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Burnout is a major challenge in health care and is associated with poor overall well-being, increased medical errors, worse patient outcomes, and low job satisfaction. There is scant literature focused on the respiratory therapist's (RT) experience of burnout, and a thorough exploration of RTs' perception of factors associated with burnout has not been reported. The aim of this qualitative study was to understand the factors associated with burnout as experienced by RTs amid the COVID-19 pandemic.We performed a post hoc, qualitative analysis of free-text responses from a survey of burnout prevalence in RTs.There were 1,114 total and 220 free-text responses. Five overarching themes emerged from the analysis: staffing, workload, physical/emotional consequences, lack of effective leadership, and lack of respect. Respondents discussed feelings of anxiety, depression, and compassion fatigue as well as concerns that lack of adequate staffing, high workload assignments, and inadequate support from leadership contributed to feelings of burnout. Specific instances of higher patient acuity, surge in critically ill patients, rapidly evolving changes in treatment recommendations, and minimal training and preparation for an extended scope of practice were reported as stressors that led to burnout. Some respondents stated that they felt a lack of respect for both the RT profession and the contribution of RTs to patient care.Themes associated with burnout in RTs included staffing, workload, physical and emotional exhaustion, lack of effective leadership, and lack of respect. These results provide potential targets for interventions to combat burnout among RTs.

Children admitted to the pediatric intensive care unit often require respiratory support for the treatment of respiratory distress and failure. Respiratory support comprises both noninvasive modalities (ie, heated humidified high-flow nasal cannula, continuous positive airway pressure, bilevel positive airway pressure, negative pressure ventilation) and invasive mechanical ventilation. In this article, we review the various essential elements and considerations involved in the planning and application of respiratory support in the treatment of the critically ill children.

BACKGROUND The use of electronic clinical decision support (CDS) systems for pediatric critical care trials is rare. We sought to describe in detail the use of a CDS tool (Children's Hospital Euglycemia for Kids Spreadsheet [CHECKS]), for the management of hyperglycemia during the 32 multicenter Heart And Lung Failure-Pediatric Insulin Titration trial. RESEARCH QUESTION In critically ill pediatric patients who were treated with CHECKS, how was user compliance associated with outcomes; and what patient and clinician factors might account for the observed differences in CHECKS compliance? STUDY DESIGN AND METHODS During an observational retrospective study of compliance with a CDS tool used during a prospective randomized controlled trial, we compared patients with high and low CHECKS compliance. We investigated the association between compliance and blood glucose metrics. We describe CHECKS and use a computer interface analysis framework (the user, function, representation, and task analysis framework) to categorize user interactions. We discuss implications for future randomized controlled trials. RESULTS Over a 4.5-year period, 658 of 698 children were treated with the CHECKS protocol for ≥24 hours with a median of 119 recommendations per patient. Compliance per patient was high (median, 99.5%), with only 30 patients having low compliance (

Context.— Problems with health care worker (HCW) well-being have become a leading concern in medicine given their severity and robust links to outcomes like medical error, mortality, and turnover. Objective.— To describe the state of the science regarding HCW well-being, including how it is measured, what outcomes it predicts, and what institutional and individual interventions appear to reduce it. Data Sources.— Peer review articles as well as multiple large data sets collected within our own research team are used to describe the nature of burnout, associations with institutional resources, and individual tools to improve well-being. Conclusions.— Rates of HCW burnout are alarmingly high, placing the health and safety of patients and HCWs at risk. To help address the urgent need to help HCWs, we summarize some of the most promising early interventions, and point toward future research that uses standardized metrics to evaluate interventions (with a focus on low-cost institutional and personal interventions).

The current study aimed to guide the assessment and improvement of psychological safety (PS) by (1) examining the psychometric properties of a brief novel PS scale, (2) assessing relationships between PS and other safety culture domains, (3) exploring whether PS differs by healthcare worker demographic factors, and (4) exploring whether PS differs by participation in 2 institutional programs, which encourage PS and speaking-up with patient safety concerns (i.e., Safety WalkRounds and Positive Leadership WalkRounds).Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate, 81%) completed the 6-item PS scale, demographics, safety culture scales, and questions on exposure to institutional initiatives. Psychometric analyses, correlations, analyses of variance, and t tests were used to test the properties of the PS scale and how it differs by demographic factors and exposure to PS-enhancing initiatives.The PS scale exhibited strong psychometric properties, and a 1-factor model fit the data well (Cronbach α = 0.80; root mean square error approximation = 0.08; Confirmatory Fit Index = 0.97; Tucker-Lewis Fit Index = 0.95). Psychological Safety scores differed significantly by role, shift, shift length, and years in specialty. The PS scale correlated significantly and in expected directions with safety culture scales. The PS score was significantly higher in work settings with higher rates of exposure to Safety WalkRounds or Positive Leadership WalkRounds.The PS scale is brief, diagnostic, and actionable. It exhibits strong psychometric properties; is associated with better safety, teamwork climate, and well-being; differs by demographic factors; and is significantly higher for those who have been exposed to PS-enhancing initiatives.

