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Objectives: To increase the number of nights without sleep interruptions for routine tasks in recovering PICU patients., Design: Prospective quality improvement project., Setting: Single-center, free-standing, tertiary children's hospital., Patients: Patients admitted to the PICU for greater than 72 hours and eligible for early mobilization., Interventions: A multidisciplinary sleep hygiene team was created to improve sleep hygiene in critically ill patients eligible for early mobilization. This team rewrote local nursing policies to avoid routine tasks between 11 pm and 5 am . The team provided periodic control chart updates to staff detailing progress made protecting sleep. Discussions of sleep hygiene were added to the daily goal sheet and a sleep hygiene order set was created. Finally, the PICU quality dashboard was modified to show whether a sleep hygiene order set was initiated in eligible patients., Measurements and Main Results: Routine tasks were defined as daily chest radiographs, baths, routine tracheostomy care, central line dressing changes, twice daily medications, weights, and Foley care. After a year of data collection, avoidance of routine pupillary examinations was added to the sleep protection criteria. Baseline data was collected for 2 months prior to the creation of the sleep hygiene team. Screening of eligible patients occurred 1 week each month. The data were analyzed utilizing control charts. Baseline data demonstrated 32% of PICU patients without sleep interruptions. The centerline increased to 58% after the initial interventions but dropped to 33% after inclusion of pupillary checks. Following the introduction of the daily goal sheet, sleep hygiene order set, and tracking on the quality board, 49% of patients went without interruptions., Conclusions: The initiation of a sleep hygiene team along with retiming routine tasks, daily discussions on rounds with the daily goal sheet, introduction of a sleep hygiene order set, and transparent tracking improved the percentage of patients with protected sleep., Competing Interests: Dr. Bhattarai received funding through stocks from Decibel Therapeutics, Nuance Communications, Supernus Pharmaceuticals, Inovio Pharmaceuticals, TFF Pharmaceuticals, Galera Therapeutics, Bristol-Myers Squibb, CVS Health, Cardinal Health, Gilead Sciences, Novavax, Quest Diagnostics, and Teladoc. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objective: To reduce the frequency of non-ICU arrests through the implementation of an intramural collaborative focused on patient deterioration., Design: Prospective quality improvement project., Setting: Single-center, free-standing, tertiary children's hospital., Patients: All patients admitted to acute care units., Interventions: The Late Rescue Collaborative was formed in 2014 to monitor compliance with hospital escalation protocols and evaluate episodes of patient deterioration. The collaborative is a multidisciplinary team of physicians, nurses, and respiratory care providers. Three monthly meetings occur: 1) individual acute care unit-based meetings to evaluate trends and performance; 2) hospital-wide multidisciplinary whole group meetings to review hospital trends in deterioration and share lessons learned; and 3) steering committee to determine areas of focus. Based on these three meetings, unit- and hospital-based interventions have been put in place to improve recognition of deterioration and promote early rescue., Measurements and Main Results: Rates of rapid response team activations, unplanned transfers, and non-ICU arrest are reported. Non-ICU arrest rates fell from a baseline of 0.31 per 1,000 non-ICU patient days to a new centerline of 0.11 and sustained for 36 months. Days between non-ICU arrests increased from a baseline of 15.5 days in year 2014 to a new centerline of 61.5 days and sustained for 37 months. Mortality following non-ICU arrests fell from four in 2014 and 2015 to zero in years 2016-2018., Conclusion: The Late Rescue Collaborative is an effective tool to improve patient safety by reducing non-ICU arrests.

Objective: To evaluate the ability of a Pediatric Early Warning Score to predict deterioration in different subspecialty patient populations., Design: Single center, retrospective cohort study. Patients were classified into five groups: 1) cardiac; 2) hematology/oncology/bone marrow transplant; 3) surgical; 4) neurologic; and 5) general medical. The relationship between the Pediatric Early Warning Score and unplanned ICU transfer requiring initiation of specific ICU therapies (intubation, high-flow nasal cannula, noninvasive ventilation, inotropes, or aggressive fluid hydration within 12 hr of transfer) was evaluated., Setting: Tertiary care, free-standing, academic children's hospital., Patients: All hospitalized acute care patients admitted over a 6-month time period (September 2012 to March 2013)., Interventions: None., Measurements and Main Results: During the study time period, 33,800 patient-days and 136 deteriorations were evaluated. Area under the curve ranged from 0.88 (surgical) to 0.94 (cardiac). Sensitivities for a Pediatric Early Warning Score greater than or equal to 3 ranged from 75% (surgical) to 94% (cardiology) and number needed to evaluate to find one deterioration was 11.5 (neurologic) to 43 patients (surgical). Sensitivities for a Pediatric Early Warning Score greater than or equal to 4 ranged from 54% (general medical) to 79% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 5.5 (neurologic) to 12 patients (general medical). Sensitivities for a Pediatric Early Warning Score of greater than or equal to 5 ranged from 25% (surgical) to 58% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 3.5 (cardiac, hematology/oncology/bone marrow transplant, neurologic) to eight patients (surgical)., Conclusions: An elevated Pediatric Early Warning Score is associated with ICU transfer and receipt of ICU-specific interventions in patients across different pediatric subspecialty patient populations.

