Shari Simone

Educational preparation and postgraduate training curriculum for pediatric critical care nurse practitioners.

Background: Nurse practitioners (NPs) in pediatric intensive care units have increased dramatically over recent years. Although state regulations are changing pediatric nurse practitioner certification, licensure and credentialing requirements, available acute care, and critical care educational programs are limited. Thus, entry-level practitioners continue to have varied clinical experience and educational preparation. Objective: To describe the current educational preparation and scope of practice of pediatric NPs and provide guidelines for postgraduate training to successfully integrate NPs into the pediatric intensive care unit (PICU). Design: A group of NPs practicing in pediatric critical care recognized the imminent need for comprehensive orientation guidelines that are readily accessible to physicians and other nurse practitioners to successfully transition entry-level NPs into the PICU. The NPs held many discussions to identify commonalities and differences in the education foundation in pediatric NP programs, expected clinical experience and knowledge of NP students, and anticipated needs and gaps for the entry-level practitioner. A convenience sample of 20 pediatric critical care nurse practitioners practicing for ≥5 yrs were interviewed to examine current orientation processes for entry-level NPs into the PICU. Sample orientation guidelines, job descriptions, and procedural competency forms were collected and reviewed from various PICUs across the United States. An orientation model was drafted and distributed to a secondary panel of ten experienced practitioners to gather expert opinions. Responses were reviewed and a revised draft of the document was distributed to a group of APNs involved in postgraduate education. Results: A PICU orientation model for entry-level pediatric critical care nurse practitioners was developed. Conclusions: The orientation curriculum presented here may serve as a resource for NPs and collaborating physicians who are developing a training program for entry-level practitioners.

Implications of thrombocytopenia and platelet course on pediatric intensive care unit outcomes.

Introduction: Thrombocytopenia has been shown to be an independent predictor of mortality and prolonged hospital length of stay in critically ill adults. Studies are lacking in the pediatric intensive care unit population. We evaluated the relationship between platelet counts at admission, platelet course, and outcomes. Hypotheses: 1) Thrombocytopenia at the time of admission to the pediatric intensive care unit is a risk factor for increased mortality and prolonged length of stay. 2) Thrombocytopenia at any point during pediatric intensive care unit stay is associated with increased mortality and length of stay. 3) Falling platelet counts during a pediatric intensive care unit course are associated with greater mortality and longer length of stay. Method: Prospective observational study. Study Population: All patients admitted to a multidisciplinary tertiary care pediatric intensive care unit in a University Hospital over the course of a year. Analysis of Data: Data were analyzed using logistic and linear regression. Results: Thrombocytopenia (platelet count <150 × 109/L) was present in 17.3% of pediatric intensive care unit patients on admission. Mortality was higher in thrombocytopenic patients (17.6% vs. 2.47%, p < 0.001). The median length of stay in the thrombocytopenia and nonthrombocytopenia groups was 4 days vs. 1.6 days, respectively (p < 0.001). The pediatric intensive care unit patients (25.3%) were thrombocytopenic at some point in their stay. They had higher mortality (17.1% vs. 0.9%, odds ratio [OR] 23.8, 95% confidence interval [CI] 5.2–108.6, p < 0.0005) and longer length of stay (median 6.6 days vs. 1.5 days, p < 0.0005) compared with those who were never thrombocytopenic. For every 10% fall in platelet count from the time of admission, the OR for mortality was 1.4 (95% CI 1.1–1.8) and the length of stay was longer (p < 0.0005). Patients with normal platelet counts at admission who later developed thrombocytopenia had increased mortality (OR 18.6, 95% CI 3.2–107.3) and longer length of stay (p < 0.0005) compared with those who did not develop thrombocytopenia. Conclusion: Thrombocytopenia and falling platelet counts are associated with increased risk of mortality and length of stay in the pediatric intensive care unit.

Dexmedetomidine Use in Critically Ill Children with Acute Respiratory Failure

Objective: Care of critically ill children includes sedation but current therapies are suboptimal. To describe dexmedetomidine use in children supported on mechanical ventilation for acute respiratory failure. Design: Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure clinical trial. Setting: Thirty-one PICUs. Patients: Data from 2,449 children; 2 weeks to 17 years old. Interventions: Sedation practices were unrestrained in the usual care arm. Patients were categorized as receiving dexmedetomidine as a primary sedative, secondary sedative, periextubation agent, or never prescribed. Dexmedetomidine exposure and sedation and clinical profiles are described. Measurements and Main Results: Of 1,224 usual care patients, 596 (49%) received dexmedetomidine. Dexmedetomidine as a primary sedative patients (n = 138; 11%) were less critically ill (Pediatric Risk of Mortality III-12 score median, 6 [interquartile range, 3–11]) and when compared with all other cohorts, experienced more episodic agitation. In the intervention group, time in sedation target improved from 28% to 50% within 1 day of initiating dexmedetomidine as a primary sedative. Dexmedetomidine as a secondary sedative usual care patients (n = 280; 23%) included more children with severe pediatric acute respiratory distress syndrome or organ failure. Dexmedetomidine as a secondary sedative patients experienced more inadequate pain (22% vs 11%) and sedation (31% vs 16%) events. Dexmedetomidine as a periextubation agent patients (n = 178; 15%) were those known to not tolerate an awake, intubated state and experienced a shorter ventilator weaning process (2.1 vs 2.3 d). Conclusions: Our data support the use of dexmedetomidine as a primary agent in low criticality patients offering the benefit of rapid achievement of targeted sedation levels. Dexmedetomidine as a secondary agent does not appear to add benefit. The use of dexmedetomidine to facilitate extubation in children intolerant of an awake, intubated state may abbreviate ventilator weaning. These data support a broader armamentarium of pediatric critical care sedation.

