New Morbidities During Critical Illness and Associated Risk of ICU Readmission: Virtual Pediatric Systems Cohort, 2017-2020

OBJECTIVES

To describe change in Functional Status Scale (FSS) associated with critical illness and assess associated development of new morbidities with PICU readmission.

DESIGN

Retrospective, cross-sectional cohort study using the Virtual Pediatric Systems (VPS; Los Angeles, CA) database.

SETTING

One hundred twenty-six U.S. PICUs participating in VPS.

SUBJECTS

Children younger than 21 years old admitted 2017-2020 and followed to December 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 40,654 patients, 86.2% were classified as having good function or mild dysfunction before illness. Most patients did not have a change in their FSS category during hospitalization. Survival with new morbidity occurred most in children with baseline good/mild dysfunction (8.7%). Hospital mortality increased across categories of baseline dysfunction. Of 39,701 survivors, 14.2% were readmitted within 1 year. Median time to readmission was 159 days. In multivariable, mixed-effects Cox modeling, time to readmission was most associated with discharge functional status (hazard ratio [HR], 5.3 [95% CI, 4.6-6.1] for those with very severe dysfunction), and associated with lower hazard in those who survived with new morbidity (HR, 0.7 [95% CI, 0.6-0.7]).

CONCLUSIONS

Development of new morbidities occurs commonly in pediatric critical illness, but we failed to find an association with greater hazard of PICU readmission. Instead, patient functional status is associated with hazard of PICU readmission.

Codesign of remote data collection for chronic management of pediatric home mechanical ventilation

INTRODUCTION

Outpatient monitoring of children using invasive home mechanical ventilation (IHMV) is recommended, but access to care can be difficult. This study tested if remote (home-based) data collection was feasible and acceptable in chronic IHMV management.

METHODS

A codesign study was conducted with an IHMV program, home nurses, and English- and Spanish-speaking parent-guardians of children using IHMV (0-17 years; n = 19). After prototyping, parents used a remote patient monitoring (RPM) bundle to collect patient heart rate, respiratory rate (RR), oxygen saturation, end-tidal carbon dioxide (EtCO2 ), and ventilator pressure/volume over 8 weeks. User feedback was analyzed using qualitative methods and the System Usability Scale (SUS). Expected marginal mean differences within patient measures when awake, asleep, or after a break were calculated using mixed effects models.

RESULTS

Patients were a median 2.9 years old and 11 (58%) took breaks off the ventilator. RPM data were entered on a mean of 83.7% (SD ± 29.1%) weeks. SUS scores were 84.8 (SD ± 10.5) for nurses and 91.8 (SD ± 10.1) for parents. Over 90% of parents agreed/strongly agreed that RPM data collection was feasible and relevant to their child's care. Within-patient comparisons revealed that EtCO2 (break-vs-asleep 2.55 mmHg, d = 0.79 [0.42-1.15], p < .001; awake-vs-break 1.48, d = -0.49 [0.13-0.84], p = .02) and RR (break-vs-asleep 16.14, d = 2.12 [1.71-2.53], p < .001; awake-vs-break 3.44, d = 0.45 [0.10-0.04], p = .03) were significantly higher during ventilator breaks.

CONCLUSIONS

RPM data collection in children with IHMV was feasible, acceptable, and captured clinically meaningful vital sign changes during ventilator breaks, supporting the clinical utility of RPM in IHMV management.

Paying Family Medical Caregivers for Children's Home Healthcare in Colorado: A Working Medicaid Model

OBJECTIVE

To compare the characteristics and healthcare use of children with medical complexity who receive paid certified nursing assistant (CNA) care by a family member (family CNA) and by a traditional nonfamily member (nonfamily CNA).

STUDY DESIGN

This was retrospective cohort study of children who received CNA care through Colorado's Medicaid paid family caregiving program between 2017 and 2019 by a home healthcare agency. We compared patient characteristics between the family CNA and nonfamily CNA groups. A multivariable Poisson regression model was used to compare hospitalization rates (days in the hospital per year), adjusting for patient age patient sex, nursing care, and complex chronic condition.

RESULTS

Of 861 patients, 79% (n = 680) received family CNA care and 21% (n = 181) received nonfamily CNA care. Patient demographics and hospitalization did not differ between the groups, although patients who had family CNAs were less likely to receive additional nursing-level care (42% vs 60%, P < .01). Family and nonfamily CNA caregivers had similar characteristics, except that family CNA caregivers had substantially better 3-year retention (82% vs 9%, P < .01) despite lower average hourly pay ($14.60 vs $17.60 per hour, P < .01). Hospitalizations were rare (<10% of patients). In the adjusted model, patients who received family CNA care experienced 1 more hospitalized day per year, compared with patients who received nonfamily CNA care (P < .001).

CONCLUSIONS

Paid family caregivers provided CAN-level care to children with medical complexity with a greater employee retention compared with nonfamily CNA caregivers, with marginally different hospitalization rates using a family-centered approach. This model may help address workforce shortages while also providing income to family caregivers.

Child Opportunity Index and Emergent PICU Readmissions: A Retrospective, Cross-Sectional Study of 43 U.S. Hospitals

OBJECTIVES

To examine the association between a validated composite measure of neighborhood factors, the Child Opportunity Index (COI), and emergent PICU readmission during the year following discharge for survivors of pediatric critical illness.

DESIGN

Retrospective cross-sectional study.

SETTING

Forty-three U.S. children's hospitals contributing to the Pediatric Health Information System administrative dataset.

PATIENTS

Children (< 18 yr) with at least one emergent PICU admission in 2018-2019 who survived an index admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 78,839 patients, 26% resided in very low COI neighborhoods, 21% in low COI, 19% in moderate COI, 17% in high COI, and 17% in very high COI neighborhoods, and 12.6% had an emergent PICU readmission within 1 year. After adjusting for patient-level demographic and clinical factors, residence in neighborhoods with moderate, low, and very low COI was associated with increased odds of emergent 1-year PICU readmission relative to patients in very high COI neighborhoods. Lower COI levels were associated with readmission in diabetic ketoacidosis and asthma. We failed to find an association between COI and emergent PICU readmission in patients with an index PICU admission diagnosis of respiratory conditions, sepsis, or trauma.