The COVID 19 pandemic placed unprecedented strain on healthcare systems and workers, likely also impacting patient safety and outcomes. This study aimed to understand how teamwork climate changed during that pandemic and how these changes affected safety culture and workforce well-being.This cross-sectional observational study of 50,000 healthcare workers (HCWs) in 3 large U.S. health systems used scheduled culture survey results at 2 distinct time points: before and during the first year of the COVID 19 pandemic. The SCORE survey measured 9 culture domains: teamwork climate, safety climate, leadership engagement, improvement readiness, emotional exhaustion, emotional exhaustion climate, thriving, recovery, and work-life balance.Response rate before and during the pandemic was 75.45% and 74.79%, respectively. Overall, HCWs reporting favorable teamwork climate declined (45.6%-43.7%, P0.0001). At a facility level, 35% of facilities saw teamwork climate decline, while only 4% saw an increase in teamwork climate. Facilities with decreased teamwork climate had associated decreases in every culture domain, while facilities with improved teamwork climate maintained well-being domains and saw improvements in every other culture domain.Healthcare worker teamwork norms worsened during the COVID-19 pandemic. Teamwork climate trend was closely associated with other safety culture metrics. Speaking up, resolving conflicts, and interdisciplinary coordination of care were especially predictive. Facilities sustaining these behaviors were able to maintain other workplace norms and workforce well-being metrics despite a global health crisis. Proactive team training may provide substantial benefit to team performance and HCW well-being during stressful times.

BACKGROUND: Interventions to decrease burnout and increase well-being in health care workers (HCWs) and improve organizational safety culture are urgently needed. This study was conducted to determine the association between Positive Leadership WalkRounds (PosWR), an organizational practice in which leaders conduct rounds and ask staff about what is going well, and HCW well-being and organizational safety culture. METHODS: This study was conducted in a large academic health care system in which senior leaders were encouraged to conduct PosWR. The researchers used data from a routine cross-sectional survey of clinical and nonclinical HCWs, which included a question about recall of exposure of HCWs to PosWR: “Do senior leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?”—along with measures of well-being and safety culture. T-tests compared work settings in the first and fourth quartiles for PosWR exposure across SCORE (Safety, Communication, Operational Reliability, and Engagement) domains of safety culture and workforce well-being. RESULTS: Electronic surveys were returned by 10,627 out of 13,040 possible respondents (response rate 81.5%) from 396 work settings. Exposure to PosWR was reported by 63.1% of respondents overall, with a mean of 63.4% (standard deviation = 20.0) across work settings. Exposure to PosWR was most commonly reported by HCWs in leadership roles (83.8%). Compared to work settings in the fourth (< 50%) quartile for PosWR exposure, those in the first (> 88%) quartile revealed a higher percentage of respondents reporting good patient safety norms (49.6% vs. 69.6%, p < 0.001); good readiness to engage in quality improvement activities (60.6% vs. 76.6%, p < 0.001); good leadership accessibility and feedback behavior (51.9% vs. 67.2%, p < 0.001); good teamwork norms (36.8% vs. 52.7%, p < 0.001); and good work-life balance norms (61.9% vs. 68.9%, p = 0.003). Compared to the fourth quartile, the first quartile had a lower percentage of respondents reporting emotional exhaustion in themselves (45.9% vs. 32.4%, p < 0.001), and in their colleagues (60.5% vs. 47.7%, p < 0.001). CONCLUSION: Exposure to PosWR was associated with better HCW well-being and safety culture.

