Nosocomial Infections During Extracorporeal Membrane Oxygenation in Neonatal, Pediatric, and Adult Patients: A Comprehensive Narrative Review Objectives: Extracorporeal membrane oxygenation is increasingly used in critically ill patients with refractory cardiopulmonary failure. Nosocomial infection acquired during extracorporeal membrane oxygenation represents one of the most frequent complications but the available evidence on the risk of infection and its association with outcomes has not been comprehensively analyzed. We performed a narrative review examining the epidemiology of nosocomial infection during extracorporeal membrane oxygenation, association with clinical outcomes, and preventive strategies. Data Sources: We searched PubMed, Web of Science, EMBASE, and the Cochrane Library between 1972 and June 2018. Study Selection: We included any article which detailed nosocomial infection during extracorporeal membrane oxygenation. Articles were excluded if they were not written in English, detailed extracorporeal membrane oxygenation use for infections acquired prior to extracorporeal membrane oxygenation, or used other forms of extracorporeal support such as ventricular assist devices. Data Extraction: Two reviewers independently assessed eligibility and extracted data. We screened 984 abstracts and included 59 articles in the final review. Data Synthesis: The reported risk of nosocomial infection among patients receiving extracorporeal membrane oxygenation ranged from 3.5% to 64% per extracorporeal membrane oxygenation run, while the incidence of infection ranged from 10.1 to 116.2/1,000 extracorporeal membrane oxygenation days. Nosocomial infections during extracorporeal membrane oxygenation were consistently associated with longer duration of extracorporeal membrane oxygenation and, in several large multicenter studies, with increased mortality. Risk factors for nosocomial infection included duration of extracorporeal membrane oxygenation, mechanical and hemorrhagic complications on extracorporeal membrane oxygenation, and use of venoarterial and central extracorporeal membrane oxygenation. Biomarkers had low specificity for infection in this population. Few studies examined strategies on how to prevent nosocomial infection on extracorporeal membrane oxygenation. Conclusions: Nosocomial infections in extracorporeal membrane oxygenation patients are common and associated with worse outcomes. There is substantial variation in the rates of reported infection, and thus, it is possible that some may be preventable. The evidence for current diagnostic, preventive, and therapeutic strategies for infection during extracorporeal membrane oxygenation is limited and requires further investigation. Supplemental digital content is available for this article. Direct URL citationsappear 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: gmaclaren@iinet.net.au ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Prevalence and Outcomes of Balloon Atrial Septostomy in Neonates With Transposition of Great Arteries Objectives: Transposition of the great arteries is the most common cyanotic congenital heart defect. Surgical correction usually occurs in the first week of life; presence of restrictive interatrial communication and severe hypoxemia warrants urgent intervention with balloon atrial septostomy and medical stabilization prior to surgery. The main objective of this study is to compare the characteristics, outcomes, and mortality risks in patients with transposition of the great arteries who underwent balloon atrial septostomy during their hospitalization versus transposition of the great arteries patients who have not undergone this procedure. Design: Retrospective analysis of administrative data. Setting: Data from Kids’ Inpatient Database complemented with the National Inpatient Sample dataset for the years 1998–2014, this includes data from participating hospitals in 47 U.S. States and the District of Columbia. Patients: Neonates admitted with transposition of the great arteries. Interventions: None. Measurements and Main Results: A total of 17,392 neonates with diagnosis of transposition of the great arteries were captured in the databases we used. Male-to-female ratio was 2:1. The rate of balloon atrial septostomy in patients with transposition of the great arteries was 27.7% without significant change over the years. There was no significant difference in mortality between balloon atrial septostomy and no balloon atrial septostomy (6.3% vs 6.7%; p = 0.29). Neonates with balloon atrial septostomy had a two-fold increase in their length of stay compared with no balloon