CONCLUSIONS

Children living in neighborhoods with lower child opportunity had an increased risk of emergent 1-year readmission to the PICU, particularly children with chronic conditions such as asthma and diabetes. Assessing the neighborhood context to which children return following critical illness may inform community-level initiatives to foster recovery and reduce the risk of adverse outcomes.

Machine learning models to predict and benchmark PICU length of stay with application to children with critical bronchiolitis

OBJECTIVE

To create models for prediction and benchmarking of pediatric intensive care unit (PICU) length of stay (LOS) for patients with critical bronchiolitis.

HYPOTHESIS

We hypothesize that machine learning models applied to an administrative database will be able to accurately predict and benchmark the PICU LOS for critical bronchiolitis.

DESIGN

Retrospective cohort study.

PATIENTS

All patients less than 24-month-old admitted to the PICU with a diagnosis of bronchiolitis in the Pediatric Health Information Systems (PHIS) Database from 2016 to 2019.

METHODOLOGY

Two random forest models were developed to predict the PICU LOS. Model 1 was developed for benchmarking using all data available in the PHIS database for the hospitalization. Model 2 was developed for prediction using only data available on hospital admission. Models were evaluated using R² values, mean standard error (MSE), and the observed to expected ratio (O/E), which is the total observed LOS divided by the total predicted LOS from the model.

RESULTS

The models were trained on 13,838 patients admitted from 2016 to 2018 and validated on 5254 patients admitted in 2019. While Model 1 had superior R² (0.51 vs. 0.10) and (MSE) (0.21 vs. 0.37) values compared to Model 2, the O/E ratios were similar (1.18 vs. 1.20). Institutional median O/E (LOS) ratio was 1.01 (IQR 0.90-1.09) with wide variability present between institutions.

CONCLUSIONS

Machine learning models developed using an administrative database were able to predict and benchmark the length of PICU stay for patients with critical bronchiolitis.

Measuring Social Health Following Pediatric Critical Illness: A Scoping Review and Conceptual Framework

OBJECTIVE

Social health is an important component of recovery following critical illness as modeled in the pediatric Post-Intensive Care Syndrome framework. We conducted a scoping review of studies measuring social outcomes (measurable components of social health) following pediatric critical illness and propose a conceptual framework of the social outcomes measured in these studies.

DATA SOURCES

PubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane Registry.

STUDY SELECTION

We identified studies evaluating social outcomes in pediatric intensive care unit (PICU) survivors or their families from 1970-2017 as part of a broader scoping review of outcomes after pediatric critical illness.

DATA EXTRACTION

We identified articles by dual review and dual-extracted study characteristics, instruments, and instrument validation and administration information. For instruments used in studies evaluating a social outcome, we collected instrument content and described it using qualitative methods adapted to a scoping review.

DATA SYNTHESIS

Of 407 articles identified in the scoping review, 223 (55%) evaluated a social outcome. The majority were conducted in North America and the United Kingdom, with wide variation in methodology and population. Among these studies, 38 unique instruments were used to evaluate a social outcome. Specific social outcomes measured included individual (independence, attachment, empathy, social behaviors, social cognition, and social interest), environmental (community perceptions and environment), and network (activities and relationships) characteristics, together with school and family outcomes. While many instruments assessed more than one social outcome, no instrument evaluated all areas of social outcome.

CONCLUSIONS

The full range of social outcomes reported following pediatric critical illness were not captured by any single instrument. The lack of a comprehensive instrument focused on social outcomes may contribute to under-appreciation of the importance of social outcomes and their under-representation in PICU outcomes research. A more comprehensive evaluation of social outcomes will improve understanding of overall recovery following pediatric critical illness.

Children With Medical Complexity and Mental and Behavioral Disorders in the Emergency Department

BACKGROUND

To assess the overlap and admission or transfer rate of children with chronic complex conditions (CCC) and with mental or behavioral health (MBH) disorders among children presenting to the emergency department (ED).

METHODS

We performed a cross-sectional analysis from 2 data sources: hospitals in the Pediatric Health Information System (PHIS) and from a statewide sample (Illinois COMPdata). We included ED encounters 2 to 21 years and compared differences in admission and/or transfer between subgroups. Among patients with both a CCC and MBH, we evaluated if a primary MBH diagnosis was associated with admission or transfer.

RESULTS

There were 11 880 930 encounters in the PHIS dataset; 0.7% had an MBH and CCC, 2.2% had an MBH, and 8.0% had a CCC. Patients with an MBH and CCC had a greater need for admission or transfer (86.5%) compared with patients with an MBH alone (57.7%) or CCC alone (52.0%). Among 5 362 701 patients in the COMPdata set, 0.2% had an MBH and CCC, 2.1% had an MBH, and 3.2% had a CCC, with similar admission or transfer needs between groups (61.8% admission or transfer with CCC and MBH; 42.8% MBH alone, and 27.3% with CCC alone). Within both datasets, patients with both a MBH and CCC had a higher odds of admission or transfer when their primary diagnosis was an MBH disorder.

CONCLUSIONS

While accounting for a small proportion of ED patients, CCC with concomitant MBH have a higher need for admission or transfer relative to other patients.

Variable Identification of Children With Medical Complexity in United States PICUs

OBJECTIVES

Children with medical complexity are at increased risk for critical illness and adverse outcomes. However, there is currently no consensus definition of medical complexity in pediatric critical care research.

DESIGN

Retrospective, cross-sectional cohort study.

SETTING

One hundred thirty-one U.S. PICUs participating in the Virtual Pediatric Systems Database.

