Performance of an Automated Screening Algorithm for Early Detection of Pediatric Severe Sepsis Objectives: To create and evaluate a continuous automated alert system embedded in the electronic health record for the detection of severe sepsis among pediatric inpatient and emergency department patients. Design: Retrospective cohort study. The main outcome was the algorithm’s appropriate detection of severe sepsis. Episodes of severe sepsis were identified by chart review of encounters with clinical interventions consistent with sepsis treatment, use of a diagnosis code for sepsis, or deaths. The algorithm was initially tested based upon criteria of the International Pediatric Sepsis Consensus Conference; we present iterative changes which were made to increase the positive predictive value and generate an improved algorithm for clinical use. Setting: A quaternary care, freestanding children’s hospital with 404 inpatient beds, 70 ICU beds, and approximately 60,000 emergency department visits per year Patients: All patients less than 18 years presenting to the emergency department or admitted to an inpatient floor or ICU (excluding neonatal intensive care) between August 1, 2016, and December 28, 2016. Intervention: Creation of a pediatric sepsis screening algorithm. Measurements and Main Results: There were 288 (1.0%) episodes of severe sepsis among 29,010 encounters. The final version of the algorithm alerted in 9.0% (CI, 8.7–9.3%) of the encounters with sensitivity 72% (CI, 67–77%) for an episode of severe sepsis; specificity 91.8% (CI, 91.5–92.1%); positive predictive value 8.1% (CI, 7.0–9.2%); negative predictive value 99.7% (CI, 99.6–99.8%). Positive predictive value was highest in the ICUs (10.4%) and emergency department (9.6%). Conclusions: A continuous, automated electronic health record-based sepsis screening algorithm identified severe sepsis among children in the inpatient and emergency department settings and can be deployed to support early detection, although performance varied significantly by hospital location. Drs. Eisenberg and Madden contributed equally to this work. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). Cerner Corporation provided project management and statistical support for this project. Dr. Christianson disclosed work for hire, and he disclosed that he was employed by Cerner Corporation, which is the developer of the Millennium electronic health record system implemented at the study site. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: matthew.eisenberg@childrens.harvard.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Developing Pediatric Critical Care in Kenya Objective: To describe efforts to improve the care of critically ill children in a tertiary care public hospital in a resource-limited setting. Design: Descriptive. Setting: Pediatric wards at the Kenyatta National Hospital in Nairobi, Kenya. Patients: Critically ill children admitted to the hospital. Interventions: A graduated approach to improving critical care capacity in a resource-limited setting. Measurements and Main Results: Pediatric mortality was tracked in the adult ICU and PICU following the engagement of a pediatric intensivist and creation of a critical care team. Mortality declined from 76.2% to 37.5% in the first 2 years of the new PICU. Conclusions: Caring for critically ill children in resource-limited setting presents many challenges. The stepwise approach described here has led to a nearly 50% reduction in mortality among critically ill children at Kenyatta National Hospital. It is a viable strategy to begin to address the disproportionate number of critically ill and injured children in resource-limited setting. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: drrash_21@yahoo.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

A Machine Learning-Based Triage Tool for Children With Acute Infection in a Low Resource Setting Objectives: To deploy machine learning tools (random forests) to develop a model that reliably predicts hospital mortality in children with acute infections residing in low- and middle-income countries, using age and other variables collected at hospital admission. Design: Post hoc analysis of a single-center, prospective, before-and-after feasibility trial. Setting: Rural district hospital in Rwanda, a low-income country in Sub-Sahara Africa. Patients: Infants and children greater than 28 days and less than 18 years of life hospitalized because of an acute infection. Interventions: None. Measurements and Main Results: Age, vital signs (heart rate, respiratory rate, and temperature) capillary refill time, altered mental state collected at hospital admission, as well as survival status at hospital discharge were extracted from the trial database. This information was collected for 1,579 adult and pediatric patients admitted to a regional referral hospital with an acute infection in rural Rwanda. Nine-hundred forty-nine children were included in this analysis. We predicted survival in study subjects using random forests, a machine learning algorithm. Five prediction models, all including age plus two to five other variables, were tested. Three distinct optimization criteria of the algorithm were then compared. The in-hospital mortality was 1.5% (n = 14). All five models could predict in-hospital mortality with an area under the receiver operating characteristic curve ranging between 0.69 and 0.8. The model including age, respiratory rate, capillary refill time, altered mental state exhibited the highest predictive value area under the receiver operating characteristic curve 0.8 (95% CI, 0.78–0.8) with the lowest possible number of variables. Conclusions: A machine learning-based algorithm could reliably predict hospital mortality in a Sub-Sahara African population of 949 children with an acute infection using easily collected information at admission which includes age, respiratory rate, capillary refill time, and altered mental state. Future studies need to evaluate and strengthen this algorithm in larger pediatric populations, both in high- and low-/middle-income countries. The views expressed in this publication are those of the author(s) and not necessarily those of African Academy of Sciences, New Partnership for Africa’s Development Agency, Wellcome Trust, or the UK government. Supported, in part, by grant from the Life Priority Fund, the Hellman Foundation, and the King Baudouin Foundation. The research project was supported by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine through the Surviving Sepsis Campaign. Dr. Kwizera disclosed that he is supported by The Developing Excellence in Leadership, Training and Science (DELTAS) Africa Initiative grant number DEL-15-011 to Training Health Researchers into Vocational Excellence in East Africa-2. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences Alliance for Accelerating Excellence in Science in Africa and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency with funding from the Wellcome Trust grant number 107742/Z/15/Z and the UK government. Dr. Patterson disclosed that the Surviving Sepsis in Resource Limited Environments project was supported by grants from the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM), with the SCCM grant supported by a donation from the Hellman Foundation. He disclosed that his son and daughter have participated in infrastructure development and education projects in Gitwe, Rwanda that were funded by the Hellman Foundation. Ms. Harmon’s institution received funding from Hellman Foundation (Judith Hellman principal) and King Baudouin Foundation through ESICM, and she received other support in the form of supplies for the clinics and hospital in the amount of $10,000 from the Becton Dickinson Corporation. Dr. Duenser received funding from Life Priority Fund, Hellman Foundation, and King Baudouin, all of which were paid to the Surviving Sepsis Campaign. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Martin W. Dünser, MD, DESA, EDIC, Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Krankenhausstrasse 9, 4040 Linz, Austria. E-mail: Martin.Duenser@kepleruniklinikum.at ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Bleeding and Thrombosis With Pediatric Extracorporeal Life Support: A Roadmap for Management, Research, and the Future From the Pediatric Cardiac Intensive Care Society (Part Two) Objectives: To make recommendations on improving understanding of bleeding and thrombosis with pediatric extracorporeal life support including future research directions. Data Sources: Evaluation of literature and consensus conferences of pediatric critical care and extracorporeal life support experts. Study Selection: A team of 10 experts with pediatric cardiac and extracorporeal membrane oxygenation experience and expertise met through the Pediatric Cardiac Intensive Care Society to review current knowledge and make recommendations for future research to establish “best practice” for anticoagulation management related to extracorporeal life support. Data Extraction/Data Synthesis: This white paper focuses on clinical understanding and limitations of current strategies to monitor anticoagulation. For each test of anticoagulation, limitations of current knowledge are addressed and future research directions suggested. Conclusions: No consensus on best practice for anticoagulation monitoring exists. Structured scientific evaluation to answer questions regarding anticoagulation monitoring and bleeding and thrombotic events should occur in multicenter studies using standardized approaches and well-defined endpoints. Outcomes related to need for component change, blood product administration, healthcare outcome, and economic assessment should be incorporated into studies. All centers should report data on patient receiving extracorporeal life support to a registry. The work for this project occurred during monthly phone meetings and at each of the institutions listed above for the authors. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). Dr. Reddy’s institution received funding from the National Institutes of Health and the American Heart Association. Dr. Thiagarajan’s institution received funding from Bristol Myers Squibb and Pfizer. Dr. Dalton received funding from Innovative Extracorporeal Membrane Oxygenation (ECMO) Concepts (consultant), and she disclosed off-label product use of ECMO. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jamiepenk@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

