Objectives: We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016. Design: Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey. Setting: PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU. Subjects: Physician medical directors and nurse managers. Interventions: None. Measurements and Main Results: PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital. Conclusions: U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.

Objectives: To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States. Design: Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders. Setting: Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease. Participants: Cardiac ICU or mixed ICU physician medical directors or designees. Measurements and Main Results: One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001). Conclusions: Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.

ProblemCertain animals around marine hydrothermal vents and cold seeps have formed a symbiotic relationship with chemosynthetic microbes. In particular, vesicomyid clams, vestimentiferans, and some bathymodiolin mussels take up hydrogen sulfide from vent or seep emissions for thiotrophic endosymbionts. These endosymbionts oxidize the AbstractVesicomyid clams, vestimentiferans, and some bathymodiolin mussels from hydrothermal vents and cold seeps possess thiotrophic endosymbionts, high levels of hypotaurine and, in tissues with symbionts, thiotaurine. The latter, a product of hypotaurine and sulfide, may store and/or transport sulfide non-toxically, and the ratio to hypotaurine plus thiotaurine (Th/[H + Th]) may reflect an animal's sulfide exposure. To test this, we analyzed seep and vent animals with in situ sulfide measurements. Calyptogena kilmeri clams occur at high-sulfide seeps in Monterey Canyon, while C. (Vesicomya) pacifica clams occur at seeps with lower levels but take up and metabolize sulfide more effectively. From one seep where they co-occur, both had gill thiotaurine contents at 22-25 mmol kg )1 wet mass, and while C. (V.) pacifica had a higher blood sulfide level, it had a lower Th/[H + Th] (0.39) than C. kilmeri (0.63). However, these same species from different seeps with lower sulfide exposures had lower ratios. Bathymodiolus thermophilus [East Pacific Rise (EPR 9°50¢ N)] from high-(84 lm) and a low-(7 lm) sulfide vents had gill ratios of 0.40 and 0.12, respectively. Trophosomes of Riftia pachyptila (EPR 9°50¢ N) from medium-(33 lm) and low-(4 lm) sulfide vents had ratios of 0.23 and 0.20, respectively (not significantly different). Ridgeia piscesae vestimentiferans (Juan de Fuca Ridge) have very different phenotypes at high-and low-sulfide sites, and their trophosomes had the greatest differences: 0.81 and 0.04 ratios from high-and low-sulfide sites, respectively. Thus Th/ [H + Th] may indicate sulfide exposure levels within species, but not in interspecies comparisons, possibly due to phylogenetic and metabolic differences. Total H + Th was constant within each species (except in R. piscesae); the sum may indicate the maximum potential sulfide load that a species faces.

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At least 45 specialized pediatric neurocritical care services exist in the United States. Eighty percent of these services are a consultation service to the PICU. Hospitals with level 1 trauma status, greater numbers of PICU beds, and greater numbers of patients with pediatric neurocritical care conditions were associated with the existence of pediatric neurocritical care as a clinical service.

Objective: To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States. Design: REDCap surveys were sent by email from May till August 2019 to medical directors (“directors”) of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure. Measurements and main results: Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%). Conclusions: Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

Introduction: Suboptimal hand hygiene (HH) remains a significant modifiable cause of healthcare-associated infections in the intensive care unit. We report a single-center, quality improvement project aimed at improving adherence to optimal HH among physicians, nurse practitioners, and nursing staff, and to sustain any improvement over time. Methods: A key driver diagram was developed to identify 5 primary drivers of change: leadership support, education initiatives, patient-family engagement, increased audit frequency, and individual feedback to promote accountability. We examined HH compliance over 3 years in 3 phases (pre-intervention, intervention, and post-intervention). The intervention period involved a multimodal approach designed to influence unit culture as well as individual HH practice. HH screens were installed outside the patient rooms to provide just-in-time reminders and display of regularly updated HH adherence data for provider groups. Results: We recorded 6,563 HH opportunities, providers included nurses (66%), attendings (12%), fellow/resident (16%), and nurse practitioners (NP) (6%). All clinical groups demonstrated HH compliance >90% during the post-intervention period. The improvements in practice were sustained for a year after the intervention. Conclusion: Our report highlights modifiable factors that impact HH and may inform quality improvement interventions aimed at improving HH compliance at other centers.

Objective: To assess the training and the future workforce needs of paediatric cardiac critical care faculty. Design: REDCap surveys were sent May−August 2019 to medical directors and faculty at the 120 US centres participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database. Faculty and directors were asked about personal training pathway and planned employment changes. Directors were additionally asked for current faculty numbers, expected job openings, presence of training programmes, and numbers of trainees. Predictive modelling of the workforce was performed using respondents’ data. Patient volume was projected from US Census data and compared to projected provider availability. Measurements and main results: Sixty-six per cent (79/120) of directors and 62% (294/477) of contacted faculty responded. Most respondents had training that incorporated critical care medicine with the majority completing training beyond categorical fellowship. Younger respondents and those in dedicated cardiac ICUs were more significantly likely to have advanced training or dual fellowships in cardiology and critical care medicine. An estimated 49–63 faculty enter the workforce annually from various training pathways. Based on modelling, these faculty will likely fill current and projected open positions over the next 5 years. Conclusions: Paediatric cardiac critical care training has evolved, such that the majority of faculty now have dual fellowship or advanced training. The projected number of incoming faculty will likely fill open positions within the next 5 years. Institutions with existing or anticipated training programmes should be cognisant of these data and prepare graduates for an increasingly competitive market.