SUBJECTS

Children less than 21 years old admitted from 2017 to 2019. Multisystem complexity was identified on the basis of two common definitions of medical complexity, Pediatric Complex Chronic Conditions (CCC), greater than or equal to 2 qualifying diagnoses, and Pediatric Medical Complexity Algorithm (PMCA), complex chronic disease.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 291,583 index PICU admissions, 226,430 (77.7%) met at least one definition of multisystem complexity, including 168,332 patients identified by CCC and 201,537 by PMCA. Of these, 143,439 (63.3%) were identified by both definitions. Cohen kappa was 0.39, indicating only fair agreement between definitions. Children identified by CCC were younger and were less frequently scheduled admissions and discharged home from the ICU than PMCA. The most common reason for admission was respiratory in both groups, although this represented a larger proportion of CCC patients. ICU and hospital length of stay were longer for patients identified by CCC. No difference in median severity of illness scoring was identified between definitions, but CCC patients had higher inhospital mortality. Readmission to the ICU in the subsequent year was seen in approximately one-fifth of patients in either group.

CONCLUSIONS

Commonly used definitions of medical complexity identified distinct populations of children with multisystem complexity in the PICU with only fair agreement.

The increasing proportion of adult discharges at children's hospitals, 2004-2019

Significant medical advances now enable individuals with pediatric illnesses to survive into adulthood. Finding medical homes for these individuals often remains challenging. We utilized the Pediatric Health Information System to measure the variation in and growth of admissions to children's hospitals, stratified by age and payor from 2004 to 2019. We identified 8,097,081 patient encounters from 30 hospitals. Compared to children, adults discharged at children's hospitals are more likely to have a complex chronic condition, have a higher median cost, and have a longer median length of stay. Hospital-level adult discharges ranged from 1.9% to 10.1% (median 4.1%; interquartile range: 2.8%-5.4%). Significantly higher increases were seen in each adult age subgroup (18-20, 21-25, and >25 years old) compared to the pediatric age group (p < .001). The number of adults discharged from children's hospitals is increasing faster than children, impacting children's hospitals and the populations they serve.

Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index

OBJECTIVE

To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI).

METHODS

We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics.

RESULTS

There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n = 140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models.

CONCLUSIONS

Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.

At-home end-tidal carbon dioxide measurement in children with invasive home mechanical ventilation

BACKGROUND

Carbon dioxide concentration trending is used in chronic management of children with invasive home mechanical ventilation (HMV) in clinical settings, but options for end-tidal carbon dioxide (EtCO₂ ) monitoring at home are limited. We hypothesized that a palm-sized, portable endotracheal capnograph (PEC) that measures EtCO₂ could be adapted for in-home use in children with HMV.

METHODS

We evaluated the internal consistency of the PEC by calculating an intraclass correlation coefficient of three back-to-back breaths by children (0-17 years) at baseline health in the clinic. Pearson's correlation was calculated for PEC EtCO₂ values with concurrent mean values of in-clinic EtCO₂ and transcutaneous CO₂ (TCM) capnometers. The Bland-Altman test determined their level of agreement. Qualitative interviews and surveys assessed usability and acceptability by family-caregivers at home.

RESULTS

CO₂ values were collected in awake children in varied activity levels and positions (N = 30). The intraclass correlation coefficient for the PEC was 0.95 (p < 0.05). The correlation between the PEC and in-clinic EtCO₂ device was 0.85 with a mean difference of -3.8 mmHg and precision of ±1.1 mmHg. The correlation between the PEC and the clinic TCM device was 0.92 with a mean difference of 0.2 mmHg and precision of ±1.0. Family-caregivers (N = 10) trialed the PEC at home; all were able to obtain measurements at home while children were awake and sometimes asleep.

CONCLUSIONS

A portable, noninvasive device for measuring EtCO₂ was feasible and acceptable, with values that trend similarly to currently in-practice, outpatient models. These devices may facilitate monitoring of EtCO₂ at home in children with invasive HMV.

Development and Validation of an Integrated Suite of Prediction Models for All-Cause 30-Day Readmissions of Children and Adolescents Aged 0 to 18 Years

IMPORTANCE

Readmission is often considered a hospital quality measure, yet no validated risk prediction models exist for children.

OBJECTIVE

To develop and validate a tool identifying patients before hospital discharge who are at risk for subsequent readmission, applicable to all ages.

DESIGN, SETTING, AND PARTICIPANTS

This population-based prognostic analysis used electronic health record-derived data from a freestanding children's hospital from January 1, 2016, to December 31, 2019. All-cause 30-day readmission was modeled using 3 years of discharge data. Data were analyzed from June 1 to November 30, 2021.

MAIN OUTCOMES AND MEASURES

Three models were derived as a complementary suite to include (1) children 6 months or older with 1 or more prior hospitalizations within the last 6 months (recent admission model [RAM]), (2) children 6 months or older with no prior hospitalizations in the last 6 months (new admission model [NAM]), and (3) children younger than 6 months (young infant model [YIM]). Generalized mixed linear models were used for all analyses. Models were validated using an additional year of discharges.

RESULTS

The derivation set contained 29 988 patients with 48 019 hospitalizations; 50.1% of these admissions were for children younger than 5 years and 54.7% were boys. In the derivation set, 4878 of 13 490 admissions (36.2%) in the RAM cohort, 2044 of 27 531 (7.4%) in the NAM cohort, and 855 of 6998 (12.2%) in the YIM cohort were followed within 30 days by a readmission. In the RAM cohort, prior utilization, current or prior procedures indicative of severity of illness (transfusion, ventilation, or central venous catheter), commercial insurance, and prolonged length of stay (LOS) were associated with readmission. In the NAM cohort, procedures, prolonged LOS, and emergency department visit in the past 6 months were associated with readmission. In the YIM cohort, LOS, prior visits, and critical procedures were associated with readmission. The area under the receiver operating characteristics curve was 83.1 (95% CI, 82.4-83.8) for the RAM cohort, 76.1 (95% CI, 75.0-77.2) for the NAM cohort, and 80.3 (95% CI, 78.8-81.9) for the YIM cohort.

CONCLUSIONS AND RELEVANCE

In this prognostic study, the suite of 3 prediction models had acceptable to excellent discrimination for children. These models may allow future improvements in tailored discharge preparedness to prevent high-risk readmissions.

Demographic and Clinical Differences Between Applied Definitions of Medical Complexity

OBJECTIVES

To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals.

METHODS

We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping.

RESULTS

Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3.