BACKGROUND: High-flow nasal cannula (HFNC) has been used in the treatment of pediatric asthma, although high-quality data comparing HFNC to aerosol mask nebulizer are lacking. We hypothesized that HFNC would perform similarly to the aerosol mask for meaningful clinical outcomes in children with critical asthma. METHODS: We retrospectively reviewed the medical records of children with critical asthma (age 2–17 y) with a modified pulmonary index score (MPIS) ≥ 8 admitted to our pediatric ICU as part of a quality improvement project. Patients were managed with our MPIS-based, respiratory therapist-driven protocol. Subjects were divided into 2 cohorts by initial respiratory support: HFNC or aerosol mask. Data included demographics, initial respiratory support, and MPIS over time. Primary outcome was hospital length of stay (LOS). Secondary outcome was difference in MPIS over time. RESULTS: We included 171 subjects, with 104 in the HFNC group and 67 in the aerosol mask group. Median (interquartile range [IQR]) age was lower in the HFNC group (5 [IQR 4–9] vs 7 [IQR 5–10] y, P = .006)], while other demographic characteristics were similar. Initial MPIS was similar between HFNC and aerosol mask groups (11 [IQR 9–12] vs 10 [IQR 9–12], P = .15). There were no significant differences for hospital LOS (2.9 [IQR 2.1–3.9] vs 3.0 [IQR 2.3–4.4] d, P = .47), pediatric ICU LOS (1.9 [IQR 1.4–2.8] vs 1.8 [IQR 1.5–3.0] d, P = .92), or time to MPIS CONCLUSIONS: HFNC performed similarly to aerosol mask in pediatric patients with critical asthma.

Burnout within health care is prevalent, and its effects are detrimental to patient outcomes, organizations, and individuals. Effects stemming from burnout include anxiety, depression, excessive alcohol and drug use, cardiovascular problems, time off work, and worse patient outcomes. Published data have suggested up to 50% of health care workers experience burnout and 79% of respiratory therapists (RTs) experience burnout. Leadership has been cited as a key driver of burnout among RTs. We aimed to identify factors associated with a positive or negative leadership perception.A post hoc analysis of an institutional review board-approved survey to evaluate RT burnout, administered via REDCap by convenience sample to 26 health care centers (3,124 potential respondents) from January 17-March 15, 2021, was performed to identify factors associated with a positive view of leadership. Survey questions included validated tools to measure leadership, burnout, staffing, COVID-19 exposure, and demographics. Data analysis was descriptive, and logistic regression was performed to evaluate factors associated with leadership perception.Of 1,080 respondents, 710 (66%) had a positive view of leadership. Univariate analysis revealed those with a positive view of leadership were more likely to be working with adequate staffing, were rarely unable to complete all work, were less likely to be burned out, disagreed that people in this work environment were burned out, were less likely to miss work for any reason, more likely to be in a leadership position, worked fewer hours in intensive care, worked in a center affiliated with a medical school, worked day shift, were less likely to care for adult patients, and were more likely to be male. Logistic regression revealed providing care to patients with COVID-19 (odds ratio [OR] 5.8-10.5,Most RTs had a positive view of their leadership. A negative leadership score was associated with higher burnout and missing work. This relationship requires further investigation to evaluate if changes in leadership practices can improve employee well-being and reduce burnout.

BACKGROUND: Burnout is a major problem in health care, with rates of approximately 33% and 50% in nurses and physicians, respectively, prior to the COVID-19 pandemic. Respiratory therapist (RT) burnout rates and drivers have not been specifically examined. The purpose of this project was to determine resilience and burnout resources available within respiratory care departments and to provide an estimate of pre- and post-COVID-19 RT burnout rates. METHODS: A survey was developed to evaluate resilience and burnout resources in respiratory care departments. The survey was posted online to the AARConnect management, education, adult acute care, neonatal/pediatrics, COVID-19, and help line communities. Data analysis was descriptive. Key drivers of burnout among RTs were identified from qualitative answers. RESULTS: There were 221 responses, and 72% reported experiencing burnout. Ten percent of the departments that responded measured burnout; 36% utilized resilience tools, and 83% offered free employee assistance for those struggling with burnout. In January 2020, 30% of departments reported an estimated burnout rate > 40%, which increased to 44% of departments (P = .007) in the COVID-19 pandemic period. The most common drivers reported were poor leadership (32%), high work load (31%), and staffing (29%); 93% of respondents agreed that burnout is a major problem in health care, 33% agreed that burnout is primarily driven by external factors, 92% agreed that RTs have a similar risk of burnout as other health care professionals, 73% agreed that they were comfortable discussing challenging situations with colleagues, 32% agreed that their leadership provided adequate support for those suffering from burnout, and 79% agreed that they would be open to utilizing resilience tools from the AARC or other professional organizations. CONCLUSIONS: Most respondents experienced burnout and few respiratory care departments measured burnout. Resilience resources were not commonly used but employee assistance and wellness programs were common. Key drivers of burnout identified were poor leadership, staffing, and high workloads.

Objectives Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. Design We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. Setting Forty international PICUs participating in the National Emergency Airway Registry for Children. Patients Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. Interventions None. Measurements and main results The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. Conclusions Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.

BACKGROUND: Scoring systems are frequently used to assess the severity of pediatric asthma exacerbations. The modified pulmonary index score (MPIS) has been found to be highly correlated with length of stay (LOS) in the pediatric intensive care unit (PICU). We sought to evaluate the use of the MPIS to predict hospital LOS for patients admitted to our PICU. METHODS: We retrospectively reviewed the medical records of pediatric asthma subjects aged 2–17 y admitted to our PICU between June 2014 and November 2017. We divided subjects a priori into 3 groups (low: MPIS 0–5; medium: MPIS 6–9; high: MPIS ≥ 10) based upon each subject9s first MPIS documented in the PICU. Hospital LOS, PICU LOS, time on continuous albuterol, and increased respiratory support were compared between groups. RESULTS: 143 subjects were included. There were no differences for demographics, medical history, cause of exacerbations, or mean heart rate between groups. There were significant differences between groups for mean breathing frequency (P S pO 2 (P = .01), and F IO 2 (P CONCLUSIONS: The MPIS thresholds used in our pathway appropriately predicted LOS in our cohort of subjects with asthma admitted to the PICU. Higher MPIS was associated with increased hospital LOS, PICU LOS, and time on continuous albuterol.

BACKGROUND: Burnout is a major challenge in health care, but its prevalence has not been evaluated in practicing respiratory therapists (RTs). The purpose of this study was to identify RT burnout prevalence and factors associated with RT burnout. METHODS: An online survey was administered at 26 centers in the United States between January and March 2021. Validated quantitative cross-sectional surveys were used to measure burnout and leadership domains. The survey was sent to department directors and distributed by the department directors to their staffs. Data analysis was descriptive, and logistic regression analysis was performed to evaluate risk factors, expressed as odds ratios (OR), for burnout. RESULTS: The survey was distributed to 3,010 RTs; the response rate was 37%. Seventy-nine percent of the respondents reported burnout, 10% with severe, 32% with moderate, and 37% with mild burnout. Univariate analysis revealed that those with burnout worked more hours per week, worked more hours per week in the ICU, primarily cared for adult patients, primarily delivered care via RT protocols, reported inadequate RT staffing, reported being unable to complete assigned work, had more frequent exposure to COVID-19 (coronavirus disease 2019), had a lower leadership score, and fewer had a positive view of leadership. Logistic regression revealed that burnout climate (OR 9.38; P < .001), inadequate RT staffing (OR 2.08 to 3.19; P = .004 to .05), unable to complete all work (OR 2.14 to 5.57; P = .003 to .02), and missed work for any reason were associated with an increased risk of burnout (OR 1.96; P = .007). Not providing patient care (OR 0.18; P = .02) and a positive leadership score (.55; P = .02) were associated with a decreased risk of burnout. CONCLUSIONS: Burnout was common among the RTs in the midst of the COVID-19 pandemic. Good leadership was protective against burnout, whereas inadequate staffing, an inability to complete work, and a burnout climate were associated with burnout.

Disruptive and unprofessional behaviors occur frequently in health care and adversely affect patient care and health care worker job satisfaction. These behaviors have rarely been evaluated at a work setting level, nor do we fully understand how disruptive behaviors (DBs) are associated with important metrics such as teamwork and safety climate, work-life balance, burnout, and depression.Using a cross-sectional survey of all health care workers in a large US health system, this study aimed to introduce a brief scale for evaluating DBs at a work setting level, evaluate the scale's psychometric properties and provide benchmarking prevalence data from the health care system, and investigate associations between DBs and other validated measures of safety culture and well-being.One or more of six DBs were reported by 97.8% of work settings. DBs were reported in similar frequencies by men and women, and by most health care worker roles. The six-item disruptive behavior scale demonstrated an internal consistency of α = 0.867. DB climate was significantly correlated with poorer teamwork climate, safety climate, job satisfaction, and perceptions of management; lower work-life balance; increased emotional exhaustion (burnout); and increased depression (p0.001 for each). A 10-unit increase in DB climate was associated with a 3.89- and 3.83-point decrease in teamwork and safety climate, respectively, and a 3.16- and 2.42-point increase in burnout and depression, respectively.Disruptive behaviors are common, measurable, and associated with safety culture and health care worker well-being. This concise DB scale affords researchers a new, valid, and actionable tool to assess DBs.