atrial septostomy (16 d vs 7 d; p < 0.0001). Stroke was present in 1.1% of balloon atrial septostomy group versus 0.6% in those who did not have balloon atrial septostomy (odds ratio, 1.85; 95% CI, 1.29–2.65; p < 0.0001). Extracorporeal membrane oxygenation was used more in balloon atrial septostomy group (5.1% vs 3.1%; p < 0.0001). Conclusions: There was no difference in mortality rate between balloon atrial septostomy and no balloon atrial septostomy patients. The prevalence of the diagnosis of stroke in this study was higher in patients who underwent balloon atrial septostomy. Furthermore, comparison of in-hospital mortality in balloon atrial septostomy and no balloon atrial septostomy revealed increased mortality risk in no balloon atrial septostomy patients transferred from other institution, no balloon atrial septostomy patients supported with extracorporeal membrane oxygenation, and balloon atrial septostomy patients diagnosed with stroke. Finally, length of stay and charges were higher in balloon atrial septostomy patients. Dr. Hamzah conceptualized and designed the study and drafted the initial article. Dr. Othman carried out the analyses, reviewed, and revised the article. Drs. Peluso and Sammour reviewed and revised the article. Dr. Aly conceptualized and designed the study and critically reviewed the article for important intellectual content. All authors approved the final article as submitted and agree to be accountable for all aspects of the work. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: HamzahM@ccf.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Catheter-Directed Pharmacologic Thrombolysis for Acute Submassive and Massive Pulmonary Emboli in Children and Adolescents—An Exploratory Report Objectives: The objective of this study is to report a single-center experience of the safety and efficacy of pulmonary artery catheter-directed thrombolysis for both massive and submassive pulmonary emboli in the pediatric and adolescent population. Design: A 22-month retrospective review of the electronic medical record and picture archiving and communication system was performed of patients less than 21 years old, presenting with massive or submassive pulmonary emboli treated with pulmonary artery catheter-directed thrombolysis at a single, tertiary care pediatric hospital. Multiple variables were analyzed including indications, technical success, clinical efficacy, and complications. Setting: A single, tertiary care pediatric hospital. Patients: Nine patients (mean 13.9 yr; range 6–19 yr) with massive and/or submassive pulmonary emboli who underwent pulmonary artery catheter-directed thrombolysis met inclusion criteria. Interventions: Catheter-directed thrombolysis. Measurements and Main Results: Pulmonary emboli was diagnosed by CT angiography in all cases. Catheter-directed thrombolysis alone was clinically successful (defined as improved cardiopulmonary function following catheter-directed thrombolysis) in seven patients (78%) with two patients not improving following catheter-directed thrombolysis. There were no immediate bleeding complications from catheter-directed thrombolysis therapy. All patients were maintained on anticoagulation treatment following catheter-directed thrombolysis. Catheter-directed thrombolysis was technically successful (defined as successful placement of pulmonary artery infusion catheters with full or partial resolution of thrombus) in all cases. Follow-up pulmonary angiography at the cessation of catheter-directed thrombolysis revealed complete thrombus resolution in four patients (44%) and partial resolution in five patients (55%). Mean pulmonary artery pressures decreased in all patients (mean precatheter-directed thrombolysis pulmonary artery pressure = 37 ± 11 mm Hg; mean postcatheter-directed thrombolysis pulmonary artery pressure = 28 ± 10 mm Hg; p = 0.0164). Conclusions: Pulmonary artery catheter-directed thrombolysis is a technically feasible therapeutic option for children and adolescents with submassive and massive pulmonary emboli. Mr. Ji and Dr. Durrence were involved in the literature search, the writing of the article, and the article preparation. Drs. Gill, Shah, and Hawkins were involved in the management of patient care, patient data, literature search, and editing of the article. Drs. Paden, Patel, and Williamson were involved in the management of patient care, data validation, and construction of the article. All authors approved the final article. Dr. Paden disclosed that he is President-elect of Extracorporeal Life Support Organization (no salary involved), has multiple patents for a novel pediatric