CONCLUSIONS

Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.

High-Frequency Utilization of the PICU

OBJECTIVES

To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without.

DESIGN

Retrospective, cross-sectional cohort study.

SETTING

United States.

PATIENTS

Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days.

CONCLUSIONS

Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.

Assessment of Underpayment for Inpatient Care at Children's Hospitals

This cross-sectional study compares cost and payer reimbursement for hospital admissions of children and assesses associations of underpayment by patients’ demographic and clinical characteristics.

Trends in Technology Assistance Among Patients With Childhood Onset Chronic Conditions

OBJECTIVE

To describe the prevalence, types, and trends over time of medical technology assistance (TA) in patients at the age of transition to adult care with childhood onset chronic conditions (COCCs) cared for at children's hospitals.

PATIENTS AND METHODS

In this retrospective repeated annual cross-sectional cohort study of the Pediatric Health Information Systems inpatient data, patients with at least 1 hospitalization from January 1, 2008, to December 31, 2018 with a selected COCC were included. The COCCs investigated were brain and spinal cord malformation, cerebral palsy, heart and great vessel malformation, cystic fibrosis, sickle cell anemia, and chronic renal failure. TA was defined as requiring an indwelling medical device to maintain health status. Trends over time in TA were analyzed with the Cochran-Armitage test and generalized linear models.

RESULTS

During the study, 381 289 unique patients accounted for 940 816 hospitalizations. Transition-aged patients (19-21 years old) represented 2.4% of all included hospitalizations over the 11-year period, whereas patients ages 21 and above represented 2.7%. The annual proportion of patients with TA increased significantly from 31.3% in 2008 to 36.9% in 2018, a 17.9% increase (P < .001).

CONCLUSIONS

In this cohort of patients with select COCCs hospitalized at children's hospitals, a substantial and growing number of patients at the age of transition to adult care required TA. Identifying adult providers with resources to manage COCCs and maintain medical devices placed in childhood is challenging. These trends warrant special attention to support the timely and successful transition of medically complex patients from pediatric to adult care.

Analyzing Trends in the Global Surge of Coronavirus Disease 2019 Pandemic Submissions to The Journal of Pediatrics

During February to December 2020, there were 498 coronavirus disease 2019 (COVID-19) pandemic-focused brief report and original article submissions to The Journal of Pediatrics. The majority were from international authors (68.1%). Early in the pandemic, geographic origin of the corresponding author paralleled the path of COVID-19 infection both within the US and around the globe.

Impact of the Coronavirus Disease 2019 Pandemic on Authorship Gender in The Journal of Pediatrics: Disproportionate Productivity by International Male Researchers

OBJECTIVE

To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on authorship gender in articles submitted to The Journal of Pediatrics.

STUDY DESIGN

Using gender-labeling algorithms and human inspection, we inferred the gender of corresponding authors of original articles submitted in January-February and April-May of 2019 and 2020 noting those articles related to the COVID-19 pandemic. We used Pearson χ² tests to determine differences in gender proportions during the selected periods in the US and internationally.

RESULTS

We analyzed 1521 original articles. Submissions increased 10.9% from January-February 2019 to January-February 2020 and 61.6% from April-May 2019 to April-May 2020. Women accounted for 56.0% of original articles in April-May 2019 but only 49.8% of original articles in April-May 2020. Original articles focused on COVID-19 represented a small percentage of additional articles submitted in January-February 2020 (1/33 or 3.0%) and (53/199 or 26.6%) in April-May 2020 compared with the number of submissions in the same months in 2019. International male corresponding authors submitted a significantly larger proportion of original articles compared with international female corresponding authors in April-May 2020 compared to April-May 2019 (P = .043). There was no difference in corresponding author gender proportion in the US (US in April-May of 2020 vs April-May of 2019; P = .95). There was no significant difference in final dispositions based on corresponding author gender for original articles from 2019 and 2020 (P = .17).

CONCLUSIONS

Original article submissions to The Journal increased in April-May 2020, with the greatest increase by international male corresponding authors. The majority of the submission growth was not related to COVID-19.

Timing of Co-occurring Chronic Conditions in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI.

METHODS

This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity.

RESULTS

The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7-3.8), 4.6 (95% CI 4.5-4.7), and 5.1 (95% CI 5.1-5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years.

CONCLUSIONS

Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

Home nursing for children with home mechanical ventilation in the United States: Key informant perspectives

OBJECTIVES & HYPOTHESIS

Children with home mechanical ventilation (HMV) require skilled care by trained caregivers, and their families feel the impacts of ubiquitous home nursing shortages. It is unknown which factors determine allocation; no standards for private duty nursing intensity exist. We sought to characterize provider experiences with and opinions on home nursing for children with HMV, hypothesizing providers would describe frequent home nursing gaps across clinical scenarios.

METHODS

Purposeful and snowball sampling identified key informant clinical providers. Survey topics included hours of home nursing received across clinical and family scenarios. Close-ended responses were analyzed using descriptive statistics and open-ended questions coded with iterative modification for major theme agreement.

RESULTS

A total of 59 respondents represented care of patients from 44 states; 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. Nearly all (97%) believed that families should receive more hours during initial home transition, yet less than half (47%) do. The majority (80.7%) thought the presence of other children in the home should influence nursing hours, yet only three (5.3%) reported other children have influence. Across hypothetical medical technology scenarios, providers consistently described children receiving fewer nursing hours than the providers' ideal practice. A third (31.7%) described discharging patients without any home nursing arranged.

CONCLUSIONS

This HMV provider sample highlights pervasive deficiency in home nursing provision with heterogenous interpretation of what constitutes ideal home care. Family and social contextual factors are infrequently considered in nursing allocations. Provider, community health, and family stakeholders must collaborate to generate national community practice standards for children with HMV.

Comparing Software Determination of Readmission Preventability With Chart Review, Provider, and Family Assessments

OBJECTIVES

To explore the concordance between software, chart reviewer, provider, and parent perspectives when assessing whether readmissions are preventable or clinically related to the initial admission.