Pediatric acute respiratory distress syndrome (PARDS) is a significant cause of morbidity and mortality in children. Children with PARDS often require intensive care admission and mechanical ventilation. Unfortunately, beyond lung protective ventilation, there are limited data to support our management strategies in PARDS. The Pediatric Acute Lung Injury Consensus Conference (PALICC) offered a new definition of PARDS in 2015 that has improved our understanding of the true epidemiology and heterogeneity of the disease as well as risk stratification. Further studies will be crucial to determine optimal management for varying disease severity. This review will present the physiologic basis of PARDS, describe the unique pediatric definition and risk stratification, and summarize the current evidence for current standards of care as well as adjunctive therapies.

BACKGROUND: Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist– driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. METHODS: We retrospectively reviewed the medical records of all pediatric asthma subjects 2–17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. RESULTS: A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9 – 6.6] d vs 2.7 [1.6 – 4.0] d, P CONCLUSIONS: The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.

Previous studies report worse short-term outcomes with hypoglycemia in critically ill children. These studies relied on intermittent blood glucose measurements, which may have introduced detection bias. We analyzed data from the Heart And Lung Failure-Pediatric INsulin Titration trial to determine the association of hypoglycemia with adverse short-term outcomes in critically ill children.Nested case-control study.Thirty-five PICUs. A computerized algorithm that guided the timing of blood glucose measurements and titration of insulin infusion, continuous glucose monitors, and standardized glucose infusion rates were used to minimize hypoglycemia.Nondiabetic children with cardiovascular and/or respiratory failure and hyperglycemia. Cases were children with any hypoglycemia (blood glucose60 mg/dL), whereas controls were children without hypoglycemia. Each case was matched with up to four unique controls according to age group, study day, and severity of illness.None.A total of 112 (16.0%) of 698 children who received the Heart And Lung Failure-Pediatric INsulin Titration protocol developed hypoglycemia, including 25 (3.6%) who developed severe hypoglycemia (blood glucose40 mg/dL). Of these, 110 cases were matched to 427 controls. Hypoglycemia was associated with fewer ICU-free days (median, 15.3 vs 20.2 d; p = 0.04) and fewer hospital-free days (0 vs 7 d; p = 0.01) through day 28. Ventilator-free days through day 28 and mortality at 28 and 90 days did not differ between groups. More children with insulin-induced versus noninsulin-induced hypoglycemia had zero ICU-free days (35.8% vs 20.9%; p = 0.008). Outcomes did not differ between children with severe versus nonsevere hypoglycemia or those with recurrent versus isolated hypoglycemia.When a computerized algorithm, continuous glucose monitors and standardized glucose infusion rates were used to manage hyperglycemia in critically ill children with cardiovascular and/or respiratory failure, severe hypoglycemia (blood glucose40 mg/dL) was uncommon, but any hypoglycemia (blood glucose60 mg/dL) remained common and was associated with worse short-term outcomes.

Intro: Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure continues to demonstrate improving outcomes, largely due to advances in technology along with refined manag...

High-frequency ventilation is commonly utilized with neonates and with children with severe respiratory failure. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) are used extensively in neonates. HFJV can also be used in older, larger children. The purpose of this narrative review is to discuss the physiologic principles behind HFJV, examine the evidence supporting its use in neonatal and pediatric ICUs, give meaningful guidance for clinical application, and highlight potential areas for future research.

Objectives To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. Design Multicenter time-series study. Setting PICUs in the United States. Patients All patients received tracheal intubations in ICUs. Interventions We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. Measurements and main results The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). Conclusions Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

Tracheal intubation by respiratory therapists (RTs) is a well-established practice that has been described primarily in adult and neonatal patients. However, minimal data exist regarding RTs' intubation performance in pediatric ICUs. The purpose of this study was to describe the current landscape of intubations performed by RTs in pediatric ICUs.A multicenter quality improvement database, the National Emergency Airway Registry for Children (NEAR4KIDS) was queried from 2015 to 2018. We performed a retrospective analysis of prospectively collected data on subject demographics, indication for intubation, difficult airway history and feature presence, provider discipline, medications, and device. Intubation outcomes included first-attempt and overall success rates, adverse events, and oxygen desaturation (ie, [Formula: see text]80%). Overall intubation success was defined as intubation achieved in ≤ 2 attempts.There were 12,056 initial intubation encounters from 46 ICUs, with 109 (0.9%) first attempts performed by RTs. Nine (20%) ICUs reported at least one intubation encounter by RTs. The number of intubations performed by RTs at individual centers ranged from 1 to 46 (RT participation rate: 0.3% to 19.6%). RTs utilized video laryngoscopy more often than other providers (53.2% for RTs vs 28.1% for others,RTs infrequently intubate in pediatric ICUs, with success rates similar to other providers but higher adverse event rates. RTs were more likely to use video laryngoscopy than other providers. RTs' intubation participation, success, and adverse event rates varied greatly across pediatric ICUs.

Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU.A retrospective cohort study of a multicenter pediatric airway quality improvement registry.Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand).Children (18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015.None.Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036).Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.

OBJECTIVES Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. DESIGN Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). SETTING Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. PATIENTS Children with medical or surgical cardiac disease who underwent intubation in an ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002). CONCLUSIONS In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.A multicenter retrospective cohort study.Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.Primary tracheal intubation in children younger than 18 years.None.Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p0.001), whereas colorimetry use decreased (0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Critically ill neonatal and pediatric patients are commonly supported with conventional mechanical ventilation. The provision of safe and effective mechanical ventilation is a crucial skill for pediatric intensivists, especially as ventilator management continues to evolve. The past 20 years have

Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.International PICUs.Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p0.001).In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

Asthma exacerbation is a common reason for children to present to the emergency department. If primary therapies fail to halt the progression of an asthma flare, status asthmaticus often leads to hospital, and potentially ICU, admission. Following the initial administration of inhaled β agonists and systemic corticosteroids, a wide array of adjunct medical therapies may be used to treat status asthmaticus. Unfortunately, the data supporting the use of these adjunct therapies are often unclear, conflicting, or absent. This review will present the physiologic basis and summarize the supporting data for a host of adjunct therapies, including ipratropium, intravenous β agonists, methylxanthines, intravenous and inhaled magnesium, heliox (helium-oxygen mixture), ketamine, antibiotics, noninvasive ventilation, inhaled anesthetics, and extracorporeal membrane oxygenation. Finally, we present a suggested care map for escalating to these therapies in children with refractory status asthmaticus.

Since the ARDSNet low tidal volume study was published in 2000,[1][1] lung-protective ventilation has become the mainstay of conventional ventilatory support for patients with ARDS. However, when clinicians are unable to meet oxygenation or ventilation goals with conventional ventilator support

Burned out healthcare workers (HCWs) are more likely to make errors, provide poor quality of care, lack work-place engagement, and ultimately leave their jobs. The research is clear: the prevalence, severity and consequential nature of HCW burnout puts institutions at risk for costly patient safety issues and turnover. The need for evidence-based approaches to this large and growing problem is urgent, and many leaders are asking, “What can healthcare institutions and individual healthcare workers do to reduce burnout and improve well-being?” Across our research we have identified how HCW burnout intersects with safety culture, errors, engagement, and operational outcomes. We have also identified evidence-based institutional programs and initiatives as well as brief individual interventions (many at low/no cost) that improve burnout in the short and long term. Across all of the interventions we have found a key factor that appears to underlie the benefits that each intervention confers.

Background: Role clarity is important for patient care but challenging in graduate medical education (GME). Methods: Badge buddies were integrated for all GME trainees at a single institution, and surveys were conducted prior to and 5 months following implementation. Results: There were 932 pre- and 498 postimplementation respondents. Following implementation, both trainees and nurses reported improved awareness of GME training level, but there were no changes in patient/family perceptions. Conclusions: Badge buddies improved caregiver awareness of GME training level but did not impact patient/family perception. Patients appear to be focused primarily on relationships with caregivers and communication skills rather than a provider’s specific role.