renal replacement device (not discussed in this manuscript), has received grants from private organizations related to extracorporeal membrane oxygenation research (not discussed in this manuscript), and he disclosed off label product use of the majority of drugs and techniques described in the manuscript in a pediatric population. Dr. Patel’s institution received funding from Pediatric Research Alliance Junior Faculty Focused Pilot Grant; she received funding from Daiichi Sankyo; she disclosed acting as institutional principal investigator for phase 2 and phase 3 clinical trials in children with venous thromboembolism; and she disclosed off-label product use of tissue plasminogen activator for a pediatric population. Dr. Williamson disclosed receiving a departmental grant to study resuscitation of pediatric trauma (unrelated to current work). The remaining authors have disclosed that they do not have any potential conflicts of interest. Written informed consent was obtained from the patients for publication of this case series, including accompanying images. For information regarding this article, E-mail: matt.hawkins@emory.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Outcomes Associated With Multiple Organ Dysfunction Syndrome in Critically Ill Children With Hyperglycemia Objectives: Patterns and outcomes of multiple organ dysfunction syndrome are unknown in critically ill children with hyperglycemia. We aimed to determine whether tight glycemic control to a lower vs. higher range influenced timing, duration, or resolution of multiple organ dysfunction syndrome as well as characterize the clinical outcomes of subgroups of multiple organ dysfunction syndrome in children enrolled in the Heart And Lung Failure-Pediatric INsulin Titration trial. Design: Planned secondary analysis of the multicenter Heart And Lung Failure-Pediatric INsulin Titration trial. Setting: Thirty-five PICUs. Patients: Critically ill children with hyperglycemia who received the Heart And Lung Failure-Pediatric INsulin Titration protocol from 2012 to 2016. Interventions: Randomization to a lower versus higher glucose target group. Measurements and Main Results: Of 698 patients analyzed, 48 (7%) never developed multiple organ dysfunction syndrome, 549 (79%) had multiple organ dysfunction syndrome without progression, 32 (5%) developed new multiple organ dysfunction syndrome, and 69 (10%) developed progressive multiple organ dysfunction syndrome. Of those whose multiple organ dysfunction syndrome resolved, 192 (34%) experienced recurrent multiple organ dysfunction syndrome. There were no significant differences in the proportion of multiple organ dysfunction syndrome subgroups between Heart And Lung Failure-Pediatric INsulin Titration glucose target groups. However, patients with new or progressive multiple organ dysfunction syndrome had fewer ICU-free days through day 28 than those without new or progressive multiple organ dysfunction syndrome, and progressive multiple organ dysfunction syndrome patients had fewer ICU-free days than those with new multiple organ dysfunction syndrome: median 25.1 days for never multiple organ dysfunction syndrome, 20.2 days for multiple organ dysfunction syndrome without progression, 18.6 days for new multiple organ dysfunction syndrome, and 0 days for progressive multiple organ dysfunction syndrome (all comparisons p < 0.001). Patients with recurrent multiple organ dysfunction syndrome experienced fewer ICU-free days than those without recurrence (median, 11.2 vs 22.8 d; p < 0.001). Conclusions: Tight glycemic control target range was not associated with differences in the proportion of new, progressive, or recurrent multiple organ dysfunction syndrome. New or progressive multiple organ dysfunction syndrome was associated with poor clinical outcomes, and progressive multiple organ dysfunction syndrome was associated with worse outcomes than new multiple organ dysfunction syndrome. In future studies, new multiple organ dysfunction syndrome and progressive multiple organ dysfunction syndrome may need to be considered separately, as they represent distinct subgroups with different, potentially modifiable risk factors. Patients with recurrent multiple organ dysfunction syndrome represent a newly characterized, high-risk group which warrants attention in future research. Members of the Heart And Lung Failure-Pediatric INsulin Titration (HALF-PINT) Study Investigators are listed in the Appendix (Supplemental Digital Content 1, http://links.lww.com/PCC/B101). 