Fola Odetola

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

Objectives: The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine “Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.” Design: Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006–2014). The PubMed/Medline/Embase literature (2006–14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. Measurements and Main Results: The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. Conclusions: The major new recommendation in the 2014 update is consideration of institution—specific use of 1) a “recognition bundle” containing a trigger tool for rapid identification of patients with septic shock, 2) a “resuscitation and stabilization bundle” to help adherence to best practice principles, and 3) a “performance bundle” to identify and overcome perceived barriers to the pursuit of best practice principles.

992: PATTERNS OF HEALTHCARE UTILIZATION AFTER HOSPITALIZATION FOR PEDIATRIC CRITICAL ILLNESS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) associated with shorter time to ventilator liberation (p<0.05). After controlling for these variables, the ventilator requirement score on the day prior to tracheostomy was most significantly associated with shorter time to ventilator liberation (HR 2.14, 95% CI 1.12–4.09, p=0.02). Conclusions: Ventilator parameters immediately prior to tracheostomy were associated with long-term weaning success. Early LTACH transfer may be most beneficial and cost-effective for patients identified as difficult to wean from mechanical ventilation.

557: Determinants of Inter-Hospital Transfer of Children from Level II to Level I Pediatric ICUs

interventions and resource allocation. The specific aims of this study are to (a) describe the disease burden of regional pediatric trauma, (b) describe the relationship between socioeconomic status, referral rates, and injury severity, and (c) derive a metric of regional trauma activity that may inform injury prevention/reduction efforts. Methods: We reviewed 6,469 cases from Akron Childrens Hospital trauma registry from 2005-2010. Records that contained missing data were excluded. The median number of trauma cases-per-zip code(ZIP) was divided by the number of residents less than 19 years old (PEDS) to derive the trauma referral rate (TRR). ZIP-level median income was used as a surrogate for socioeconomic status. The Trauma Referral Index (TRI) incorporated the TRR and ISS. TRR is reported as referrals/1000 PEDS. All data are reported as median (range). Results: The final analysis included 5815 records. Preschool children (<5y) accounted for 33% of all cases. The most common injury mechanism was falls. The overall case fatality rate by mechanism was 1.1% with suffocation having the highest (74%). Assault affected 300 cases and 196 were Preschool children. Akron (ZIP-44308) had the highest TRR, 9.6 [region 106.1(0.05-106.1)]. Canton (ZIP-44702) had the highest ISS [13, region 4.5(1-13)]. The TRI was highest in Canton (ZIP-44702), 1330.7 [region 46.4(1.2-1330.7)]. There was no relationship between median income and either TRR or ISS (p>0.10). Conclusions: There is significant heterogeneity in regional TRR and ISS among zip codes in Northeast Ohio. Median income was not inversely related to either TRR or ISS. The TRI, a metric that incorporated ZIP-based pediatric referral rates and ZIP-based injury severity, may be a useful tool in risk stratification and resource allocation for pediatric trauma. This study supports the hypothesis that ZIPbased trauma risk and referral stratification is a feasible approach to identifying trauma hotspots and these methods may be used to inform prevention strategies and resource allocation. Further regional analyses are underway to identify TRI epicenters as a function of age and mechanism of injury.