No abstract

Objectives: Clinical deterioration in hospitalized children is associated with increased risk of mortality and morbidity. A prediction model capable of accurate and early identification of pediatric patients at risk of deterioration can facilitate timely assessment and intervention, potentially improving survival and long-term outcomes. The objective of this study was to develop a model utilizing vital signs from electronic health record data for predicting clinical deterioration in pediatric ward patients. Design: Observational cohort study. Setting: An urban, tertiary-care medical center. Patients: Patients less than 18 years admitted to the general ward during years 2009–2018. Interventions: None. Measurements and Main Results: The primary outcome of clinical deterioration was defined as a direct ward-to-ICU transfer. A discrete-time logistic regression model utilizing six vital signs along with patient characteristics was developed to predict ICU transfers several hours in advance. Among 31,899 pediatric admissions, 1,375 (3.7%) experienced the outcome. Data were split into independent derivation (yr 2009–2014) and prospective validation (yr 2015–2018) cohorts. In the prospective validation cohort, the vital sign model significantly outperformed a modified version of the Bedside Pediatric Early Warning System score in predicting ICU transfers 12 hours prior to the event (C-statistic 0.78 vs 0.72; p < 0.01). Conclusions: We developed a model utilizing six commonly used vital signs to predict risk of deterioration in hospitalized children. Our model demonstrated greater accuracy in predicting ICU transfers than the modified Bedside Pediatric Early Warning System. Our model may promote opportunities for timelier intervention and risk mitigation, thereby decreasing preventable death and improving long-term health.

Data suggest inadequacy of common statistical techniques for reporting outcomes in clinical trials. The Fragility Index can measure how many events the statistical significance hinges on, and may facilitate better interpretation of trial results. This study aimed to assess the Fragility Index in pediatric randomized controlled trials (RCTs) with statistically significant findings published in high-quality medical journals. A Fragility Index was calculated on included trials with dichotomous positive outcomes. Analysis of the relationship between trial characteristics and the Fragility Index was performed. Of the 429 abstracts screened, 17 met the inclusion criteria and underwent analysis. The median Fragility Index was 7 with an interquartile range of 2–11. In 41% of the studies, the number of patients lost to follow-up or withdrawn prior to analysis was equal to or greater than the Fragility Index. There was no correlation between the RCT sample size and the Fragility Index (r = 0.249, p = 0.335) nor the event group size and the Fragility Index (r = 0.250, p = 0.334). There was a strong negative correlation between the original p-value and the Fragility Index (r = −0.700, p = 0.002). The Fragility Index is a calculated metric that may assist in applying clinical relevance to statistically significant outcomes in pediatric randomized controlled trials with dichotomous outcomes.

Introduction: Resuscitation skills decay as early as 4 months after course acquisition. Gaps in research remain regarding ideal educational modalities, timing, and frequency of curricula required to optimize skills retention. Our objective was to evaluate the impact on retention of resuscitation skills 8 months after the Pediatric Advanced Life Support (PALS) course when reinforced by an adjunct simulation-based curriculum 4 months after PALS certification. We hypothesized there would be improved retention in the intervention group.Methods: This is a partial, double-blind, randomized controlled study.First-year pediatric residents were randomized to an intervention or control group. The intervention group participated in a simulation-based curriculum grounded in principles of deliberate practice and debriefing. The control group received no intervention. T-tests were used to compare mean percent scores (M) from simulation-based assessments and multiple-choice tests immediately following the PALS course and after 8 months.Results: Intervention group (n = 12) had overall improved retention of resuscitation skills at 8 months when compared with the control group (n = 12) (mean, 0.57 ± 0.05 vs 0.52 ± 0.06; P = 0.037). No significant difference existed between individual skills stations. The intervention group had greater retention of cognitive knowledge (mean, 0.78 ± 0.09 vs 0.68 ± 0.14; P = 0.049). Residents performed 61% of assessment items correctly immediately following the PALS course.Conclusions: Resuscitation skills acquisition from the PALS course and retention are suboptimal. These findings support the use of simulationbased curricula as course adjuncts to extend retention beyond 4 months.

Background: Multi-institutional, international practice variation of pediatric anaphylaxis management by healthcare providers has not been reported.Objective: Characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. Methods:A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 healthcare institutions in six countries. The on-duty healthcare team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.Results: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15/37) of institutions. Teams used a cognitive aid for medication dosing 41% (15/37) of the time and 32% (12/37) for preparation. Epinephrine auto injectors (EAIs) were not available in 54% (20/37) of institutions and were used in only 14% (5/37) simulations. Median time to epinephrine administration was 95 seconds (IQR 77, 252) for EAI and 263 seconds (IQR 146, 407.5) for manually prepared epinephrine (p=.12). At least one medication error occurred in 68% (25/37) of simulations. Prior nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (p=.04) and administration (p=.01) errors.Latent safety threats (LSTs) were reported by 30% (11/37) of institutions, more than half of these (6/11) involved a cognitive aid. Conclusion and Relevance:A multicenter, international study of simulated pediatric anaphylaxis reveals: 1) variation in management between institutions in usage of protocols,