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 grants from the National Heart, Lung, and Blood Institute (U01 HL107681 and U01 HL108028). Drs. Marsillio’s, Wypij’s, and Ms. Asaro’s institutions received funding from National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute. Drs. Marsillio, Srinivasan, Wypij, Agus, Nadkarni, and Ms. Asaro received support for article research from the NIH. Dr. Sorce’s institution received funding from the NIH. This work was completed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Boston Children’s Hospital, and Children’s Hospital of Philadelphia based on data from the multicenter Heart And Lung Failure-Pediatric INsulin Titration trial. For information regarding this article, E-mail: LMarsillio@luriechildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Extracorporeal Membrane Oxygenation Support After Heart Transplantation in Children—Outcomes of a Single Center Cohort Objectives: Extracorporeal membrane oxygenation is used for postcardiotomy low cardiac output but is less established following heart transplantation. We characterized outcomes for children supported with extracorporeal membrane oxygenation after heart transplantation. Design: Single-center retrospective study. Setting: Large pediatric cardiac referral center. Patients: All patients who received heart transplantation and were cannulated to extracorporeal membrane oxygenation between 1995 and 2016. Interventions: Primary outcome measure was mortality 12 months postextracorporeal membrane oxygenation. Patient characteristics were analyzed for association with outcome according to early graft failure (extracorporeal membrane oxygenation ≤ 7 d after heart transplantation), or late graft failure. Measurements and Main Results: There were 246 heart transplants during the study period and 50 extracorporeal membrane oxygenation runs in 44 patients. Median time from transplant to extracorporeal membrane oxygenation was 1 day (range, 0–11.7 yr), with early graft failure in 28 patients (median 1, range 0–2 d) and 22 extracorporeal membrane oxygenation runs in 20 late graft failure patients (median, 0.8 yr; range, 8 d to 11.7 yr), including four patients with prior extracorporeal membrane oxygenation for early graft failure. Twenty-six patients (59%) survived to hospital discharge, and survival 12 months postextracorporeal membrane oxygenation was 24 patients (55%), lower in those with late graft failure (40% vs 67%; p 0.02). Independent risk factors for 12-month mortality were congenital heart disease, higher pulmonary vascular resistance indexed to body surface area (> 2.2 Woods U/m2), and higher creatinine. Higher panel reactive antibody levels were associated with 12-month mortality in the late graft failure group only. Conclusions: Extracorporeal membrane oxygenation can be effectively used to rescue patients with graft dysfunction after heart transplantation but is associated with high early mortality. Factors associated with mortality within 12 months include presence of congenital heart disease, renal dysfunction, elevated pulmonary vascular resistance indexed to body surface area and in those supported with extracorporeal membrane oxygenation late after heart transplantation, significant human leukocyte antigen sensitization. This study was performed at Boston Children’s Hospital, Boston, MA. Supported, in part, by grant from the Rochelle E. Rose Cardiac ICU Research Funds. Dr. Alexander’s institution received funding as a site principal investigator from Novartis (consultation fees), Tenax Therapeutics (supply therapeutic agent, levosimendan, only as part of an Expanded Access clinical trial), and from Extracorporeal Life Support Organization, and she disclosed off-label product use of extracorporeal membrane oxygenation. Dr. Thiagarajan’s institution received funding from Bristol-Myers Squibb and Pfizer. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Peta.Alexander@cardio.chboston.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Effect of Personalized Music Intervention in Mechanically Ventilated Children in PICU: A Pilot Study Objectives: To determine the feasibility of a personalized music intervention with mechanically ventilated patients in the PICU. Design: Pilot study with a quasi-experimental design. Setting: Tertiary children’s hospital in China with a 40-bed PICU. Patients: Children, 1 month to 7 years, with mechanical ventilation were recruited and assigned to music group (n = 25) and control group (n = 25). Interventions: Children in the music group received their own favorite music and listened for 60 minutes three times a day. The control group receive routine care without music. Measurements and Main Results: Primary outcome measure was comfort measured with the COMFORT Behavior scale 5 minutes before and after the music. Secondary outcome measures were physiologic variables; heart rate, respiration, blood pressure, oxygen saturation. Mechanical ventilation time, length of stay, and sedation medication were also collected. Qualitative analysis revealed that nurses had a positive attitude in delivering the interventions and identified improvements for the main trial. Children in the music group had lower COMFORT Behavior scores (15.7 vs 17.6; p = 0.011). Children in the music group had better physiologic outcomes; heart rate (140 vs 144; p = 0.039), respiration rate (40 vs 43; p = 0.036), systolic blood pressure (93 vs 95 mm Hg; p = 0.031), oxygen saturation (96% vs 95%; p < 0.001), diastolic blood pressure was not significantly (52 vs 53 mm Hg; p = 0.11). Children in the music group had a shorter ventilation time (148.7 vs 187.6; p = 0.044) and a shorter length of stay, but not significant (11.2 vs 13.8; p = 0.071). Children in the control group had higher total amount of on-demand midazolam (29 vs 33 mg; p = 0.040). Conclusions: Our pilot study indicates that personalized music intervention is feasible and might improve the comfort of children with mechanical ventilation. Further studies are needed to provide conclusive evidence in confirming the effectiveness of music interventions comforting critically ill children in PICUs. Dr. Zhu secured funding support of the project. Drs. Peng and Q.-j. Liu ensured nursing support in delivering the intervention and data collection. Dr. Qiu contributed to data analysis. Drs. M.-h. Liu, Zhu, Xiao, and Latour contributed to data collection and data interpretation. Drs. M.-h. Liu and Latour wrote the first draft of the article. All authors contributed to the development of the research protocol; all authors contributed to 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). This study was partially supported financially by the Health and Family Planning Commission of Hunan Province (Grant number C2017053) (to Dr. Zhu) and by the Hunan Provincial Government through the One Hundred Talent Program (to Dr. Latour). Drs. M.-h. Liu’s, Zhu’s, Peng’s, Zhang’s, Xiao’s, Q.-j. Liu’s, and Latour’s institutions received funding from Health and Family Planning Commission of Hunan Province (Grant number C2017053). Drs. M.-h. Liu’s, Zhu’s, Peng’s, Xiao’s, Q.-j. Liu’s, and Latour’s institutions received funding from Hunan Provincial Government through the Hundred Talent Program. Dr. Qiu disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail Dr. Zhu: 877845375@qq.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Provider Consensus on Candidate Protective and Risk Factors for Adverse Psychosocial Outcomes Following Discharge From a PICU: A Modified Delphi Study Objectives: Pediatric palliative care promotes interdisciplinary, family-centered care when children are faced with diagnoses threatening length and/or quality of life. A significant knowledge gap remains in how to best match pediatric palliative care resources to palliate the psychosocial impact of a PICU admission. This study was designed to identify drivers of adverse post-PICU psychosocial outcomes related to social determinants of health to inform pediatric palliative care services and improve post-PICU psychosocial outcomes. Design: Modified Delphi technique to develop consensus regarding social determinants of health and clinical factors affecting post-ICU psychosocial outcomes. Setting: All Delphi rounds were via an electronically mailed survey link. Subjects: First-round participants were PICU and pediatric palliative care clinicians at the study institution. Subsequent rounds invited participants from national PICU and pediatric palliative care professional online listserves. Interventions: None. Measurements and Main Results: Consensus was defined a priori as items assigned a score greater than or equal to 4 (5-point scale) by greater than75% of respondents. One-hundred twenty-six surveys were returned and scored. Social determinants of health risk factors included child protective services involvement (91%), caregiver with intellectual disability (87%), lack of friend or family support (82%), caregiver with behavioral health diagnosis (81%), teenage caregiver (79%), transportation challenges (79%), and language/cultural barrier (76%). Clinical risk factors included new home ventilator (94%), new tracheostomy (90%), greater than or equal to 3 hospitalizations in the prior 6 months (88%), and greater than or equal to 3 hospitalizations in the prior 12 months (82%). Social determinants of health protective factors included extended family support (91%), caregivers in a committed relationship (79%), and caregiver optimism (78%). Respondents reported that pediatric palliative care services had the greatest impact on caregiver satisfaction with the healthcare system (90%) and increased family involvement with state social services programs (80%). Conclusions: Consensus on candidate risk and protective factors for post-ICU psychosocial challenges and candidate pediatric palliative care-sensitive variables were identified. Further research is needed to operationalize and optimize a screening tool based on these consensus items and test it prospectively. Supported, in part, by grant from the study was funded internally. The authors have disclosed that they do not have any potential conflicts of interest. This study was carried out at Akron Children’s Hospital, Akron, OH. For information regarding this article, E-mail: dgrossoehme@akronchildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Pediatric Plasma and Platelet Transfusions on Extracorporeal Membrane Oxygenation: A Subgroup Analysis of Two Large International Point-Prevalence Studies and the Role of Local Guidelines Objectives: To describe the indications and thresholds for plasma and platelet transfusions for pediatric extracorporeal membrane oxygenation, to compare responses to these transfusions and to describe institutional protocols directing their administration. Design: Subgroup analysis of two prospective, observational studies paired with survey of sites who enrolled subjects into this cohort. Setting: Fifty-one PICUs in 13 countries. Patients: Children (3 d to 16 yr old) were enrolled if they received a plasma or platelet transfusion while on extracorporeal membrane oxygenation during one of the predefined screening weeks. Interventions: None. Measurements and Main Results: Forty-eight children on extracorporeal membrane oxygenation received plasma transfusions and 90 received platelet transfusions. Sixty percent of plasma transfusions (29/48) and 79% of the platelet transfusions (71/90) were given for prophylaxis of bleeding. The median (interquartile range) international normalized ratio prior to transfusion, known in 75% of the patients (36/48), was 1.45 (1.20–1.85). The median (interquartile range) total platelet count prior to transfusion, known in all of the patients, was 70 × 109/L (52–90 × 109/L). The international normalized ratio and total platelet count values prior to transfusion did not vary based on bleeding versus nonbleeding indications. The median (interquartile range) reduction in international normalized ratio for mild coagulopathies (international normalized ratio ≤ 2.0) was 0.1 (0.4–0), median (interquartile range) increase in fibrinogen was 0.2 g/L (0.1–0.4 g/L) and median increase in total platelet count was 34 × 109/L (10–74 × 109/L). Through the course of their admission, children supported by extracorporeal membrane oxygenation received a total median (interquartile range) dose of 75 mL/kg (36–159 mL/kg) of plasma transfusions and 92 mL/kg (42–239 mL/kg) of platelet transfusions. Institutional protocols varied but provided guidance for platelet transfusions more commonly. Conclusions: Children supported by extracorporeal membrane oxygenation receive large volumes of plasma and platelet transfusions with some institutional guidance in the form of protocols, but significant variation in practice. Interventional studies are necessary to provide evidence to direct the transfusion of hemostatic products in children supported by extracorporeal membrane oxygenation. Drs. Nellis and Saini contributed equally to this work. The authors have disclosed that they do not have any potential conflicts of interest. The PlasmaTV and P3T Investigators are listed in the Acknowledgments section. For information regarding this article, E-mail: man9026@med.cornell.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Pediatric Chronic Critical Illness: Gaps in Inpatient Intrateam Communication Objectives: The number of children with medical complexity and prolonged hospitalizations is rising. Strategies to adapt acute care approaches for this population are falling behind clinical demand. This study aimed to identify how inpatient team communication practices match the needs of teams caring for these patients and families, and to identify priority areas for improvement. Design: Cross-sectional mixed methods survey. Setting: Academic children’s hospital. Subjects: Interdisciplinary healthcare professionals: physicians, nurse practitioners, nurses, resident and fellow trainees, respiratory therapists, clinical