Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores.

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages.

Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores.

Application of Participatory Ergonomics to the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use.

Background: Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction.

A Research Agenda for Diagnostic Excellence in Critical Care Medicine.

Diagnosing critically ill patients in the intensive care unit is difficult. As a result, diagnostic errors in the intensive care unit are common and have been shown to cause harm. Research to improve diagnosis in critical care medicine has accelerated in past years.

Early Prediction of Multiple Organ Dysfunction in the Pediatric Intensive Care Unit.

The objective of the study is to build models for early prediction of risk for developing multiple organ dysfunction (MOD) in pediatric intensive care unit (PICU) patients. The design of the study is a retrospective observational cohort study. The setting of the study is at a single academic PICU at the Johns Hopkins Hospital, Baltimore, MD.

Culture Ordering for Patients with New-onset Fever: A Survey of Pediatric Intensive Care Unit Clinician Practices.

Introduction: Accurate assessment of infection in critically ill patients is vital to their care. Both indiscretion and under-utilization of diagnostic microbiology testing can contribute to inappropriate antibiotic administration or delays in diagnosis. However, indiscretion in diagnostic microbiology cultures may also lead to unnecessary tests that, if false-positive, would incur additional costs and unhelpful evaluations.

Prediction of Impending Septic Shock in Children With Sepsis.

Objectives: Sepsis and septic shock are leading causes of in-hospital mortality. Timely treatment is crucial in improving patient outcome, yet treatment delays remain common. Early prediction of those patients with sepsis who will progress to its most severe form, septic shock, can increase the actionable window for interventions.

Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach.

Objectives: Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients.

Design: A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process.

Diagnostic Errors in Pediatric Critical Care: A Systematic Review.

Objectives: To summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU.

Data Sources: Search of PubMed, EMBASE, and the Cochrane Library up to December 2019.

Study Selection: Studies on diagnostic error and the diagnostic process in pediatric critical care were included.

Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU.

Background: Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients.

Spectral clustering of risk score trajectories stratifies sepsis patients by clinical outcome and interventions received.

Sepsis is not a monolithic disease, but a loose collection of symptoms with diverse outcomes. Thus, stratification and subtyping of sepsis patients is of great importance. We examine the temporal evolution of patient state using our previously-published method for computing risk of transition from sepsis into septic shock.

How good is our diagnostic intuition? Clinician prediction of bacteremia in critically ill children.

Background: Clinical intuition and nonanalytic reasoning play a major role in clinical hypothesis generation; however, clinicians' intuition about whether a critically ill child is bacteremic has not been explored. We endeavored to assess pediatric critical care clinicians' ability to predict bacteremia and to evaluate what affected the accuracy of those predictions.

Methods: We conducted a retrospective review of clinicians' responses to a sepsis screening tool ("Early Sepsis Detection Tool" or "ESDT") over 6 months.

Survey-based Work System Assessment to Facilitate Large-scale Dissemination of Healthcare Quality Improvement Programs.

Introduction: The dissemination of quality improvement (QI) interventions to a broader range of healthcare settings requires a proactive assessment of local work systems and processes. The objective of this study was to examine the feasibility of using a survey-based work system assessment (WSA) tool to facilitate the dissemination of a program for optimizing blood culture (BC) use.

Methods: Informed by findings from an onsite, interview-based WSA at 2 hospitals, a 50-item WSA survey was devised and administrated to 15 hospitals participating in a QI collaborative.

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey.

Objectives: Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children.

Design: Cross-sectional electronic survey.

Data-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU.

Septic shock is a life-threatening condition in which timely treatment substantially reduces mortality. Reliable identification of patients with sepsis who are at elevated risk of developing septic shock therefore has the potential to save lives by opening an early window of intervention. We hypothesize the existence of a novel clinical state of sepsis referred to as the "pre-shock" state, and that patients with sepsis who enter this state are highly likely to develop septic shock at some future time.

Characterizing the Utilization of the Problem List for Pediatric Trauma Care.

The EHR problem list has the potential to support care coordination among the multidisciplinary care team that cares for pediatric trauma patients. To realize this potential, the need exists to ensure appropriate utilization by formulating acceptable usage and management policy. In this regard, understanding the prevailing utilization pattern is pivotal.

Association of a blood culture utilization intervention on antibiotic use in a pediatric intensive care unit.

Blood cultures are essential for the evaluation of sepsis. However, they may sometimes be obtained inappropriately, leading to high false-positive rates, largely due to contamination.1 As a quality improvement project, clinician decision-support tools for evaluating patients with fever or signs and symptoms of sepsis were implemented in April 2014 in our pediatric intensive care unit (PICU).

Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care.

Objective: To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma.

Methods: We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline.

Dissemination of a Novel Framework to Improve Blood Culture Use in Pediatric Critical Care.

Introduction: Single center work demonstrated a safe reduction in unnecessary blood culture use in critically ill children. Our objective was to develop and implement a customizable quality improvement framework to reduce unnecessary blood culture testing in critically ill children across diverse clinical settings and various institutions.

Methods: Three pediatric intensive care units (14 bed medical/cardiac; 28 bed medical; 22 bed cardiac) in 2 institutions adapted and implemented a 5-part Blood Culture Improvement Framework, supported by a coordinating multidisciplinary team.