Carley Riley

The Evolving Model of Pediatric Critical Care Delivery in North America

The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.

Prevention of Sepsis in Children: A New Paradigm for Public Policy

Sepsis is one of the leading causes of death worldwide. While the management of critically ill patients with sepsis is certainly better now compared to 20 years ago, sepsis-associated mortality remains unacceptably high. Annual deaths from sepsis in both children and adults far surpass the number of deaths from acute myocardial infarction (AMI), stroke, or cancer. Given the substantial toll that sepsis takes worldwide, prevention of sepsis remains a global priority. Multiple effective prevention strategies exist. Antibiotic prophylaxis, immunizations, and healthcare quality improvement initiatives are important means through which we may reduce the morbidity and mortality from sepsis around the world. Inclusion of these strategies in a coordinated and thoughtful campaign to reduce the global burden of sepsis is necessary for the improvement of pediatric health worldwide.

The Child Opportunity Index and Disparities in Pediatric Asthma Hospitalizations Across One Ohio Metropolitan Area, 2011-2013

Objectives To determine whether the Child Opportunity Index (COI), a nationally available measure of relative educational, health/environmental, and social/economic opportunity across census tracts within metropolitan areas, is associated with population‐ and patient‐level asthma morbidity. Study design This population‐based retrospective cohort study was conducted between 2011 and 2013 in a southwest Ohio county. Participants included all children aged 1‐16 years with hospitalizations or emergency department visits for asthma or wheezing at a major pediatric hospital. Patients were identified using discharge diagnosis codes and geocoded to their home census tract. The primary population‐level outcome was census tract asthma hospitalization rate. The primary patient‐level outcome was rehospitalization within 12 months of the index hospitalization. Census tract opportunity was characterized using the COI and its educational, health/environmental, and social/economic domains. Results Across 222 in‐county census tracts, there were 2539 geocoded hospitalizations. The median asthma‐related hospitalization rate was 5.0 per 1000 children per year (IQR, 1.9‐8.9). Median hospitalization rates in very low, low, moderate, high, and very high opportunity tracts were 9.1, 7.6, 4.6, 2.1, and 1.8 per 1000, respectively (P < .0001). The social/economic domain had the most variables significantly associated with the outcome at the population level. The adjusted patient‐level analyses showed that the COI was not significantly associated with a patients risk of rehospitalization within 12 months. Conclusions The COI was associated with population‐level asthma morbidity. The details provided by the COI may inform interventions aimed at increasing opportunity and reducing morbidity across regions.

Moving Into the Neighborhood

Improving national cardiovascular health (CVH) is the American Heart Association’s 2020 Strategic Impact Goal.1 To achieve this ambitious goal, there is an appropriate strong focus on counseling and educating our patients about hypertension, diabetes mellitus, and healthy behaviors. However, there is an additional opportunity that may ultimately be critical to our success. Too often neglected, contextual factors also have a strong influence on cardiovascular risk. By contextual variables, we mean the environment in which we live, to include the structural or built environment (eg, buildings, sidewalks, parks, recreational facilities) and the social environment (ie, the trust and bonds between community members). Emerging research is showing that these factors may influence risk through their effect on health behaviors and risk factors, as well as through other pathways. Importantly, these factors may be essential in efforts to shift the risks and improve the health of populations. Articles see p 524 In this issue of Circulation: Cardiovascular Quality and Outcomes , we have an example of the emerging literature directing our attention toward contextual factors associated with cardiovascular health. Unger et al2 report the association of a range of neighborhood characteristics with a global measure of cardiovascular health using data from the Multi-Ethnic Study of Atherosclerosis (MESA). The MESA is well designed to examine the environmental context on health because it includes a cohort of both sexes and 4 race/ethnic groups without clinical cardiovascular disease at the time of enrollment from 6 communities in different regions of the United States and captures information about the participants’ cardiovascular risk and perception of their neighborhood along with current and prior addresses that can be used to identify elements of the neighboring structural environment. Although initial studies from MESA focused …

Collective Well-Being to Improve Population Health Outcomes: An Actionable Conceptual Model and Review of the Literature

Objectives: To propose collective well-being as a holistic measure of the overall “health” of a community. To define collective well-being as a group-level construct measured across 5 domains (vitality, opportunity, connectedness, contribution, and inspiration) and introduce an actionable model that demonstrates how community characteristics affect collective well-being. To review the literature describing each domain’s association with health outcomes and community characteristics’ associations with collective well-being. Methods: We came to consensus on topics describing each component of our conceptual model. Because “well-being” is not indexed in MEDLINE, we performed topic-specific database searches and examined bibliographies of papers retrieved. We excluded articles that were limited to narrow subtopics or studies within small subpopulations. Preference was given to quasi-experimental or randomized studies, systematic reviews, or meta-analyses. Consensus was reached on inclusion or exclusion of all articles. Results: Reviewed literature supported each of the proposed domains as important aspects of collective well-being and as determinants of individual or community health. Evidence suggests a broad range of community characteristics support collective well-being. Conclusions: The health and quality of life of a community may be improved by focusing efforts on community characteristics that support key aspects of well-being. Future work should develop a unified measure of collective well-being to evaluate the relative impact of specific efforts on the collective well-being of communities.

Staffing and workforce issues in the pediatric intensive care unit

The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.

Disease prevention & health promotion: what’s critical care got to do with it?

Health systems are increasingly investing in efforts to prevent disease and promote health for populations. By and large, these prevention-related interventions have not been inclusive of critical care and the intensive care unit (ICU). However, we suggest that there is value-to patients, families, health systems, and society at large-in extending this continuum into the ICU setting and including the ICU in disease prevention and health promotion efforts. Including the ICU in this continuum allows the critical care perspective to inform (I) advocacy for prevention; (II) efforts to improve disparities in health and health care; (III) mitigation of the negative effects of critical illness and injury as well as ICU exposure; and (IV) promotion of health and well-being in the community. As disease prevention and health promotion rise as priorities within health systems, critical care can and should join, even help lead, the effort.

Emotion regulation moderates the association between chronic stress and cardiovascular disease risk in humans: a cross-sectional study

Abstract Chronic stress is a risk factor for incident cardiovascular (CV) disease. Emotion regulation is the ability to modulate one’s state or behavior in response to a given situation or stressor, and may mitigate the effect of chronic stress on CV disease risk. Data from a cohort of 754 community-dwelling young to middle-aged adults who were assessed between 2007 and 2012 on stress, emotion regulation, and CV risk measures were used to test the hypothesis that emotion regulation mitigates the effect of chronic stress on CV risk. Emotion regulation was measured using the Difficulties in Emotion Regulation Scale (DERS). We created a composite stress score using data from the Cumulative Adversity Interview and the Perceived Stress Scale. Our outcomes included blood pressure, body mass index, and insulin resistance separately and combined into a composite CV risk score. Covariates included age, sex, race, years of education, and smoking status. We used multivariable logistic regression to evaluate associations between stress measures and CV risk among participants and the impact of emotion regulation (DERS scores) on this association. We found that composite stress interacted significantly with the DERS score to affect CV risk (p = .007). A median split of the DERS scores indicated that CV risk was associated with the composite stress score in the fully adjusted model (ß = 0.206; p = .005) among participants with low emotion regulation, but not among those with high emotion regulation (ß = 0.048; p = .59). Chronic stress was associated with CV risk only among participants with poor emotion regulation. Emotion regulation is a teachable skill, and may play a role in preventing CV disease. Lay summary Emotion regulation is the ability to modify one’s reaction to a negative or stressful event, and is a teachable skill. Effective emotion regulation dampens the negative effect of chronic stress on the body, which may reduce risk for cardiovascular disease.

Analysis of a Pediatric Home Mechanical Ventilator Population

BACKGROUND: The population of children requiring home mechanical ventilation has evolved over the years and has grown to include a variety of diagnoses and needs that have led to changes in the care of this unique population. The purpose of this study was to provide a descriptive analysis of pediatric patients requiring home mechanical ventilation after hospitalization and how the evolution of this technology has impacted their care. METHODS: A retrospective, observational, longitudinal analysis of 164 children enrolled in a university-affiliated home mechanical ventilation program over 26 years was performed. Data included each childs primary diagnosis, date of tracheostomy placement, duration of mechanical ventilation during hospitalization that consisted of home mechanical ventilator initiation, total length of pediatric ICU stay, ventilator settings at time of discharge from pediatric ICU, and disposition (home, facility, or died). Univariate, bivariate, and regression analysis was used as appropriate. RESULTS: The most common diagnosis requiring the use of home mechanical ventilation was neuromuscular disease (53%), followed by chronic pulmonary disease (29%). The median length of stay in the pediatric ICU decreased significantly after the implementation of a ventilator ward (70 d [30–142] vs 36 d [18–67], P = .02). The distribution of subjects upon discharge was home (71%), skilled nursing facility (24%), and died (4%), with an increase in the proportion of subjects discharged on PEEP and those going to nursing facilities over time (P = 0.02). CONCLUSIONS: The evolution of home mechanical ventilation has allowed earlier transition out of the pediatric ICU and with increasing disposition to skilled nursing facilities over time. There has also been a change in ventilator management, including increased use of PEEP upon discharge, possibly driven by changes in ventilators and in-patient practice patterns.

Population well-being and electoral shifts

Population wellbeing, an aggregate measure of positive mental, physical, and emotional health, has previously been used as a marker of community thriving. We examined whether several community measures of wellbeing, and their change since 2012, could be used to understand electoral changes that led to the outcome of the 2016 United States presidential election. We found that areas of the US which had the largest shifts away from the incumbent party had both lower wellbeing and greater drops in wellbeing when compared with areas that did not shift. In comparison, changes in income were not related to voting shifts. Well-being may be more useful in predicting and understanding electoral outcomes than some more conventional voting determinants.