METHODS

Providers and parents of patients readmitted within 3 days to a tertiary children's hospital were enrolled in this single-site observational study. 3M Potentially Preventable Readmissions Grouping Software, chart reviewers, discharge and readmission providers, and parents assessed if readmissions were clinically related to the index admission or potentially preventable. Agreement between perspectives was measured by using Cohen's κ values.

RESULTS

The software found 67 of 118 (57%) clinically related readmissions; the identical 67 of 118 cases (57%) were found to be potentially preventable. Chart reviewers found 107 of 125 (86%) clinically related and 60 of 125 (47%) preventable readmissions compared to 68 of 92 (74%) and 27 of 92 (28%) for discharge physicians and 69 of 93 (74%) and 33 of 93 (34%) for readmitting physicians. Parents reported 9 of 36 (25%) preventable readmissions. Cohen κ values revealed no to minimal agreement on clinical relatedness of readmissions between software and chart reviewer, discharge provider, and readmission provider (0.12-0.20), whereas chart reviewers and providers had weak to moderate agreement with each other (0.43-0.75). There was no to minimal agreement on preventability between software and the other perspectives (-0.04 to 0.21), whereas chart reviewers and providers had minimal to weak agreement (0.27-0.56).

CONCLUSIONS

Measurement of preventable readmissions remains problematic, and using financial penalties for readmissions on the basis of software determinations may be unwise given low levels of agreement. Chart review supplemented by information from providers and families offers a more inclusive way to identify potentially preventable readmissions.

Attributable Delay of Discharge for Children with Long-Term Mechanical Ventilation

OBJECTIVE

To assess the reasons for discharge delays for children with long-term mechanical ventilation.

STUDY DESIGN

Charts of children (0-18 years of age) with a new tracheostomy in the Pulmonary Habilitation Program at the Ann and Robert H. Lurie Children's Hospital of Chicago were retrospectively reviewed for demographic information, medical diagnoses, medical stability, discharge to home, reasons for discharge delay, and hours of staffed home nursing. All patients were discharged on mechanical ventilation. Discharge delay was defined as >10 days after medical stability. Hospital charges were analyzed and excess charges quantified beginning with the date of delay. Descriptive statistics and Pearson χ² tests were used to compare nursing hours and demographics.

RESULTS

Of 72 patients, 55% were male with mean age 1.8 years (SD 3.8) at tracheostomy placement. The most common long-term mechanical ventilation indication was chronic lung disease (n = 47, 65%); 54% had discharge delays, the majority were primarily due to lack of home nursing (62%), followed by delay of caregiver training (18%), caregiver health and social issues (8%), and delay in a transitional care facility bed (8%). Of the 39 delayed patients, 10% ($13 217 889) of hospital charges occurred during excess days with a median of $186 061 (IQR $117 661-$386 905) per patient.

CONCLUSIONS

Over one-half of children discharged to the community from a large inpatient pediatric long-term mechanical ventilation program had a nonmedical delay of discharge home, most commonly because of home nurse staffing. This case series provides further evidence that limited availability of home nursing impedes efficient discharge and prolongs hospitalizations.

Chronic Medication Use in Children Insured by Medicaid: A Multistate Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Little is known about the use of chronic medications (CMs) in children. We assessed the prevalence of CM use in children and the association of clinical characteristics and health care resource use with the number of CMs used.

METHODS

This is a retrospective study of children ages 1 to 18 years using Medicaid from 10 states in 2014 grouped by the annual number of CMs (0, 1, 2-4, 5-9, and ≥10 medications), which are defined as a dispensed ≥30-day prescription with ≥2 dispensed refills. Trends in clinical characteristics and health care use by number of CMs were evaluated with the Cochran-Armitage trend test.

RESULTS

Of 4 594 061 subjects, 18.8% used CMs. CM use was 44.4% in children with a complex chronic condition. Across all children, the most common CM therapeutic class was neurologic (28.9%). Among CM users, 48.8% used multiple CMs (40.3% used 2-4, 7.0% used 5-9, and 0.5% used ≥10). The diversity of medications increased with increasing number of CMs: for 1 CM, amphetamine stimulants were most common (29.0%), and for ≥10 CMs, antiepileptics were most common (7.1%). Of $2.3 billion total pharmacy spending, 59.3% was attributable to children dispensed multiple CMs. Increased CM use (0 to ≥10 medications) was associated with increased emergency department use (32.1% to 56.2%) and hospitalization (2.3% to 36.7%).

CONCLUSIONS

Nearly 1 in 5 children with Medicaid used CMs. Use of multiple CMs was common and correlated with increased health care use. Understanding CM use in children should be fundamentally important to health care systems when strategizing how to provide safe, evidence-based, and cost-effective pharmaceutical care to children.

Pediatric Readmissions Within 3 Days of Discharge: Preventability, Contributing Factors, and Necessity

OBJECTIVES

Among pediatric 30-day readmissions, 20% to 30% are preventable, and ∼25% are within 3 days of discharge. We investigated the preventability, contributing factors, and necessity of 3-day pediatric readmissions.

METHODS

We enrolled patients who were readmitted within 3 days at a freestanding tertiary children's hospital in this single-site observational study from July 2016 to February 2017. We performed chart reviews and interviews with discharge and readmission providers and families. Preventability was defined by the chart reviewer's determination. Contributing factors for readmission, demographics, and clinical characteristics were analyzed for association with preventability and necessity. We analyzed qualitative data using content analysis.

RESULTS

Of the 125 readmission cases included, 60 (48%) were preventable per chart reviewer compared with 27 of 92 (29%) per discharge providers, 33 of 93 (35%) per readmission providers, and 9 of 36 (25%) per families. Preventability was associated with the following contributing factors: problems with clinical decision-making in 54 of 125 (43%) readmissions (P < .001), issues with the discharge process in 25 of 125 (20%) readmissions (P = .01), clinically related admission and readmission (P = .004), and weekday of initial discharge (P = .02). Seventeen percent were unnecessary per readmission provider. Clinically unnecessary readmissions were associated with Hispanic ethnicity (P = .02), outside-hospital transfer (P = .05), and problems with clinical decision-making (P = .01). Qualitative data highlighted disagreement on readiness for discharge and the necessity of readmission among various providers and family.