Objective: The purpose of this observational study is to explore if bedside Doppler ultrasonography of the central retinal vessels has the potential to become an ancillary study to support the timely diagnosis of brain death in children., Design: Seventeen-month prospective observational cohort., Setting: Forty-four bed pediatric medical and surgical ICU in an academic teaching hospital., Patients: All children 0-18 years old who were clinically evaluated for brain death at Children's National Health Systems were enrolled and followed until discharge or death., Interventions: None., Measurements and Main Results: All patients had at least one ophthalmic ultrasound within 30 minutes of each brain death examination. The central retinal artery peak systolic blood flow velocity, resistive index, pulsatility index, and Doppler waveforms were evaluated in each patient. Thirty-five ophthalmic ultrasounds were obtained on 13 patients, 3 months to 15 years old, who each had two clinical examinations consistent with brain death. The average systolic blood pressure during the ultrasound examinations was 102 mm Hg (± 28), diastolic blood pressure 65 mm Hg (± 24), mean arterial pressure 79 mm Hg (± 23), heart rate 133 beats/min (± 27), temperature 36°C (± 0.96), arterial CO2 35 mm Hg (± 9), and end-tidal CO2 23 mm Hg (± 6). For all examinations, the average peak systolic velocity of the central retinal artery was significantly decreased at 4.66 cm/s (± 3.2). Twelve of 13 patients had both resistive indexes greater than or equal to 1, average pulsatility indexes of 3.6 (± 3.5) with transcranial Doppler waveforms consistent with brain death. Waveform analysis of the 35 ultrasound examinations revealed 11% with tall systolic peaks without diastolic flow, 17% with oscillatory flow, 29% showed short systolic spikes, and 23% had no Doppler movement detected. A rippling "tardus-parvus" waveform was present in 20% of examinations., Conclusion: This study supports that the combination of qualitative waveform analysis and quantitative blood flow variables of the central retinal vessels may have the potential to be developed as an ancillary study for supporting the diagnosis of brain death in children.

Objective: To determine the prevalence of acute symptomatic seizures in infants with supratentorial intracranial hemorrhage, to identify potential risk factors, and to determine the effect of acute seizures on long-term morbidity and mortality., Design: Children less than 24 months with intracranial hemorrhage were identified from a neurocritical care database. All patients who received seizure prophylaxis beginning at admission were included in the study. Risk factors studied were gender, etiology, location of hemorrhage, seizure(s) on presentation, and the presence of parenchymal injury. Acute clinical and electrographic seizures were identified from hospital medical records. Subsequent development of late seizures was determined based on clinical information from patients' latest follow-up., Setting and Patients: Patients with idiopathic neonatal intracranial hemorrhage, premature infants, and those with prior history of seizures were excluded from analysis. Seventy-two infants met inclusion criteria., Interventions: None., Measurements and Main Results: Forty percent of infants had acute symptomatic seizures. The prevalence was similar regardless of whether etiology of hemorrhage was traumatic or nontraumatic. Seizures on presentation and parenchymal injury were independent risk factors of acute seizures (p = 0.001 and p = 0.006, respectively). Younger children and women were also at higher risk (p < 0.05). Twenty percent had electrographic-only seizures, and those with parenchymal injury trended toward an increased risk (p < 0.1). Acute seizures were not predictive of mortality, but nearly twice as many patients with acute seizures developed late seizures when compared with those without. Electrographic seizures and parenchymal injury were also predictive of development of late seizures (p < 0.001 and p = 0.013, respectively)., Conclusions: Despite seizure prophylaxis, infants with supratentorial intracranial hemorrhage are at high risk for acute symptomatic seizures. This is regardless of the etiology of hemorrhage. Younger patients, women, patients with parenchymal injury, and patients presenting with seizure are most likely to develop acute seizures. Although the benefits of seizure prophylaxis have not been studied in this specific population, these results suggest that it is an important component of acute care following intracranial hemorrhage.