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains.DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017.SETTING: Multicenter study conducted in 33 PICUs across eight countries.SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation.INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions.MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008).CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Objectives To investigate adaptive skills, behavior, and quality health-related quality of life in children from 32 centers enrolling in the Heart And Lung Failure-Pediatric INsulin Titration randomized controlled trial. Study design This prospective longitudinal cohort study compared the effect of 2 tight glycemic control ranges (lower target, 80-100 mg/dL vs higher target, 150-180 mg/dL) 1-year neurobehavioral and health-related quality of life outcomes. Subjects had confirmed hyperglycemia and cardiac and/or respiratory failure. Patients aged 2-16 years old enrolled between April 2012 and September 2016 were studied at 1 year after intensive care discharge. The primary outcome, adaptive skills, was assessed using the Vineland Adaptive Behavior Scale. Behavior and health-related quality of life outcomes were assessed as secondary outcomes using the Pediatric Quality of Life and Child Behavior Checklist at baseline and 1-year follow-up. Group differences were evaluated using regression models adjusting for age category, baseline overall performance, and risk of mortality. Results Of 369 eligible children, 358 survived after hospital discharge and 214 (60%) completed follow-up. One-year Vineland Adaptive Behavior Scale-II composite scores were not different (mean ± SD, 79.9 ± 25.5 vs 79.4 ± 26.9, lower vs higher target; P = .20). Improvement in Pediatric Quality of Life total health from baseline was greater in the higher target group (adjusted mean difference, 8.2; 95% CI, 1.1-15.3; P = .02). Conclusions One-year adaptive behavior in critically ill children with lower vs higher target glycemic control did not differ. The higher target group demonstrated improvement from baseline in overall health. This study affirms the lack of benefit of lower glucose targeting. Trial registration ClinicalTrials.gov : NCT01565941 .

Introduction: Hypoxemic respiratory failure is a common problem in critical care. Current management strategies, including mechanical ventilation and extracorporeal membranous oxygenation, can be efficacious but these therapies put patients at risk for toxicities associated with invasive forms of support.Areas covered: In this manuscript, we discuss intravenous oxygen (IVO2), a novel method to improve oxygen delivery that involves intravenous administration of a physiologic solution containing dissolved oxygen at hyperbaric concentrations. After a brief review of the physiology behind supersaturated fluids, we summarize the current evidence surrounding IVO2.Expert commentary: Although not yet at the stage of clinical testing in the United States and Europe, IVO2 has been used safely in Asia. Furthermore, preliminary laboratory data have been encouraging, suggesting that IVO2 may play a role in the management of patients with hypoxemic respiratory failure in years to come. However, significantly mo...

INTRODUCTION: Bag mask ventilation (BMV) and tracheal intubation (TI) are aerosol generating procedures The COVID-19 pandemic impacted North America since March 2020, possibly altering TI practice We hypothesized that during COVID-19 there was more use of rapid sequence intubation (RSI) without BMV and more use of video laryngoscopy (VL) and apneic oxygenation (AO) as techniques to reduce patient to provider transmission of SARS CoV 2 METHODS: Prospective observational cohort of initial TIs from NEAR4KIDS database: two periods (April-June 2019: Pre-COVID and April-June 2020: COVID) were chosen We evaluated the difference in patient, provider, and practice characteristics as well as the adverse TI associated events (TIAEs) and oxygen desaturation (SpO2

Rapidly rising health care costs and increased focus on patient outcomes and safety have ensured that “business as usual” is no longer acceptable or sustainable. Achieving the highest quality care for patients with congenital and acquired heart disease requires efficient and consistent application of evidence-based best practices. This requires physicians and health care organizations to reevaluate current practices and to employ performance improvement principles and strategies that have proven to be successful in other industries. This chapter highlights the importance of quality in today's health care environment and details how quality and performance improvement marries with the traditional concept of evidence-based medicine to enhance care. The basics of performance improvement methodologies are reviewed, and improvement at the unit and organizational level is discussed. Finally, the importance of collaborative efforts in this complex patient population is presented.

Technological advancement is a cornerstone in the practice of respiratory care. Applying new technology to solve clinical problems requires careful investigation to ensure the safety and efficacy of new devices, protocols, and treatment modalities. New technologies are often rapidly incorporated

Respiratory failure remains one of the most common reasons for children to be admitted to the ICU, and a large number of these patients require invasive mechanical ventilation and progress to ARDS. Mortality related to ARDS correlates directly with the severity of lung disease, and patients who

IntroductionChildren with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.Materials and methodsWe sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.ResultsA total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; pConclusionsThe overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.