Akira Nishisaki

Objectives: Cognitive aids are widely used in pediatric emergency departments (PEDs), yet real-world use is difficult to assess via self-report or the medical record. We used video review to assess whether (adoption) and how (fidelity) the NEAR4PEM Preintubation Checklist was used during tracheal intubations (TIs) in PEDs. Methods: Prospective observational study at 2 tertiary PEDs with continuous multivideo camera recording in resuscitative areas. Four independent reviewers used a standardized video abstraction tool to evaluate checklist use in checklist item verbalization, completion, timing, and efficiency (time spent on the checklist). Results: Among 47 TIs, the checklist was used in 34 (72%). Thirty (88%) cases (22 medical, 8 trauma) were available for video review. Inter-reviewer concordance on all data elements was 96%. Verbalization of all 26 checklist items occurred in only 10% of cases. For most items, verbalization occurred in >80% of TIs and completion in ≥70%. Lower rates were observed for “limit on attempts/duration discussed” (verbalized in 33%, completed in 23%) and for “rescue devices identified/prepared” (verbalized in 63%, completed in 47%). Several preparation and equipment tasks were typically completed before checklist verbalization, whereas anticipatory-planning elements—such as difficult airway considerations, limits on attempts, and postintubation planning—were more often addressed after checklist prompting. Median checklist completion time was 2 minutes (IQR: 1 to 3min). Reviewers reported that the checklist was used effectively for patient preparation and enhanced team communication in 28 cases (93%). Conclusions: While checklist adoption was high, checklist item completion varied widely, potentially highlighting which elements function as true cognitive aids versus those reflecting routine practice. Video review provides a feasible and uniquely informative method to measure real-world implementation and identify opportunities to improve ED cognitive aid use.

BACKGROUND: Acute kidney injury (AKI) is common in critically ill children and is associated with high morbidity and mortality. Risk prediction models designed for clinical decision support implementation can facilitate early identification and proactive mitigation of AKI risk. Existing models have primarily been validated using single-center data, partly because of the lack of appropriately detailed multicenter datasets. OBJECTIVE: To determine the performance of a single-center model to predict new AKI at 72 hours of ICU admission in children across two multicenter datasets and refine this model to improve prediction performance while maintaining acceptable alert burden. DERIVATION AND VALIDATION COHORTS: We analyzed two datasets: the Pediatric Learning Health System Network–Virtual Pediatric Systems (PEDSNET-VPS) dataset, created through the linkage of PEDSnet electronic health record (EHR) extraction with VPS (LLC, http://www.myvps.org), and the PICU Data Collaborative dataset, created through EHR extraction and harmonization from eight participating institutions. We divided each dataset into a derivation and test split. PREDICTION MODEL: We first recalibrated an existing single-center model and measured discrimination (area under the receiver operating characteristic curve [AUROC] and area under the precision-recall curve [AUPRC]) and performance at multiple cutpoints. We next added features available at 12 hours of ICU admission, optimizing by precision and recall. We measured discrimination and performance at multiple cutpoints and identified the features contributing most to the risk score. RESULTS: In total we analyzed 186,540 ICU admissions. We found early AKI by serum creatinine criteria within 72 hours of admission in 2.2–2.7%. Initial recalibration of an existing single-center model demonstrated poor discrimination (AUROC 0.65–0.78; AUPRC 0.10–0.12). Following the addition of new features, the model had higher AUROC (0.80–0.88) and AUPRC (0.13–0.22). CONCLUSIONS: In this first use of two new multicenter datasets, we found improved performance in a model designed using features available at 12 hours of ICU admission, balancing sensitivity and precision to predict patients at risk for AKI development.

BACKGROUND: Existing PICU early warning systems lack sufficient accuracy and timeliness for effective preparation. Machine learning approaches may improve prediction of critical deterioration events (CDEs), but their operational utility relative to existing tools remains unclear. OBJECTIVES: To develop a machine learning model for early detection of CDEs and evaluate operational utility against existing tools using a novel alert burden analysis. DERIVATION COHORT: PICU admissions (ages 0–24 yr, stay ≥ 24 hr) at a quaternary children’s hospital from 2014 to 2020 ( n = 12,771 patients; 21,141 admissions). CDEs (6% of patients) included cardiopulmonary resuscitation, extracorporeal membrane oxygenation initiation, dilute epinephrine administration, or unplanned intubation. VALIDATION COHORT: Temporally distinct PICU admissions from 2021 to 2022 ( n = 5144 patients; 6929 admissions; 6% CDE rate). PREDICTION MODEL: An ensemble of extreme gradient-boosted models (PICU Warning INdex [P-WIN]) trained to predict CDEs at 1–12-hour horizons using 550 features derived from demographics, medications, laboratory results, and vital signs. RESULTS: P-WIN demonstrated excellent discrimination at 2-hour (area under the receiver operating characteristic curve [AUROC], 0.95 [95% CI, 0.94–0.96] and area under the precision-recall curve [AUPRC], 0.76 [95% CI, 0.72–0.80]) and 12-hour horizons (AUROC, 0.93 [95% CI, 0.92–0.94] and AUPRC, 0.68 [95% CI, 0.64–0.72]). To alert before 80% of events, P-WIN generated 0.20 alerts per patient-day at a median 10.17 hours before CDE. Compared with the existing rule-based PICU Warning Tool (alerting before 38% of events), P-WIN generated one-third the alert burden at equivalent sensitivity (0.03 vs. 0.10 alerts per patient-day). CONCLUSIONS: P-WIN accurately predicted PICU CDEs up to 12 hours in advance with low alert burden, providing a viable opportunity for shifting care from reactive rescue to proactive, resource-intensive preparation and prevention.

Tracheal intubation (TI)-associated cardiac arrest (TI-CA) occurs in 1.7% of pediatric ICU TIs. Our objective was to evaluate resuscitation characteristics and outcomes between cardiac arrest patients with and without TI-CA. Secondary analysis of cardiac arrest patients in both ICU-RESUS trial and ancillary CPR-NOVA study. The primary exposure was TI-CA, defined as cardiac arrest occurred during TI procedure or within 20 min after endotracheal tube placement. The primary outcome was survival to hospital discharge with favorable neurological outcome (Pediatric Cerebral Performance Category score 1–3 or unchanged). Among 315 children with cardiac arrests, 48 (15.2%) met criteria for TI-CA. Pre-existing medical conditions were similar between groups. Pre-arrest non-invasive mechanical ventilation was more common among TI-CA patients (18/48, 37.5%) compared to non-TI-CA patients (35/267, 13.1%). In 48% (23/48), the TI-CA occurred within 20 min after intubation (i.e., not during intubation). Duration of CPR was longer in TI-CA patients (median 11.0 min, interquartile range [IQR]: 2.5, 35.5) than non-TI-CA patients (median 5.0 min, IQR 2.0, 21.0), p = 0.03. Return of spontaneous circulation occurred in 32/48 (66.7%) TI-CA versus 186/267 (69.7%) non-TI-CA, p = 0.73. Survival to hospital discharge with favorable neurological outcome occurred in 29/48 (60.4%) TI-CA versus 146/267 (54.7%) non-TI-CA, p = 0.53. Fifteen percent of these pediatric ICU cardiac arrests were associated with TI. Half of TI-CA occurred after endotracheal tube placement. While duration of CPR was longer in TI-CA patients, there were no differences in unadjusted outcomes following TI-CA versus non-TI-CA. The ICU-RESUS (ClinicalTrials.gov Identifier: NCT 02837497).

OBJECTIVES: To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019. DESIGN/SETTING: Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia. SUBJECTS: Critically ill children requiring TI in a PICU or pediatric cardiac ICU. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62–0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1–5 yr: 59.4%, 6–10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021). CONCLUSIONS: TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.

Tracheal intubation (TI) in critically ill children is a life-saving but high-risk procedure that involves multiple team members with diverse clinical skills. We aim to examine the association between the provider-reported teamwork rating and the occurrence of adverse TI-associated events (TIAEs). A retrospective analysis of prospectively collected data from 45 pediatric intensive care units in the National Emergency Airway Registry for Children (NEAR4KIDS) database from January 2013 to March 2018 was performed. A composite teamwork score was generated using the average of each of five (7-point Likert scale) domains in the teamwork assessment tool. Poor teamwork was defined as an average score of 4 or lower. Team provider stress data were also recorded with each intubation. A total of 12,536 TIs were reported from 2013 to 2018. Approximately 4.1% (n = 520) rated a poor teamwork score. TIs indicated for shock were more commonly associated with a poor teamwork score, while those indicated for procedures and those utilizing neuromuscular blockade were less commonly associated with a poor teamwork score. TIs with poor teamwork were associated with a higher occurrence of adverse TIAE (24.4% vs 14.4%, p < 0.001), severe TIAE (13.7% vs 5.9%, p < 0.001), and peri-intubation hypoxemia < 80% (26.4% vs 17.9%, p < 0.001). After adjusting for indication, provider type, and neuromuscular blockade use, poor teamwork was associated with higher odds of adverse TIAEs (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.35–2.34), severe TIAEs (OR, 2.23; 95% CI, 1.47–3.37), and hypoxemia (OR, 1.63; 95% CI, 1.25–2.03). TIs with poor teamwork were independently associated with a higher occurrence of TIAEs, severe TIAEs, and hypoxemia.

To characterize tracheal intubation process of care and safety outcomes in a large tertiary pediatric intensive care unit using a pediatric adaptation of the National Emergency Airway Registry. Variances in process of care and safety outcome of intubation in the pediatric intensive care unit have not been described. We hypothesize that tracheal intubation is a common but high-risk procedure and that the novel pediatric adaptation of the National Emergency Airway Registry is a feasible tool to capture variances in process of care and outcomes. Prospective descriptive study. A single 45-bed tertiary noncardiac pediatric intensive care unit in a large university-affiliated children's hospital. Critically ill children who required intubation in the pediatric intensive care unit. Airway management data were prospectively collected for all initial airway management from July 2007 through September 2008 using the National Emergency Airway Registry tool tailored for pediatric application with explicit operational definitions. One hundred ninety-seven initial intubation encounters were reported (averaging one every 2.3 days). The first course intubation method was oral intubation in 181 (91.9%) and nasal in 16 (9.1%). Unwanted tracheal intubation-associated events were frequently reported (n = 38 [19.3%]), but severe tracheal intubation-associated events were rare (n = 6 [3.0%]). Esophageal intubation with immediate recognition was the most common tracheal intubation-associated event (n = 22). Desaturation <80% was reported in 51 of 183 (27.7%) and more than two intubation attempts in 30 of 196 (15.3%), both associated with occurrence of a tracheal intubation-associated event (p < .001, p = .001, respectively). Interestingly, patient age, history of difficult airway, and first attempt by resident were not associated with tracheal intubation-associated events. Unwanted tracheal intubation-associated events occurred frequently, but severe tracheal intubation-associated events were rare. Our novel registry can be used to describe the pediatric intensive care unit tracheal intubation procedural process of care and safety outcomes.