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Objectives: The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists., Data Sources: An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists., Study Selection: Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models., Data Extraction: Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review., Data Synthesis: Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records., Conclusions: Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

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.

Introduction:: The number of websites for the critical care provider is rapidly growing, including websites that are part of the Free Open Access Med(ical ed)ucation (FOAM) movement. With this rapidly expanding number of websites, critical appraisal is needed to identify quality websites. The last major review of critical care websites was published in 2011, and thus a new review of the websites relevant to the critical care clinician is necessary., Methods:: A new assessment tool for evaluating critical care medicine education websites, the Critical Care Medical Education Website Quality Evaluation Tool (CCMEWQET), was modified from existing tools. A PubMed and Startpage search from 2007 to 2017 was conducted to identify websites relevant to critical care medicine education. These websites were scored based on the CCMEWQET., Results:: Ninety-seven websites relevant for critical care medicine education were identified and scored, and the top ten websites were described in detail. Common types of resources available on these websites included blog posts, podcasts, videos, online journal clubs, and interactive components such as quizzes. Almost one quarter of websites (n = 22) classified themselves as FOAM websites. The top ten websites most often included an editorial process, high-quality and appropriately attributed graphics and multimedia, scored much higher for comprehensiveness and ease of access, and included opportunities for interactive learning., Conclusion:: Many excellent online resources for critical care medicine education currently exist, and the number is likely to continue to increase. Opportunities for improvement in many websites include more active engagement of learners, upgrading navigation abilities, incorporating an editorial process, and providing appropriate attribution for graphics and media.

Objectives: To describe growth trends in the number of programs, positions, and applicants in pediatric critical care medicine fellowship training as part of the Pediatric Critical Care Medicine Training Study., Design: Descriptive study., Settings: Available archived Match data through the National Resident Matching Program and training data from the Accreditation Council for Graduate Medical Education., Patients: None., Interventions: None., Measurements and Main Results: We analyzed all data on programs, positions, and applicants through the National Resident Matching Program Specialties Matching Service during the study period of 2004 to 2016. We also analyzed available training data available through the Accreditation Council for Graduate Medical Education for the corresponding study period. During the 12-year study period, there was a statistically significant expansion in programs (38%), positions (82%), and applicants (151%). Correspondingly, the percentage of pediatric critical care medicine programs participating in the Match as a percentage of all Accreditation Council for Graduate Medical Education-accredited programs for that academic year increased 24%. As of 2015, 94% of total first year positions offered for pediatric critical care medicine were through the Match., Conclusions: For the period 2004 to 2016, there was a substantial increase in positions and applicants applying for training in pediatric critical care medicine. We document an increase in demand (i.e., applicants) that has been matched by an increase in supply (i.e., positions) for pediatric critical care medicine fellowship training. The nearly complete use of the National Resident Matching Program for placing applicants in training positions in pediatric critical care medicine suggests that these data can be used to inform workforce analysis in pediatric critical care medicine.

Problem: Health care professionals are familiar with engaging in local communities of practice (CoPs) within their hospital, region, and/or country, but despite the availability of online technologies that facilitate online global collaboration, the health care sector has yet to fully embrace these tools., Approach: In 2013, OPENPediatrics (an online social learning platform) launched the World Shared Practices video (WSP) series to engage and coalesce the global community of critical care clinicians. Each month, a 30- to 45-minute video featuring a pediatric critical care medicine expert, interspersed with questions for the audience, is released. Viewers contribute to the community discussion by leaving comments that display alongside the video. Clinicians are encouraged to asynchronously host an educational conference so they can watch the videos and participate in the discussion together., Outcomes: From March 2013-November 2015, 28 WSPs were launched on a variety of topics. They were viewed over 18,414 times by 1,864 viewers in 132 countries and 760 hospitals; 1,155 comments were submitted. Attending physicians/consultants were the largest audience (36% [671/1,864]), and 37% (30/81) of responding viewers that commented in WSPs watched in small groups. The WSP series was reported to add value to respondents' learning or teaching and to have had a positive impact on their knowledge or practice., Next Steps: Future research will focus on further describing the context and structure of the CoP and on more deeply investigating its higher-level outcomes and impact. More work is needed to identify barriers and strategies that improve online community engagement.

Objectives: Advances in Internet technology now enable unprecedented global collaboration and collective knowledge exchange. Up to this time, there have been limited efforts to use these technologies to actively promote knowledge exchange across the global pediatric critical care community. To develop an open-access, peer-reviewed, not-for-profit Internet-based learning application, OPENPediatrics, a collaborative effort with the World Federation of Pediatric Intensive and Critical Care Societies, was designed to promote postgraduate educational knowledge exchange for physicians, nurses, and others caring for critically ill children worldwide., Design: Description of program development., Setting: International multicenter tertiary pediatric critical care units across six continents., Subjects: Multidisciplinary pediatric critical care providers., Interventions: A software application, providing information on demand, curricular pathways, and videoconferencing, downloaded to a local computer., Measurements and Main Results: In 2010, a survey assessing postgraduate educational needs was distributed through World Federation of Pediatric Intensive and Critical Care Societies to constituent societies. Four hundred and twenty-nine critical care providers from 49 countries responded to the single e-mail survey request. Respondents included 68% physicians and 28% nurses who care for critically ill children. Fifty-two percent of respondents reported accessing the Internet at least weekly to obtain professional educational information. The five highest requests were for educational content on respiratory care [mechanical ventilation] (48% [38%]), sepsis (28%), neurology (25%), cardiology (14%), extracorporeal membrane oxygenation (10%), and ethics (8%). Based on these findings, and in collaboration with researchers in adult learning and online courseware, an application was developed and is currently being used by 770 registered users in 60 countries., Conclusions: We describe here the development and implementation of an Internet-based application which is among the first efforts designed to promote global knowledge exchange for physicians and nurses caring for critically ill children. This application has the potential to evolve new methods in postgraduate education. Ongoing assessment of the efficacy of Internet-based learning platforms will be necessary.

Purpose: Recent changes in duty hour allowances and economic constraints are forcing a paradigm shift in graduate medical education in the United States. Internet-based learning is a rapidly growing component of postgraduate medical education, including the field of critical care medicine. Here, we define the key concepts of Internet-based learning, summarize the current literature, and describe how Internet-based learning may be uniquely suited for the critical care provider., Methods: A MEDLINE/PubMed search from January 2000 to July 2011 using the search terms: "e-learning," "Web-based learning," "computer-aided instruction," "adult learning," "knowledge retention," "intensive care," and "critical care.", Results: The growth of the Internet is marked by the development of new technologies, including more user-derived tools. Nonmedical fields have embraced Internet-based learning as a valuable teaching tool. A recent meta-analysis described Internet-based learning in the medical field as being more effective than no intervention and likely as efficacious as traditional teaching methods. Web sites containing interactive features are aptly suited for the adult learner, complementing the paradigm shift to more learner-centered education. Interactive cases, simulators, and games may allow for improvement in clinical care. The total time spent utilizing Internet-based resources, as well as the frequency of returning to those sites, may influence educational gains., Conclusion: Internet-based learning may provide an opportunity for assistance in the transformation of medical education. Many features of Web-based learning, including interactivity, make it advantageous for the adult medical learner, especially in the field of critical care medicine, and further work is necessary to develop a robust learning platform incorporating a variety of learning modalities for critical care providers.

Objective: The low incidence of crises in pediatrics, coupled with logistic issues and restricted work hours for trainees, hinders opportunities for frequent practice of crisis management and teamwork skills. We hypothesized that a dedicated simulator suite contiguous to the intensive care unit (ICU) would enhance the frequency and breadth of critical-incident training for a range of clinicians., Design: Descriptive study., Setting: A tertiary-care pediatric teaching hospital., Measurements and Main Results: A realistic pediatric simulator suite was constructed 100 feet from the ICU, at a total base cost of $290,000. The simulation room is an exact replica of an ICU bed space, incorporating high-fidelity mannequin simulators. To capture an even wider audience, a portable unit was also created. Leaders from seven departments-critical care, cardiac intensive care, emergency medicine, transport medicine, anesthesia, respiratory care, and general pediatrics-completed instructor training to ensure effective debriefing techniques. Pediatric staff, including 100% of critical care fellows, 86% of nurses, 90% of respiratory therapists, and 74% of pediatric house staff, participated in >1500 learning encounters per year. All individuals were trained during their normal workday in the hospital. Courses in crisis resource management, skills acquisition, annual review, orientation, and trauma management (1,116, 98, 90, 60, and 60 encounters per year, respectively) were all designed by a multidisciplinary committee to ensure goal-directed education to a range of audiences. Annual costs were on par with those at other centers (approximately 44 dollars per trainee encounter)., Conclusions: An onsite and comprehensive simulation program can significantly increase the opportunities for clinicians from multiple disciplines, in the course of their daily routines, to repetitively practice responses to pediatric medical crises. After an initial capital investment, the training appears to be cost-effective. Hospital-based simulator suites may point the way forward as a new paradigm for the effective education of today's busy clinicians.

Improving the quality of end-of-life care has become a national health care priority. A necessary step in this process in the pediatric intensive care unit (ICU) is examining the knowledge, attitudes,and behaviors of pediatric critical care practitioners in this area. In addition, the perspectives of bereaved parents must be uncovered as well. In this article, the empirical data in the literature on end-of-life care in the pediatric ICU are reviewed, common ethical controversies in this environment are discussed, and promising interventions for the future are presented.

Objective: To determine types, sources, and predictors of conflicts among patients with prolonged stay in the ICU., Design and Setting: We prospectively identified conflicts by interviewing treating physicians and nurses at two stages during the patients' stays. We then classified conflicts by type and source and used a case-control design to identify predictors of team-family conflicts., Design and Setting: Seven medical and surgical ICUs at four teaching hospitals in Boston, USA., Patients: All patients admitted to the participating ICUs over an 11-month period whose stay exceeded the 85th percentile length of stay for their respective unit ( n=656)., Measurements and Results: Clinicians identified 248 conflicts involving 209 patients; hence, nearly one-third of patients had conflict associated with their care: 142 conflicts (57%) were team-family disputes, 76 (31%) were intrateam disputes, and 30 (12%) occurred among family members. Disagreements over life-sustaining treatment led to 63 team-family conflicts (44%). Other leading sources were poor communication (44%), the unavailability of family decision makers (15%), and the surrogates' (perceived) inability to make decisions (16%). Nurses detected all types of conflict more frequently than physicians, especially intrateam conflicts. The presence of a spouse reduced the probability of team-family conflict generally (odds ratio 0.64) and team-family disputes over life-sustaining treatment specifically (odds ratio 0.49)., Conclusions: Conflict is common in the care of patients with prolonged stays in the ICU. However, efforts to improve the quality of care for critically ill patients that focus on team-family disagreements over life-sustaining treatment miss significant discord in a variety of other areas.

Objective: To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care., Design: Cross-sectional survey., Setting: A random sample of clinicians at 31 pediatric hospitals in the United States., Measurements and Main Results: The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care., Conclusions: Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.

Ethical dilemmas in clinical practice frequently center around who should make decisions for the patient, and what common principles can be used in making those decisions. In pediatrics, these dilemmas are complicated by balancing the interests of the child with the rights of parents and the responsibilities of clinicians. Other sources of controversy in caring for the pediatric population concern the confusion that continues around such issues as informed assent, the present standing of the "Baby Doe" regulations, and the forgoing of life-sustaining treatments. This article discusses the framework for decision-making in children that has evolved in ethics and the law over the last several decades.