pharmacists, occupational therapists, physical therapists, social workers, and child life specialists. Interventions: None. Measurements and Main Results: Four-hundred eight interdisciplinary healthcare professionals participated (33% response rate). Half (53 %) worked in ICUs and 37% had greater than 10 years clinical experience. Three overarching themes emerged regarding communication during care of children with prolonged hospitalizations are as follows: 1) Dysfunctional team collaboration: the many involved healthcare providers for these children have inconsistent team meetings and few platforms for reaching clinical consensus; 2) Continuity gaps: time-limited clinician rotations and no designated longitudinal clinical leaders undermine relationships with families and key elements of shared decision-making; and 3) Inadequate communication skills and tools: healthcare professionals have inadequate training to address complex conversations and big picture concerns, and often default to daily management conversations. Nearly half (40%) perceived intra-team conflict to occur more commonly during care of these children compared with those with short hospitalizations, and many feel unskilled to address these conflicts. Healthcare providers working in ICUs were more likely than other healthcare providers to find care of children with chronic critical illness stressful “most of the time” (ICU 46%; 60/131 vs non-ICU 25%; 21/84; p = 0.02). Conclusions: Acute care inpatient communication practices require modification to meet the needs of healthcare professionals who provide longitudinal care to children with repeated and prolonged hospitalizations. Improvement strategies should prioritize building collaboration, continuity, and communication skills among healthcare professionals. This work was performed at Charlotte Bloomberg Children’s Center Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287. Supported, in part, by grant from the Johns Hopkins Children’s Center Pediatric Innovation Award. Dr. Barone received other support from Clinical and Research Fellowship in Pediatric Palliative Care funded by the Stavros Niarchos Foundation. Dr. Boss’ institution received funding from Johns Hopkins Children’s Center, National Palliative Care Research Center, and Cambia Foundation Sojourns Scholar Leadership Award. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Renee D. Boss, MD, MHS, Department of Pediatrics, Johns Hopkins University School of Medicine, Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21287. E-mail: rboss1@jhmi.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Performance of a Clinical Decision Support Tool to Identify PICU Patients at High Risk for Clinical Deterioration Objectives: To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool. Design: Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours. Setting: Two quaternary care medical-surgical PICUs—The Children’s Hospital of Philadelphia and Cincinnati Children’s Hospital Medical Center. Patients: The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution. Interventions: We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration. Measurements and Main Results: The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis. Conclusions: Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance. 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 grant from an American Academy of Pediatrics Section of Critical Care Small Project Award and the Cincinnati Children’s Hospital Medical Center Place Outcomes Research Award. This work performed at The Children’s Hospital of Philadelphia and Cincinnati Children’s Hospital Medical Center. Dr. Dewan’s institution received funding from American Academy of Pediatrics Section of Critical Care Small Project Award and Cincinnati Children’s Hospital Medical Center Place Outcomes Research Award, and she received support for article research from the National Institutes of Health (NIH). Dr. Muthu’s institution received funding from Agency for Healthcare Research and Quality (AHRQ) and Pew Charitable Trusts, and he received funding from Phrase Health. Dr. Brady’s institution received funding from AHRQ and NIH. Dr. Kirkendall received funding from American Academy of Pediatrics, Council on Clinical Information Technology (reimbursed for travel costs/hotels for executive meetings); Goodis, Thompson and Miller, PA (expert legal case review); and VigiLanz (licensing royalties for software). Dr. Wolfe received funding from Zoll Medical (speaking honoraria). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: maya.dewan@cchmc.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies