Our database is a single-center, pediatric-specific database of patients admitted to a quaternary-level children's hospital and supported on extracorporeal membrane oxygenation (ECMO) for refractory respiratory failure. To date, the majority of ECMO research utilizes low resolution registry data that inherently overlook the level of data intensity involved in managing these patients. The exhaustive nature of our database stands in direct contrast and captures information that would otherwise be missed. In addition to including patient demographics, vital signs, ventilator settings, vasoactive support, ECMO parameters, and laboratory markers of tissue oxygenation and gas exchange, our database uniquely incorporates airway clearance regimens, chest radiography findings, and functional status scales to assess patient outcomes. By constructing a more comprehensive database representing the data-rich critical care environment, we hope to glean more accurate insights into how management strategies impact patient outcomes.
This chapter focuses on lineage analysis in the vertebrate nervous system. It begins with the definition of lineal analysis followed by a discussion of methods of lineage analysis. It then presents examples of lineage analysis conducted in the vertebrate central nervous system (CNS). Lineage analysis of the retina has shown that retinal progenitors are multipotent, most likely through the final cell division; the pattern of cell divisions can be symmetric or asymmetric with respect to the mitotic behavior of daughter cells; and postmitotic retinal cells migrate radially with relatively little tangential migration.
Abstract Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO). Design: Single-center, observational pre- and post-implementation cohort study. Setting: Academic pediatric hospital. Patients: Patients in the PICU, CICU, and NICU receiving ECMO support. Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline. Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications. Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg. Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.
Objectives: To assess the skill of bag-tube manual ventilation with the flow-inflating bag in multiprofessional PICU team members using a mobile simulation unit. Design: Prospective observational study from January 2022 to April 2022. Setting: In situ mobile simulation using the flow-inflating bag in an academic PICU. Subjects: Multiprofessional PICU team members including nurses, respiratory therapists, nurse practitioners, fellows, and attendings. Interventions: None. Measurements and Main Results: We enrolled 129 participants who twice completed 1-minute tasks performing bag-tube manual ventilation with a flow-inflating bag. Sessions were video recorded; four could not be analyzed. Only 30% of participants reported being very to extremely confident, and the majority (62%) reported infrequent skill performance. Task success was defined as achieving target pressure ranges during 80% of the delivered breaths, respiratory rate (RR) of 25–35 breaths/min, and successful pop-off valve engagement. Only five of 129 participants (4%) achieved successful ventilation as defined. Overall, participants were more likely to deliver lower pressures and faster rate. Maintaining target positive end-expiratory pressure (PEEP) was least likely to be achieved (19% success), followed by RR (52%), pop-off valve (64%), then peak inspiratory pressure (71%). Nurses were less likely to achieve target pressures compared with all other professions. Conclusions: Multiprofessional PICU team members have highly variable self-confidence with bag-tube manual ventilation using a flow-inflating bag. Observed performance demonstrates rare success with achieving targeted ventilation parameters, in particular maintenance of PEEP. Future research should focus on developing mobile simulation units to facilitate profession-specific, real-time coaching to teach high-quality manual ventilation that can be translated to the bedside.
Abstract Background Few validated assessment tools are available to support sustainable implementation, an increasingly recognized need among clinicians. We describe the development of the Clinical Sustainability Assessment Tool, or CSAT, designed to assess factors that contribute to sustainable practices in clinical settings. Methods Fifty participants from clinical and research fields were recruited to brainstorm factors that lead to sustained clinical practices. Once repeated factors were removed, participants sorted remaining factors based on similarity. Using concept mapping analyses, we grouped these factors into meaningful domains and developed an initial tool. We then recruited 126 practicing clinicians to pilot and evaluate the tool. Individuals were recruited from clinical settings across pediatric (53%) and adult (47%) medical and surgical subspecialties, and averaged 11 years in their position. The data were analyzed using confirmatory factor analysis (CFA) to test hypothesized subscale structure in the instrument. We used root mean square error of approximation (RMSEA) and the standardized root mean square residual (SRMR) to assess fit and thus the ability of CSAT to measure the identified domains. Results The concept mapping resulted in seven domains and 47 items. The pilot and CFA resulted in 35 items, five per domain. The RMSEA of 0.084 and the SRMR of 0.075 indicated good fit. The final domains were: engaged staff and leadership, engaged stakeholders, organizational readiness, workflow integration, implementation and training, monitoring and evaluation, and outcomes and effectiveness. Conclusions The CSAT is a new reliable assessment tool which allows for greater practical and scientific understanding of contextual factors that enable sustainable clinical practices over time. The full CSAT instrument is available at https://sustaintool.org.