CONCLUSIONS

More than one-half of 3-day readmissions were considered either preventable or unnecessary. Clinical decision-making, discharge processes, and improving consensus among families and providers may be valuable areas for future efforts to reduce readmission.

Pediatric patients with home mechanical ventilation: The health services landscape

OBJECTIVE

Children with invasive home mechanical ventilation (HMV) are a growing population with complex health service needs. Single institution studies provide insight into successful program structures and outcomes. Our study objectives were to assess health service structures, providers, and programs caring for this population throughout the U.S., and to understand barriers to high-quality care.

DESIGN

Using purposeful sampling with capture-recapture and snowball sampling methods, we identified key informants for care of the U.S. pediatric HMV population. Informants received web-based surveys with two reminders. Survey domains included respondent characteristics, HMV team composition, and barriers to care.

RESULTS

Survey response was 71% with 101 completed. Respondents caring for patients in 45 states included physicians (61%), nurses (20%), therapists (12%), case managers (4%), and social workers (2%). Half (53%) of physicians were fellowship trained, most commonly pulmonology (22%) and critical care medicine (13%). The majority (65%) of providers described a dedicated HMV service. The majority (61%) of respondents from a HMV service provided both inpatient and outpatient care. Nearly all respondents (96%) described an inadequate supply of home nurses and 88% reported inadequate respite facilities.

CONCLUSIONS

Children with HMV assistance receive care from a diverse group of providers with varied team structure. Heterogeneity may reflect patient diversity and provider interest, increasing efficacy but challenging standardization nationwide. Despite team structure variability, similar home care difficulties were universally experienced. Data suggest that the home nursing shortage is a national impediment to quality and efficient discharge with limited community-based support for this vulnerable population.

The Role of Gender in Publication in The Journal of Pediatrics 2015-2016: Equal Reviews, Unequal Opportunities

OBJECTIVES

To examine whether the gender of corresponding authors, reviewers, and editors led to differential publication recommendations and outcomes for original research articles and invited editorials submitted to The Journal of Pediatrics in 2015 and 2016.

STUDY DESIGN

Names of corresponding authors, reviewers, editors, and editorial writers in The Journal of Pediatrics databases for 2015-2016 were analyzed to determine gender using computer algorithms and Internet searches. Reviewer recommendations and final editor dispositions were stratified by their gender and the gender of the corresponding authors.

RESULTS

Of 3729 original manuscripts, 54.3% had female corresponding authors. Women were the associate editor (40.2% of submissions), guest editor (34.8%), or primary reviewer (37.4%), with no gender difference in editor or reviewer assignments for submissions by female vs male corresponding authors. There were no outcome differences by author gender for manuscripts overseen by female (P = .71) or male (P = .62) editors nor recommendation differences by female (P = .18) or male (P = .71) reviewers. Female editors had a lower acceptance rate overall than male editors (20.1% vs 25.6%; P < .001). Women were statistically less likely to accept and complete the invitation to peer review original articles (34.0%; 2295 of 6743) compared with men (40.0%; 3930 of 9823; P < .001). Women wrote 33 of 107 editorials (30.8%).

CONCLUSIONS

There were no differences in reviewer recommendations or editor decisions for original research articles based on corresponding author gender. However, women had fewer opportunities to serve as peer reviewers and editorial writers than would be expected given their representation as academic pediatric faculty.

Gender Differences in the Authorship of Original Research in Pediatric Journals, 2001-2016

OBJECTIVES

To examine the gender of authors of original research in 3 high-impact pediatric journals between 2001 and 2016, given the importance of publishing on academic promotion, and to compare authorship gender with the percentage of women on editorial boards and with academic faculty composition.

STUDY DESIGN

We assessed the prevalence of female first and senior (last-listed) authorship of original research articles published in 3 pediatric-focused journals Pediatrics, JAMA Pediatrics (entitled Archives of Pediatric and Adolescent Medicine until 2013), and The Journal of Pediatrics. We also examined the gender breakdown of the main editors and the broader editorial boards of these journals. In addition, we examined whether junior female faculty co-authored with male or female senior faculty.

RESULTS

Of 3895 original articles, 22 were excluded because the gender of either the first or senior author could not be determined from the name. An analysis of authorship by year showed increasing female representation across the selected journals in both first (39.8% in 2001, 57.7% in 2016) and senior (28.6% in 2001, 38.1% in 2016) authors, respectively. Editorial boards also showed increasing female representation (17.8% in 2001 to 39.8% in 2016). Junior female faculty were more likely to co-author with senior female women (female first and last author); the gap remained unchanged despite the increasing number of women entering pediatrics.

CONCLUSIONS

Women are underrepresented as authors and editors, although the gap is closing. Junior women are less likely to co-author with senior men, which may be a disservice given current gender disparities in promotion and leadership.

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children

BACKGROUND

Targeted temperature management is recommended for comatose adults and children after out-of-hospital cardiac arrest; however, data on temperature management after in-hospital cardiac arrest are limited.

METHODS

In a trial conducted at 37 children's hospitals, we compared two temperature interventions in children who had had in-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose children older than 48 hours and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a score of 70 or higher on the Vineland Adaptive Behavior Scales, second edition (VABS-II, on which scores range from 20 to 160, with higher scores indicating better function), was evaluated among patients who had had a VABS-II score of at least 70 before the cardiac arrest.

RESULTS

The trial was terminated because of futility after 329 patients had undergone randomization. Among the 257 patients who had a VABS-II score of at least 70 before cardiac arrest and who could be evaluated, the rate of the primary efficacy outcome did not differ significantly between the hypothermia group and the normothermia group (36% [48 of 133 patients] and 39% [48 of 124 patients], respectively; relative risk, 0.92; 95% confidence interval [CI], 0.67 to 1.27; P=0.63). Among 317 patients who could be evaluated for change in neurobehavioral function, the change in VABS-II score from baseline to 12 months did not differ significantly between the groups (P=0.70). Among 327 patients who could be evaluated for 1-year survival, the rate of 1-year survival did not differ significantly between the hypothermia group and the normothermia group (49% [81 of 166 patients] and 46% [74 of 161 patients], respectively; relative risk, 1.07; 95% CI, 0.85 to 1.34; P=0.56). The incidences of blood-product use, infection, and serious adverse events, as well as 28-day mortality, did not differ significantly between groups.

CONCLUSIONS

Among comatose children who survived in-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a favorable functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute; THAPCA-IH ClinicalTrials.gov number, NCT00880087 .).

Education of pediatric subspecialty fellows in transport medicine: a national survey

BACKGROUND

The transport of critically ill patients to children's hospitals is essential to current practice. The AAP Section on Transport Medicine has raised concerns about future leadership in the field as trainees receive less exposure to transport medicine. This study identifies the priorities of pediatric subspecialty fellows, fellowship directors and nursing directors in transport medicine education.

METHODS

Internet based surveys were distributed to fellows, fellowship directors and nursing directors of transport teams affiliated with ACGME-approved fellowships in Neonatal-Perinatal Medicine (NPM), Pediatric Critical Care Medicine (PCCM), and Pediatric Emergency Medicine (PEM). Data collection occurred November 2013 to March 2014.

RESULTS

Four hundred and sixty-six responses were collected (357 fellows, 82 directors, 27 nursing directors): Six curricular elements were ranked by respondents: Transport Physiology (TP), Medical Control (MC), Vehicle Safety (VS), Medicolegal Issues (ML), Medical Protocols (MP) and State and Federal Regulations (SFR). Fellows and fellowship directors were not significantly different: TP (p = 0.63), VS (p = 0.45), SFR (p = 0.58), ML (p = 0.07), MP (p = 0.98), and MC (p = 0.36). Comparison of subspecialties found significant differences: PEM considered TP less important than NPM and PCCM (p < 0.001, p < 0.001), VS less important than NPM (p = 0.001). PEM viewed SFR and MC more important than PCCM (p = 0.006, p = 0.002); ML more important than PCCM and NPM (p = 0.001, p < 0.001). PCCM ranked MC more important than NPM (p = 0.004). Nursing directors considered TP less important than NPM and PCCM (p < 0.001, p = 0.002).

CONCLUSIONS

When ranking curricular elements in transport medicine, fellows and fellowship directors do not differ, but comparison of subspecialties notes significant differences. A fellow curriculum in transport medicine will utilize these results.

Trends in Health Care Spending for Children in Medicaid With High Resource Use

OBJECTIVES

To assess characteristics associated with health care spending trends among child high resource users in Medicaid.

METHODS

This retrospective analysis included 48 743 children ages 1 to 18 years continuously enrolled from 2009-2013 in 10 state Medicaid programs (Truven MarketScan Medicaid Database) also in the top 5% of all health care spending in 2010. Using multivariable regression, associations were assessed between baseline demographic, clinical, and health services characteristics (using 2009-2010 data) with subsequent health care spending (ie, transiently, intermittently, persistently high) from 2011-2013.

RESULTS

High spending from 2011-2013 was transient for 54.2%, persistent for 32.9%, and intermittent for 12.9%. Regarding demographic characteristics, the highest likelihood of persistent versus transient spending occurred in children aged 13 to 18 years versus 1 to 2 years in 2010 (odds ratio [OR], 3.0 [95% confidence interval (CI), 2.7-3.4]). Regarding clinical characteristics, the highest likelihoods were in children with ≥6 chronic conditions (OR, 4.8 [95% CI, 3.5-6.6]), a respiratory complex chronic condition (OR, 2.5 [95% CI, 2.2-2.8]), or a neuromuscular complex chronic condition (OR, 2.3 [95% CI, 2.2-2.5]). Hospitalization and emergency department (ED) use in 2010 were associated with a decreased likelihood of persistent spending in 2011-2013 (hospitalization OR, 0.7 [95% CI, 0.7-0.7]); ED OR, 0.8 [95% CI, 0.8-0.8]).

CONCLUSIONS

Most children with high spending in Medicaid are without persistently high spending in subsequent years. Adolescent age, multiple chronic conditions, and certain complex chronic conditions increased the likelihood of persistently high spending; hospital and ED use decreased it. These data may help inform the development of new models of care and financing to optimize health and save resources in children with high resource use.

Identification of Fail Points for Discharging Pediatric Patients With New Tracheostomy and Ventilator

BACKGROUND AND OBJECTIVES

The core mission of the Pulmonary Habilitation Program is to train and prepare caregivers for the care of a ventilated child in the home. It exists within a free-standing children's hospital. The program is supported by a multidisciplinary staff and serves ∼100 children. Through standardizing electronic documentation with process-specific tracking for the discharge process, the Pulmonary Habilitation Program team sought to identify intervention opportunities for more efficient and effective discharges.

METHODS

The process of discharge was described using an iterative process, with the multidisciplinary team and discharge milestones noted in the medical chart.

RESULTS

Several nonmedical factors contribute to prolonged hospital stays, including parent training, approval from the state agency for home care, and staffing of home nursing. Children had median lengths of stay of 141 days (interquartile range, 68 to 177).

CONCLUSIONS

As a result of this initial investigation, application to the state agency and training for caregivers have been initiated sooner, when a tracheostomy is first placed.

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

BACKGROUND AND OBJECTIVES

Opportunities to improve health care quality and contain spending may differ between high and low resource users. This study's objectives were to assess health care and spending among children with Medicaid insurance by their resource use.

METHODS

Retrospective cross-sectional analysis of 2012 Medicaid health administrative data from 10 states of children ages 11 months to 18 years. Subjects were categorized into 4 spending groups, each representing ∼25% of total spending: the least expensive 80% of children (n = 2,868,267), the next 15% expensive (n = 537,800), the next 4% expensive (n = 143,413), and the top 1% (n = 35,853). We compared per-member-per-month (PMPM) spending across the groups using the Kruskal-Wallis test.