Patterns of Sedation Weaning in Critically Ill Children Recovering From Acute Respiratory Failure.

Objective: To characterize sedation weaning patterns in typical practice settings among children recovering from critical illness. Design: A descriptive secondary analysis of data that were prospectively collected during the prerandomization phase (January to July 2009) of a clinical trial of sedation management. Setting: Twenty-two PICUs across the United States. Patients: The sample included 145 patients, aged 2 weeks to 17 years, mechanically ventilated for acute respiratory failure who received at least five consecutive days of opioid exposure. Interventions: None. Measurements and Main Results: Group comparisons were made between patients with an intermittent weaning pattern, defined as a 20% or greater increase in daily opioid dose after the start of weaning, and the remaining patients defined as having a steady weaning pattern. Demographic and clinical characteristics, tolerance to sedatives, and iatrogenic withdrawal symptoms were evaluated. Sixty-six patients (46%) were intermittently weaned; 79 patients were steadily weaned. Prior to weaning, intermittently weaned patients received higher peak and cumulative doses and longer exposures to opioids and benzodiazepines, demonstrated more sedative tolerance (58% vs 41%), and received more chloral hydrate and barbiturates compared with steadily weaned patients. During weaning, intermittently weaned patients assessed for withdrawal had a higher incidence of Withdrawal Assessment Tool-version 1 scores of greater than or equal to 3 (85% vs 46%) and received more sedative classes compared with steadily weaned patients. Conclusions: This study characterizes sedative administration practices for pediatric patients prior to and during weaning from sedation after critical illness. It provides a novel methodology for describing weaning in an at-risk pediatric population that may be helpful in future research on weaning strategies to prevent iatrogenic withdrawal syndrome.

Artifacts Use in Safety Critical Information Transfer: A Preliminary Study of the Information Arena

Highly skilled professionals in mission critical work domains communicate complicated, critical information, frequently under time pressure. For example, sustained operations require shift work, which results in hand-offs of responsibilities and need of information transfers. There is a growing interest to support their communications through advanced information technology. We observed usage of information artifacts in a pediatric intensive care unit to study information transfers to guide the design of support technology. In contrast to published studies, we examined the context of supporting environment that contains rich information sources gathered or tailored for verbal discourses. We called the supporting environment “information arena.” Clinicians prepare for their personal information arena as well as the shared information arena (e.g., paper notes, charts, mobile computers). Patterns of artifact uses during discourses revealed several distinct roles of artifacts, as well as constraints on design of such artifacts. For example, artifacts in shared information arena should be easily manageable to support fluid and dynamic conversation flow. We also uncover several potential future roles for information artifacts to support information transfer.

Racial and Ethnic Disparities in Parental Refusal of Consent in a Large, Multisite Pediatric Critical Care Clinical Trial

Objective To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their childs participation in a multisite pediatric critical care clinical trial. Study design We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a 31‐center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. Result Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non‐Hispanic White (White), non‐Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56‐2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10‐1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37‐3.36, P < .001). Conclusions Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their childs participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. Trial registration ClinicalTrials.gov: NCT00814099.

Optimizing Team Dynamics: An Assessment of Physician Trainees and Advanced Practice Providers Collaborative Practice.

Objectives: The presence of advanced practice providers has become increasingly common in many ICUs. The ideal staffing model for units that contain both advanced practice providers and physician trainees has not been described. The objectives of this study were to evaluate ICU staffing models that include physician trainees and advanced practice providers and their effects on patient outcomes, resident and fellow education, and training experience. A second aim was to assess strategies to promote collaboration between team members. Data Sources: PubMed, CINAHL, OVID MEDLINE, and Cochrane Review from 2002 to 2015. Study Selection: Experimental study designs conducted in an ICU setting. Data Extraction: Two reviewers screened articles for eligibility and independently abstracted data using the identified search terms. Data Synthesis: We found 21 articles describing ICU team structure and outcomes. Four articles were found describing the impact of advanced practice providers on resident or fellow education. Two articles were found discussing strategies to promote collaboration between advanced practice providers and critical care fellows or residents. Conclusions: Several articles were identified describing the utilization of advanced practice providers in the ICU and the impact of models of care on patient outcomes. Limited data exist describing the impact of advanced practice providers on resident and fellow education and training experience. In addition, there are minimal data describing methods to enhance collaboration between providers. Future research should focus on determining the optimal ICU team structure to improve patient outcomes, education of trainees, and job satisfaction of team members and methods to promote collaboration between advanced practice providers and physicians in training.