey R. Fineman, Debra H. Fiser, Frank A. Fish, James E. Fletcher, J. Julio Pérez Fontán, Michael L. Forbes, Norman Fost, Joel E. Frader, Deborah Franzon, F. Jay Fricker, Aaron L. Friedman, Bradley P. Fuhrman, France Gauvin, Eli Gilad, James C. Gilbert, Brett P. Giroir, Stuart L. Goldstein, James Graham, Jerril W. Green, Thomas P. Green, Stephanie Greene, James A. Griffith, Mauro Grossi, Björn Gunnarsson, Scott A. Hagen, Cecil D. Hahn, Craig Hallstrom, Yong Y. Han, Cary O. Harding, William G. Harmon, Eric Harry, Mary E. Hartman, Christopher Heard, Lynn Hernan, Mark J. Heulitt, Robert W. Hickey, Julien I.E. Hoffman, Karen T. Hofmann, Gregory A. Hollman, James C. Huhta, Hector E. James, David Jardine, Alberto Jarillo, Etienne Javouey, James A. Johns, Kristin K. Johnson, Michael V. Johnston, Deborah P. Jones, Prashant Joshi, Prince J. Kannankeril, Robert K. Kanter, John A. Kellum, Michael Kelly, Patrick M. Kochanek, Samuel A. Kocoshis, Thomas J. Kulik, Vasanth H. Kumar, Jacques Lacroix, Yichen Lai, Joanne M. Langley, Stanley T. Lau, Peter Laussen, Yi-Horng Lee, Mary W. Lieh-Lai, D. Michael Lindsay, Catherine Litalien, Naomi L.C. Luban, Robert E. Lynch, Frank Maffei, James P. Marcin, Mary Michele Mariscalco, Barry P. Markovitz, Lynn D. Martin, Anne G. Matlow, John E. Mayer, Paula Mazur, E. Dean McKenzie, Gwenn E. McLaughlin, Nilesh Mehta, Renuka Mehta, Ann J. Melvin, Jean-Christophe Mercier, Kelly Michelson, Kelly A. Michienzi, Patricia A. Moloney-Harmon, Frederick C. Morin, Michele Moss, Vinay Nadkarni, Carol E. Nicholson, Victoria F. Norwood, Daniel Notterman, Alan Nugent, Peter Oishi, Victor Olivar, Richard A. Orr, Yves Ouellette, Daiva Parakininkas, Margaret M. Parker, Anthony L. Pearson-Shaver, Mary Jane F. Petruzzi, Maury N. Pinsk, Murray M. Pollack, Steven Pon, Alice Pong, Lara Primak, Audra Prince, Jean-Damien Ricard, Tom B. Rice, Gail E. Richards, Debra Ann Ridling, Joan Roberts, Kimberly Roth, Alexandre T. Rotta, Daniel Rubens, Jeffrey S. Rubenstein, Christopher M. Rubino, Randall Ruppel, Peter J. Safar, Ashok P. Sarnaik, Joel B. Sarner, Georges Saumon, Matthew C. Scanlon, Kenneth Schenkman, Stephen M. Schexnayder, Charles L. Schleien, Timothy A. Sentongo, Thomas P. Shanley, Frank Shann, Dennis W.W. Shaw, Sam D. Shemie, Peter Skippen, Anthony D. Slonim, Laurie Smith, Lincoln Smith, David M. Steinhorn, Waldemar E. Storm, Marc Sturgill, Marianne T. Sweetser, Jordan M. Symons, Robert C. Tasker, Ann E. Thompson, Ann Henderson Tilton, Nicole H. Tobin, I. David Todres, Peter Trinkaus, David J. Vaughan, Shekhar T. Venkataraman, Rapheus C.Q. Villanueva, Patricia C. Wankum, R. Scott Watson, Wayne R. Waz, Carl G.M. Weigle, Maria B. Weimer, Ed Weinberger, David L. Wessel, William T. West, Randall C. Wetzel, Dale Whitby, Hector R. Wong, Ellen G. Wood, Alan D. Woolf, James Woytash, Ofer Yanay, Arno Zaritsky, Danielle M. Zerr, and Jerry J. Zimmerman

Published
2006
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14. Joint Statement on Mechanical Circulatory Support in Children

Author

Graeme, MacLaren, Ali, Dodge-Khatami, Heidi J, Dalton, Iki, Adachi, Melvin, Almodovar, Gail, Annich, Robert, Bartlett, Ronald, Bronicki, Katherine, Brown, Warwick, Butt, David, Cooper, Markus, Demuth, Yves, D'Udekem, Charles, Fraser, Anne-Marie, Guerguerian, Micheal, Heard, Steven, Horton, Rebecca, Ichord, Robert, Jaquiss, Peter, Laussen, Laurance, Lequier, Song, Lou, Bradley, Marino, Michael, McMullan, Mark, Ogino, Giles, Peek, Rene, Pretre, Mark, Rodefeld, Alicia, Schmidt, Steven, Schwartz, Lara, Shekerdemian, Nobuaki, Shime, Ben, Sivarajan, Brigitte, Stiller, and Ravi, Thiagarajan

Subjects
medicine.medical_specialty, Critical Care, Statement (logic), medicine.medical_treatment, MEDLINE, Advanced Cardiac Life Support, Critical Care and Intensive Care Medicine, Pediatrics, Extracorporeal, Extracorporeal Membrane Oxygenation, Intensive care, Extracorporeal membrane oxygenation, Humans, Medicine, Child, Intensive care medicine, Societies, Medical, business.industry, Extramural, Advanced cardiac life support, medicine.disease, Life support, Pediatrics, Perinatology and Child Health, Heart-Assist Devices, Medical emergency, business
Published
2013
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