RESULTS

PMPM spending was $68 (least expensive 80%), $349 (next 15%), $1200 (next 4%), and $6738 (top 1%). Between the least and most expensive groups, percentages of total spending were higher for inpatient (<1% vs 46%) and mental health (7% vs 24%) but lower for emergency (15% vs 1%) and primary (23% vs 1%) care (all Ps < .001). From the least to most expensive groups, increases in PMPM spending were smallest for primary care (from $15 to $33) and much larger for inpatient ($0.28 to $3129), mental health ($4 to $1609), specialty care ($8 to $768), and pharmacy ($4 to $699).

CONCLUSIONS

As resource use increases in children with Medicaid, spending rises unevenly across health services: Spending on primary care rises modestly compared with other health services. Future studies should assess whether more spending on primary care leads to better quality and cost containment for high resource users.

Red Blood Cell Distribution Width as a Pragmatic Marker for Outcome in Pediatric Critical Illness

Background

Red cell distribution width (RDW) is a routine laboratory measure associated with poor outcomes in adult critical illness.

Objective

We determined the utility of RDW as an early pragmatic biomarker for outcome in pediatric critical illness.

Methods

We used multivariable logistic regression to test the association of RDW on the first day of pediatric intensive care unit (PICU) admission with prolonged PICU length of stay (LOS) >48 hours and mortality. The area under the receiver operating characteristic curve (AUROC) for RDW was compared to the Pediatric Index of Mortality (PIM)-2 score.

Results

Over a 13-month period, 596 unique patients had RDW measured on the first day of PICU admission. Sepsis was an effect modifier for LOS >48 hours but not mortality. In sepsis, RDW was not associated with LOS >48 hours. For patients without sepsis, each 1% increase in RDW was associated with 1.17 (95% CI 1.06, 1.30) increased odds of LOS >48 hours. In all patients, RDW was independently associated with PICU mortality (OR 1.25, 95% CI 1.09, 1.43). The AUROC for RDW to predict LOS >48 hours and mortality was 0.61 (95% CI 0.56, 0.66) and 0.65 (95% CI 0.55, 0.75), respectively. Although the AUROC for mortality was comparable to PIM-2 (0.75, 95% CI 0.66, 0.83; p = 0.18), RDW did not increase the discriminative utility when added to PIM-2. Despite the moderate AUROC, RDW <13.4% (upper limit of lower quartile) had 53% risk of LOS >48 hours and 3.3% risk of mortality compared to patients with an RDW >15.7% (lower limit of upper quartile) who had 78% risk of LOS >48 hours and 12.9% risk of mortality (p<0.001 for both outcomes).

Conclusions

Elevated RDW was associated with outcome in pediatric critical illness and provided similar prognostic information as the more complex PIM-2 severity of illness score. Distinct RDW thresholds best discriminate low- versus high-risk patients.

Therapeutic hypothermia after out-of-hospital cardiac arrest in children

BACKGROUND

Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.

METHODS

We conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.

RESULTS

A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.

CONCLUSIONS

In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

Professionalism and Communication Education in Pediatric Critical Care Medicine: The Learner Perspective

OBJECTIVE

Communication and professionalism are often challenging to teach, and the impact of the use of a given approach is not known. We undertook this investigation to establish pediatric critical care medicine (PCCM) trainee perception of education in professionalism and communication and to compare their responses from those obtained from PCCM fellowship program directors.

METHODS

The Education in Pediatric Intensive Care (E.P.I.C.) Investigators used the modified Delphi technique to develop a survey examining teaching of professionalism and communication. After piloting, the survey was sent to all 283 PCCM fellows in training in the United States.

RESULTS

Survey response rate was 47% (133 of 283). Despite high rates of teaching overall, deficiencies were noted in all areas of communication and professionalism assessed. The largest areas of deficiency included not being specifically taught how to communicate: as a member of a nonclinical group (reported in 24%), across a broad range of socioeconomic and cultural backgrounds (19%) or how to provide consultation outside of the intensive care unit (17%). Only 50% of fellows rated education in communication as "very good/excellent." However, most felt confident in their communication abilities. For professionalism, fellows reported not being taught accountability (12%), how to conduct a peer review (12%), and how to handle potential conflict between personal beliefs, circumstances, and professional values (10%). Fifty-seven percent of fellows felt that their professionalism education was "very good/excellent," but nearly all expressed confidence in these skills. Compared with program directors, fellows reported more deficiencies in both communication and professionalism.

CONCLUSIONS

There are numerous components of communication and professionalism that PCCM fellows perceive as not being specifically taught. Despite these deficiencies, fellow confidence remains high. Substantial opportunities exist to improve teaching in these areas.

Performance of capnometry in non-intubated infants in the pediatric intensive care unit

Background

Assessing the ventilatory status of non-intubated infants in the Pediatric Intensive Care Unit (PICU) is a constant challenge. Methods to evaluate ventilation include arterial blood gas analysis (ABG), which is invasive and intermittent, and transcutaneous carbon dioxide monitoring (P_tcCO2), which, while non-invasive, is also intermittent. A method that is non-invasive and continuous would be of great benefit in this population. We hypothesized that non-invasive capnometry via sidestream monitoring of exhaled carbon dioxide (CO₂) would provide an acceptable measurement of ventilatory status when compared to ABG or P_tcCO2.

Methods

Preliminary prospective study of infants less than one year of age admitted to the PICU in a large urban teaching hospital. Infants not intubated and not requiring non-invasive ventilation were eligible. A sidestream CO₂ reading was obtained in a convenience sample of 39 patients. A simultaneous ABG was collected in those with an arterial catheter, and a P_tcCO2 was obtained in those without.

Results

Correlation of sidestream CO₂ with ABG was excellent (r² = 0.907). Sidestream correlated less well with P_tcCO2 (r² = 0.649). Results were not significantly altered when weight and respiratory rate were added as independent variables. Bland-Altman analysis revealed a bias of -2.7 with a precision of ±6.5 when comparing sidestream CO₂ to ABG, and a bias of -1.7 with a precision of ±9.9 when comparing sidestream CO₂ to P_tcCO2.

Conclusions

Performance of sidestream monitoring of exhaled CO₂ is acceptable clinical trending to assess the effectiveness of ventilation in non-intubated infants in the PICU.