The Occurrence and Risk Factors of Inappropriately Deep Tip Position of Microcuff Pediatric Endotracheal Tube During PICU Stay: A Retrospective Cohort Pilot Study Objectives: Cuffed endotracheal tubes are being used increasingly for pediatric patients on mechanical ventilation. Appropriate placement of the tube tip for Microcuff (Kimberley-Clark, Roswell, GA) pediatric endotracheal tube is guided by the intubation depth mark on the device. However, inappropriately deep tip position is sometimes observed during PICU stay. The purpose of this study was to assess the occurrence and risk factors of inappropriately deep tip position of Microcuff pediatric endotracheal tube during PICU stay. Design: A retrospective cohort study. Setting: The PICU at the National Center for Child Health and Development, one of the largest tertiary pediatric hospitals in Japan. Patients: All patients on mechanical ventilation with Microcuff pediatric endotracheal tube admitted between February 1, 2015, and July 31, 2016, were enrolled. Interventions: None. Measurements and Main Results: The primary outcome was the occurrence of inappropriately deep tip position, defined as a position of the tube tip less than 5 mm above the carina on a chest radiograph. There were 179 cases (157 patients) requiring mechanical ventilation with Microcuff pediatric endotracheal tube during the study period. An inappropriately deep tip position was found in 42 cases (23.5%), including bronchial intubation in 13 cases (7.3%). In multivariate analysis, height in cm (odds ratio, 0.93; p < 0.001), history of abdominal disease or previous abdominal surgery (odds ratio, 4.38; p = 0.004), and oversized endotracheal tube (odds ratio, 2.93; p = 0.042) were found to be independent risk factors. Conclusions: The occurrence of inappropriately deep tip position of Microcuff pediatric endotracheal tube during PICU stay was 23.5%. The possibility of an inappropriately deep tip position should be considered whenever patients with the above risk factors, a history of abdominal disease or previous abdominal surgery, and small children are treated or when oversized endotracheal tubes are used. Dr. Matsuoka reviewed the electronic health records and wrote the draft of the article. Dr. Ide conceptualized and designed the study, supervised the review of the patient data, and wrote the final article. Dr. Matsudo co-reviewed the patients’ chest radiographs. Dr. Kobayashi supervised the data analysis. Drs. Nishimura and Nakagawa conceptualized and designed the study. All the authors read and approved the final article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: ide-k@ncchd.go.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Methods Used to Maximize Follow-up: Lessons Learned From the Therapeutic Hypothermia After Pediatric Cardiac Arrest Trials Objectives: To describe telephone interview completion rates among 12-month cardiac arrest survivors enrolled in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials, identify key characteristics of the completed follow-up interviews at both 3- and 12-month postcardiac arrest, and describe strategies implemented to promote follow-up. Setting: Centralized telephone follow-up interviews. Design: Retrospective report of data collected for Therapeutic Hypothermia after Pediatric Cardiac Arrest trials, and summary of strategies used to maximize follow-up completion. Patients: Twelve-month survivors (n = 251) from 39 Therapeutic Hypothermia after Pediatric Cardiac Arrest PICU sites in the United States, Canada, and United Kingdom. Interventions: Not applicable. Measurements and Main Results: The 3- and 12-month telephone interviews included completion of the Vineland Adaptive Behavior Scales, Second Edition. Vineland Adaptive Behavior Scales, Second Edition data were available on 96% of 3-month survivors (242/251) and 95% of 12-month survivors (239/251) with no differences in demographics between those with and without completed Vineland Adaptive Behavior Scales, Second Edition. At 12 months, a substantial minority of interviews were completed with caregivers other than parents (10%), after calls attempts were made on 6 or more days (18%), and during evenings/weekends (17%). Strategies included emphasizing the relationship between study teams and participants, ongoing communication between study team members across sites, promoting site engagement during the study’s final year, and withholding payment for work associated with the primary outcome until work had been completed. Conclusions: It is feasible to use telephone follow-up interviews to successfully collect detailed neurobehavioral outcome about children following pediatric cardiac arrest. Future studies should consider availability of the telephone interviewer to conduct calls at times convenient for families, using a range of respondents, ongoing engagement with site teams, and site payment related to primary outcome completion. This work is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or National Institutes of Health. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). Additional members of the Therapeutic Hypothermia after Pediatric Cardiac Arrest trial investigators are listed in Supplemental Appendix 1 (Supplemental Digital Content 2, http://links.lww.com/PCC/B50). Supported, in part, by the National Heart, Lung, and Blood Institute grants HL094345 (to Dr. Moler) and HL094339 (to Dr. Dean). Supported, in part, from the following federal planning grants contributed to the planning of the Therapeutic Hypothermia after Pediatric Cardiac Arrest trials: HD044955 and HD050531 (to Dr. Moler). Additional in part support from the following research networks: Pediatric Emergency Care Applied Research Network from cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008; and the Collaborative Pediatric Critical Care Research Network from cooperative agreements U10HD500009, U10HD050096, U10HD049981, U10HD049945, U10HD049983, U10HD050012, and U01HD049934. Site support from P30HD040677, UL1TR000003UL1, RR 024986, and UL1 TR 000433. Dr. Moler’s, Mr. Page’s, and Drs. Meert’s, Holubkov’s, and Slomine’s institution received funding from the National Institutes of Health (NIH). Ms. Gildea’s and Drs. Dean’s and Christensen’s institution received funding from the National Heart, Lung, and Blood Institute. All authors received support for article research from the NIH. For information regarding this article, E-mail: Slomine@kennedykrieger.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Volume Guaranteed Ventilation During Neonatal Transport Objectives: To compare tidal volumes, inflating pressures and other ventilator variables of infants receiving synchronized intermitted mandatory ventilation with volume guarantee during emergency neonatal transport with those of infants receiving synchronized intermitted mandatory ventilation without volume guarantee. Design: Retrospective observational study. Setting: A regional neonatal emergency transport service. Patients: We enrolled 77 infants undergoing emergency neonatal transfer. Forty-five infants were ventilated with synchronized intermittent mandatory ventilation with volume guarantee and 32 with synchronized intermitted mandatory ventilation without volume guarantee. Interventions: Infants received synchronized intermitted mandatory ventilation with or without volume guarantee during interhospital emergency neonatal transport using a Fabian + nCPAP evolution neonatal ventilator (Software Version: 4.0.1; Acutronic Medical Instruments, Hirzel, Switzerland). Measurements and Main Results: We downloaded detailed ventilator data with 0.5 Hz sampling rate. We analyzed data with the Python computer language and its data science packages. The mean expiratory tidal volume of inflations was lower and less variable in infants ventilated with volume guarantee than in babies ventilated without volume guarantee (group median 4.8 vs 6.0 mL/kg; p = 0.001). Babies ventilated with synchronized intermittent mandatory ventilation with volume guarantee had on average lower and more variable peak inflating pressures than babies ventilated without volume guarantee (group median 15.5 vs 19.5 cm H2O;p = 0.0004). With volume guarantee, a lower proportion of the total minute ventilation was attributed to ventilator inflations rather than to spontaneous breaths between inflations (group median 66% vs 83%; p = 0.02). With volume guarantee, babies had fewer inflations with tidal volumes greater than 6 mL/kg and greater than 8 mL/kg (group medians 3% vs 44% and 0% vs 7%, respectively; p = 0.0001). The larger tidal volumes in the non-volume guarantee group were not associated with significant hypocapnia except in one case. Conclusions: During neonatal transport, synchronized intermittent mandatory ventilation with volume guarantee ventilation reduced the occurrence of excessive tidal volumes, but it was associated with larger contribution of spontaneous breaths to minute ventilation compared with synchronized intermitted mandatory ventilation without volume guarantee. This work was performed at Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge, CB2 0QQ, United Kingdom and Neonatal Emergency and Transport Service of the Peter Cerny Foundation, 53 Bókay János Street, Budapest, 1083 Hungary. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). Dr. Kovacs received funding from Sanofi Hungary and Syreon Research Institute. Dr. Szilagyi received funding from Peter Cerny Ambulance Service for Curing Sick Babies. Dr. Morley received funding from ACUTRONIC Medical (consultant for neonatal resuscitation research, but not for any aspect of their ventilators). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: gusztav.belteki@addenbrookes.nhs.uk ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Survival and Cardiopulmonary Resuscitation Hemodynamics Following Cardiac Arrest in Children With Surgical Compared to Medical Heart Disease Objectives: To assess the association of diastolic blood pressure cutoffs (≥ 25 mm Hg in infants and ≥ 30 mm Hg in children) during cardiopulmonary resuscitation with return of spontaneous circulation and survival in surgical cardiac versus medical cardiac patients. Secondarily, we assessed whether these diastolic blood pressure targets were feasible to achieve and associated with outcome in physiology unique to congenital heart disease (single ventricle infants, open chest), and influenced outcomes when extracorporeal cardiopulmonary resuscitation was deployed. Design: Multicenter, prospective, observational cohort analysis. Setting: Tertiary PICU and cardiac ICUs within the Collaborative Pediatric Critical Care Research Network. Patients: Patients with invasive arterial catheters during cardiopulmonary resuscitation and surgical cardiac or medical cardiac illness category. Interventions: None. Measurements and Main Results: Hemodynamic waveforms during cardiopulmonary resuscitation were analyzed on 113 patients, 88 surgical cardiac and 25 medical cardiac. A similar percent of surgical cardiac (51/88; 58%) and medical cardiac (17/25; 68%) patients reached the diastolic blood pressure targets (p = 0.488). Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients (p = 0.018), but not medical cardiac patients (p = 0.359). Fifty-three percent (16/30) of patients with single ventricles attained the target diastolic blood pressure. In patients with an open chest at the start of chest compressions, 11 of 20 (55%) attained the target diastolic blood pressure. In the 33 extracorporeal cardiopulmonary resuscitation patients, 16 patients (48%) met the diastolic blood pressure target with no difference between survivors and nonsurvivors (p = 0.296). Conclusions: During resuscitation in an ICU, with invasive monitoring in place, diastolic blood pressure targets of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children can be achieved in patients with both surgical and medical heart disease. Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients, but not medical cardiac patients. Diastolic blood pressure targets were feasible to achieve in 1) single ventricle patients, 2) open chest physiology, and 3) extracorporeal cardiopulmonary resuscitation patients. A complete list of Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network members are listed in the Acknowledgments section. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal). Supported, in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services: UG1HD050096, UG1HD049981, UG1HD049983, UG1HD063108, UG1HD083171, UG1HD083166, UG1HD083170, U10HD050012, U10HD063106, U10HD063114, and U01HD049934. Drs. Yates’s, Berger’s, and Carcillo’s institutions received funding from the National Institutes of Child Health and Human Development. Drs. Yates, Reeder, Meert, Berger, Wessel, Newth, Carcillo, McQuillen, Harrison, Moler, Pollack, Carpenter, Dean, Nadkarni, and Berg received support for article research from the National Institutes of Health (NIH). Dr. Sutton’s institution received funding from National Heart, Lung, and Blood Institute R01 to study cardiopulmonary resuscitation quality improvement bundle; he received funding from Zoll Medical (speaking honoraria); and he disclosed he is a volunteer for the American Heart Association (AHA), is the Chair for AHA’s Get with the Guidelines Resuscitation Pediatric Research Task Force, and was an author for the 2015 and 2018 Pediatric Advanced Life Support Guidelines. Drs. Reeder’s, Meert’s, Wessel’s, Harrison’s, Moler’s, Pollack’s, Dean’s, and Berg’s institutions received funding from the NIH. Dr. Berger’s institution received funding from Association for Pediatric Pulmonary Hypertension and Actelion Pharmaceutical. Dr. Newth received funding from Philips Research North America. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Andrew.yates@nationwidechildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Compassionate Discharges from the PICU: Retraction No abstract available

Effects of Healthcare-Associated Infections on Length of PICU Stay and Mortality Objectives: To identify the effects of healthcare-associated infections on length of PICU stay and mortality. Design: Retrospective, single-center, observational study. Setting: PICU of a tertiary children’s hospital. Patients: Consecutive patients who stayed greater than 48 hours in the PICU between January 2013 and December 2017. Interventions: None. Measurements and Main Results: Data were retrospectively collected from medical records. We identified occurrences of common healthcare-associated infections, including bloodstream infection, pneumonia, and urinary tract infection, defined according to the 2008 definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the effects of each healthcare-associated infection on length of PICU stay and PICU mortality using multivariable analysis. Among 1,622 admissions with a PICU stay greater than 48 hours, the median age was 299 days and male patients comprised 51% of admissions. The primary diagnostic categories were cardiovascular (58% of admissions), respiratory (21%), gastrointestinal (8%), and neurologic/muscular (6%). The median length of PICU stay was 6 days, and the PICU mortality rate was 2.5%. A total of 167 healthcare-associated infections were identified, including 67 bloodstream infections (40%), 43 pneumonias (26%), and 57 urinary tract infections (34%). There were 152 admissions with at least one healthcare-associated infection (9.4% of admissions with a stay > 48 hr). On multivariable analysis, although each healthcare-associated infection was not significantly associated with mortality, bloodstream infection was associated with an extra length of PICU stay of 10.2 days (95% CI, 7.9–12.6 d), pneumonia 14.2 days (11.3–17.2 d), and urinary tract infection 6.5 days (4.0–9.0 d). Accordingly, 9.7% of patient-days were due to these three healthcare-associated infections among patients with a stay greater than 48 hours. Conclusions: Although healthcare-associated infections were not associated with PICU mortality, they were associated with extra length of PICU stay. As 9.7% of patient-days were due to healthcare-associated infections, robust prevention efforts are warranted. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: hatachi@wch.opho.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies