OBJECTIVES:To determine if a priori standardization of outcome hemostatic definitions alone was adequate to enable useful comparison between two cohorts of pediatric extracorporeal membrane oxygenation (ECMO) patients, managed according to local practice and protocol. DESIGN:Comparison of two separate prospective cohort studies performed at different centers with standardized outcome definitions agreed upon a priori. SETTING:General and cardiac PICUs at the Royal Children's Hospital (RCH) in Melbourne, Australia, and the Sophia Children's Hospital (SCH) in Rotterdam, The Netherlands. PATIENTS:Children (0-18 yr old) undergoing ECMO. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Although outcome definitions were standardized a priori, the interpretation of surgical interventions varied. The SCH study included 47 ECMO runs (September 2019 to April 2023), and the RCH study included 97 ECMO runs (September 2016 to Jan 2022). Significant differences in patient populations were noted. RCH patients biased toward frequent cardiac ECMO indications, central cannulation, and cardiopulmonary bypass before ECMO. The frequency of outcome ascertainment was not standardized. CONCLUSIONS:This international comparison shows that standardizing hemostatic outcome definitions alone is insufficient for sensible comparison. Uniform interpretation of definitions, consistent frequency of outcome ascertainment, and stratification based on patient populations and ECMO practices are required. Our results highlight the granularity of detail needed for cross-center comparison of hemostatic outcomes in pediatric ECMO. Further work is needed as we move toward potential multicenter trials of pediatric ECMO.

To explore parents' experiences of holding children for healthcare procedures in an Australian paediatric hospital setting. A qualitative exploratory study was undertaken at a paediatric tertiary hospital in Melbourne, Australia. Semi-structured interviews were conducted with parents of children who had undergone a procedure during their hospital admission. Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Eight parents were interviewed, with four themes becoming apparent from their experiences, representing the multiple roles parents undertook when holding their child for a procedure. Parent as a protector was identified as the overarching role, with all roles involving aspects of parents protecting their child. The remaining roles included comforter-where parents supported their child by providing reassurance and being present; helper-where parents actively sought a role or stepped up to assist during a procedure and enforcer-where at times parents had a belief that to facilitate some procedures holding was necessary. A sliding-scale schema illustrates that these roles are not static, but rather positioned along a continuum, with some parents moving between roles throughout a procedure. This study provided valuable insight into the complexity of parents' involvement when supporting their child during a procedure. The varying roles suggest parents balance the desire for their child to feel safe (holding as a comforter) with wanting to get the procedure done (holding as an enforcer). This research impacts clinicians, parents and children involved in healthcare procedures. Clinicians can use the sliding-scale schema that illustrates the distinct roles parents can take on, as a visual tool to promote parental involvement and help parents define their role during a procedure. Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline was utilised when reporting findings. No patient or public contribution.

BACKGROUND:Routine post operative anal dilatations have been standard practice in the management of anorectal malformations (ARM) since 1982. Recent studies, however, have questioned their necessity and effectiveness. This systematic review aimed to synthesise the available literature pertaining to the effectiveness of routine post operative dilatations in preventing anal strictures following ARM surgery. METHODS:A systematic search of Cochrane Library, PubMed, Medline, and EMBASE databases was conducted for English-language articles published between January 1990 and December 2023. Studies reporting on children with ARM who underwent reconstructive surgery, followed by anal dilatations, were included. The primary outcome was the development of anal strictures. RESULTS:Seven studies met the inclusion criteria. Of the 400 patients, 311 (77.7 %) patients received routine post operative dilatations (RPD). Stricture rates ranged widely, with the Peña protocol, considered standard practice, resulting in stricture rates between 0 % and 39 %. Alternative approaches showed similar outcomes: daily non-Hegar dilatations (using digital manipulation or candles) resulted in stricture rates of 0-22 %, while weekly dilatations performed by surgeons showed rates of 15-18 %. In the single randomised controlled trial that included a non-dilatation group, comparable stricture rates were observed between patients who received dilatations (21 %) and those who did not (24 %). The heterogeneity in study designs, populations, and outcome measures limited direct comparisons. CONCLUSION:While RPDs have been the standard of care, the available evidence suggests that their universal necessity may be questioned. Alternative approaches appear to achieve comparable outcomes, however the variability in available evidence and lack of large-scale randomised trials both highlight the need for further research to guide evidence-based practice in post operative care for ARM patients. LEVEL OF EVIDENCE:Level IV.

INTRODUCTION:Children on organ transplant lists are more likely than adult patients to develop complications or die whilst waiting for a transplant. This reflects children's frequent need for size-matched organs, which are rarely available. OBJECTIVES:The aim of this study was to review characteristics of patients deemed unsuitable for organ donation in a paediatric intensive care unit over a 5-year period to identify opportunities for practice improvement. METHODS:This was a quantitative, retrospective, observational study, using a descriptive design. Data were extracted from the clinical intensive care database STATIC into Microsoft Excel for children who died between the 1st of January 2018 and the 31st of December 2022. Data were analysed descriptively. RESULTS:Across the 5 years, 226 children died; 94 (41%) were referred to the state organ donation service DonateLife, and 26 (11.5%) became organ donors. Most children died from a cardiac cause. Of the total children who died, 152 (66%) were deemed to be unsuitable for organ donation. The most common reasons for children being deemed unsuitable for organ donation were as follows: poor organ function (46%), pre-existing systemic disease (34%), sepsis (15%), too young (10.5%), and due to legislation (9.8%). CONCLUSION:This study identified cohorts of patients who were deemed unsuitable for organ donation. Based on published evidence, some of these patients may have been suitable or could have been considered for organ donation. Identifying these cohorts may optimise knowledge translation regarding donor suitability, with the outcome of increasing organ donation opportunities.

Background and aims Invasive devices are widely used in healthcare settings; however, pediatric patients are especially vulnerable to invasive device-associated harm. This study aimed to explore invasive device utility, prevalence, harm, and clinical practice across three Australian pediatric tertiary hospitals. Methods In 2022–2023, a multi-center, observational, rolling-point-prevalence survey was conducted. Fifty-per-cent of inpatients were systemically sampled by random allocation. Patients with devices were then followed for up to 3-days for device-related complications/failures and management/removal characteristics. Results Of the 285 patients audited, 78.2% had an invasive device ( n = 412 devices), with a median of 1 device-per-patient (interquartile range 1–2), with a maximum of 13 devices-per-patient. Over half of devices were vascular access devices ( n = 223; 54.1%), followed by gastrointestinal devices ( n = 112; 27.2%). The point-prevalence of all device complications on Day 0 was 10.7% (44/412 devices) and period-prevalence throughout the audit period was 27.7% (114/412 devices). The period-prevalence of device failure was 13.4% (55/412 devices). Conclusions The study highlighted a high prevalence of invasive devices among hospitalized patients. One-in-ten devices failed during the audit period. These findings underscore the need for vigilant monitoring and improved strategies to minimize complications and enhance the safety of invasive devices in pediatric hospital settings. Impact A high prevalence of invasive devices among hospitalized patients was reported. Of the 285 patients audited, almost 80% had an invasive device (total 412 devices), with a median of 1 device-per-patient and a maximum of 13 devices-per-patient. The most common devices used in pediatric healthcare are vascular access devices ( n = 223; 54.1%), however, 16% ( n = 36) of these devices failed, and one-third had complications. The point prevalence of all device complications at day 0 was 10.7% (44 out of 412 devices), with a period prevalence of 27.7% (114 out of 412 devices) throughout the audit period.

Objective: To characterize surface-bound proteins and to measure the thickness of fibrin fibers bound to extracorporeal membrane oxygenation (ECMO) circuits used in children. Design: Single-center observational prospective study, April to November 2021. Setting: PICU, Royal Children’s Hospital, Melbourne, Australia. Patients: Patients aged less than 18 years on venoarterial ECMO and without preexisting disorder. Interventions: None. Measurements and Main Results: ECMO circuits were collected from six patients. Circuit samples were collected from five different sites, and subsequently processed for proteomic and scanning electron microscopy (SEM) studies. The concentration of proteins bound to ECMO circuit samples was measured using a bicinchoninic acid protein assay, whereas characterization of the bound proteome was performed using data-independent acquisition mass spectrometry. The Reactome Over-representation Pathway Analyses tool was used to identify functional pathways related to bound proteins. For the SEM studies, ECMO circuit samples were prepared and imaged, and the thickness of bound fibrin fibers was measured using the Fiji ImageJ software, version 1.53c (https://imagej.net/software/fiji/). Protein binding to ECMO circuit samples and fibrin networks showed significant intra-circuit and interpatient variation. The median (range) total protein concentration was 19.0 (0–76.9) μg/mL, and the median total number of proteins was 2011 (1435–2777). A total of 933 proteins were commonly bound to ECMO circuit samples from all patients and were functionally involved in 212 pathways, with signal transduction, cell cycle, and metabolism of proteins being the top three pathway categories. The median intra-circuit fibrin fiber thickness was 0.20 (0.15–0.24) μm, whereas the median interpatient fibrin fiber thickness was 0.18 (0.15–0.21) μm. Conclusions: In this report, we have characterized proteins and fiber fibrin thickness bound to ECMO circuits in six children. The techniques and approaches may be useful for investigating interactions between blood, coagulation, and the ECMO circuit and have the potential for circuit design.

CONTEXT:The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood. OBJECTIVES:This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care. DATA SOURCES:Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched. STUDY SELECTION:Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included. DATA EXTRACTION:Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used. MAIN OUTCOMES AND MEASURES:Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor). RESULTS:Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications. CONCLUSIONS:This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

AIM:To explore collaboration and social dynamics within paediatric Morbidity and Mortality meetings. DESIGN:Qualitative Exploratory Case Study Methodology incorporating semi-structured interviews and qualitative observations. METHODS:Data were collected in a large quaternary paediatric hospital in Melbourne, Australia. Semi-structured interviews with meeting attendees were conducted after observing and documenting meeting conduct. Reflexive thematic analysis was used to interpret data and generate a thematic map of findings. RESULTS:Forty-four interviews and 32 meeting observations were conducted between July 2019 and January 2020. Participants valued collaboration between attendees in Morbidity and Mortality meetings, however there were barriers to this. They included differing views about roles and negative impacts of hierarchies and authority. Senior doctors dominated discussion, and participants described this occasionally signalling reverence and respect, but sometimes signified intimidation and feeling unsure about how to contribute. Because of this complexity, successfully achieving positive social dynamics in a meeting required active promotion and management. CONCLUSION:Morbidity and Mortality meetings mirror the complexity and richness of the clinical environment. Descriptions of how meeting conduct can shape positive workplace culture and address hierarchical obstructions to safe clinical care highlight their far-reaching potential. Effective collaboration is an intrinsic part of realising this value. IMPACT:This paper addresses a paucity in the literature in understanding how social dynamics and collaboration in Morbidity and Mortality meetings are interpreted and experienced. These findings illuminate challenges and obstacles to achieving a productive and equitable social dynamic in meetings. They also illustrate positive discrimination strategies that may improve participation and widespread engagement of nurses, junior doctors, and allied health professionals. Importantly, fostering constructive social dynamics in the Morbidity and Mortality meeting could positively impact patient safety culture and therefore patient care. PATIENT OR PUBLIC CONTRIBUTION:No patient or public contribution.

The continuous contact between blood and the foreign surface of the extracorporeal membrane oxygenation (ECMO) circuit contributes to hemostatic, inflammatory, and other physiological disturbances observed during ECMO. Although previous studies have extensively investigated blood samples from patients on ECMO, cell adsorption to the ECMO circuit as an additional factor that could potentially influence clinical outcomes, has largely been overlooked. Here we provide a detailed immunofluorescence (IF) protocol designed to characterize cellular binding on ECMO circuits collected from patients. Extracorporeal membrane oxygenation circuits were collected from three pediatric patients and an albumin primed-only ECMO circuit was used as control. Circuit samples from five different sites within each ECMO circuit were collected and processed for the IF protocol. CD14 and CD42a antibodies were used to identify platelets and leukocytes bound to each ECMO circuit sample and images captured using inverted fluorescence microscopy. The protocol enables the comprehensive characterization of platelet and leukocyte binding to ECMO circuits collected from patients, which could in turn extend our knowledge of the characteristics of circuit binding and may provide guidance for improved ECMO circuit design.

Purpose of the Study Extracorporeal membrane oxygenation (ECMO) circuit priming procedures are crucial for removing air bubbles and the albumin in priming solution is thought to create a protective layer against blood exposure and protein binding.1 However, the binding profile to the ECMO circuit after priming remains unexplored. This study aims to characterize proteins bound to the ECMO circuit after priming, and the corresponding priming solutions using data-dependent acquisition mass spectrometry (DDA-MS). Main Results Information on the ECMO circuit information, priming procedures, circuit collection, sample preparations, and experimental protocols for DDA-MS are detailed in Appendix 1, Supplemental Digital Content, https://links.lww.com/ASAIO/B305. An unused ECMO circuit was collected after 4 hour priming procedures, and circuit samples from five different sites (Figure 1) were collected for this study.Figure 1.: The basic diagram of ECMO circuit. Circuit samples were collected from site 1: postvenous cannula, site 2: prepump head, site 3: post-pump head to oxygenator, site 4: post-oxygenator, site 5: pre arterial cannula. ECMO, extracorporeal membrane oxygenation.The median total protein concentration of the five ECMO circuit samples was 3.24 μg/ml. Specifically, site 1 showed the highest total protein concentration of 51.10 μg/ml, followed by site 2 and site 5 of 12.72 μg/ml and 3.24 μg/ml, respectively, whereas no protein was detected from site 3 nor site 4. The total protein concentration of 20% albumin solution, Plasma-Lyte 148 solution, and the priming reagent mix were 204.00, 15.71, and 25.63 μg/ml, respectively. Due to insufficient protein concentration across other sites, only the site 1 ECMO circuit sample, 20% albumin solution, Plasma-Lyte 148 solution, and the priming reagent were analyzed using DDA-MS. In total, 129 different proteins were identified among all samples, with 121 proteins specifically identified bound to the ECMO circuit sample. Although 27, 33, and 32 proteins were identified among 20% albumin solution, Plasma-Lyte 148 solution, and the priming reagent mix, respectively. The Venn diagram of the identified proteins demonstrated the overlap between samples (eFigure 1, Supplemental Digital Content, https://links.lww.com/ASAIO/B305). Principal Component Analysis (PCA) analysis showed minimal separation between the 20% albumin solution and the priming reagent, whereas significant separation between Plasma-Lyte 148 solution and the circuit samples (eFigure 2, Supplemental Digital Content, https://links.lww.com/ASAIO/B305). The detailed list of identified proteins for each sample is presented in eTable 1, Supplemental Digital Content, https://links.lww.com/ASAIO/B305. The pathway analysis of the 121 proteins bound to the ECMO circuit sample showed involvement across 67 pathways divided into 15 categories. Specifically, immune system, hemostasis, and signal transduction represented the top three pathway categories with the greatest number of pathways involved (Figure 2). The detailed pathway analysis results are included in eTable 2, Supplemental Digital Content, https://links.lww.com/ASAIO/B305.Figure 2.: Pathway analysis of the 121 proteins bound to the ECMO circuit. ECMO, extracorporeal membrane oxygenation.Discussion In clinical practice, priming of the ECMO circuit before use in patient care serves as a preventive measure, which mitigates the blood exposure to the ECMO circuit through precoating with albumin. In this study, we demonstrated that besides albumin, a significant number of other proteins were identified bound to the ECMO circuit sample. In addition, complex protein compositions were identified in 20% albumin solution and Plasma-Lyte 148 solution. According to the product information,2 the 20% albumin solution is manufactured from human plasma using predominantly chromatographic techniques. Although it is prepared by undergoing rigorous purification processes, trace amounts of other residual proteins may remain in the final product due to the limitation of the purification methodology. Despite the fact that the Plasma-Lyte solution, being declared as a sterile, nonpyrogenic isotonic solution,3 various proteins may still be introduced during the manufacturing process. However, given the low protein concentration detected in the original Plasma-Lyte solution and the subsequent dilution with the 20% albumin solution before priming, the total quantity of identified proteins is very limited. The complex bound proteome of the ECMO circuit sample could be attributed by several factors and indicates potential impacts to patients during the following ECMO support. In this study, the total protein amount bound to different sites showed significant intra-circuit variation, with site 1 having the highest protein concentration. This could be due to the flow pressure variation between different sites of the ECMO circuit during priming process, which leads to differences in protein adsorption between sites.4 Our study showed a significantly greater number of proteins bound to site 1 ECMO circuit sample when compared with the 20% albumin solution and Plasma-Lyte 148 solution. This difference may be attributed to preexisting proteins on the ECMO circuit, which potentially be introduced during the manufacture or circuit setup before priming, or to limitation of protein identification in the 20% albumin solution. The overwhelming presence of albumin in the 20% albumin solution could potentially cause an ion suppression effect of DDA-MS, which obscures the detection of other less abundant proteins and hinders the comprehensive protein identification.5 Although for the ECMO circuit sample, the albumin was diluted by mixing with Plasma-Lyte 148 solution, but also the binding protein composition depends on the binding affinity and evolves with the priming time. Specifically, the less abundant proteins with higher binding affinity in the priming solutions were selectively accumulated to the ECMO circuit during the priming procedures. It is hypothesized that upon connection to the patient, these bound proteins would continue to interact with other blood components.6 The pathway analysis based on proteins bound to the ECMO circuit showed involvement of multiple pathways, which may have potential impacts to patients during ECMO support. However, this result needs to be interpreted with caution, due to the inability to confirm whether bound proteins have potentiating or inhibiting effects. Future studies will need to further investigate the impacts of these bound proteins on the patient outcomes during ongoing support. Given the variability in ECMO circuit priming solutions and procedures across different institutions,7 the method described in this paper offers a potential framework for future research aimed at characterizing the proteins bound to ECMO circuits following different priming procedures. This will enable a deeper understanding of how these clinical practice variations may uniquely affect patient outcomes during subsequent ECMO support. In conclusion, this study characterized proteins bound to the ECMO circuit after priming procedures and detailed protein profiles in the corresponding priming solutions. The total protein concentration bound to the primed ECMO circuit showed significant intra-circuit variation. Complex protein profiles were identified among the primed ECMO circuit and the corresponding priming solutions. Acknowledgment The authors like to thank the participants and their families for participating in this study. The authors like to acknowledge funding from the Australian National Health and Medical Research Council (NHMRC) grant APP1129317. Additionally, the authors also like to acknowledge the staff from the RCH PICU and perfusion teams at the RCH for obtaining the ECMO circuit.

Introduction Central venous access devices (CVADs) are commonly used for the treatment of paediatric cancer patients. Catheter locking is a routine intervention that prevents CVAD-associated adverse events, such as infection, occlusion and thrombosis. While laboratory and clinical data are promising, tetra-EDTA (T-EDTA) has yet to be rigorously evaluated or introduced in cancer care as a catheter lock.Methods and analysis This is a protocol for a two-arm, superiority type 1 hybrid effectiveness-implementation randomised controlled trial conducted at seven hospitals across Australia and New Zealand. Randomisation will be in a 3:2 ratio between the saline (heparinised saline and normal saline) and T-EDTA groups, with randomly varied blocks of size 10 or 20 and stratification by (1) healthcare facility; (2) CVAD type and (3) duration of dwell since insertion. Within the saline group, there will be a random allocation between normal and heparin saline. Participants can be re-recruited and randomised on insertion of a new CVAD. Primary outcome for effectiveness will be a composite of CVAD-associated bloodstream infections (CABSI), CVAD-associated thrombosis or CVAD occlusion during CVAD dwell or at removal. Secondary outcomes will include CABSI, CVAD-associated-thrombosis, CVAD failure, incidental asymptomatic CVAD-associated-thrombosis, other adverse events, health-related quality of life, healthcare costs and mortality. To achieve 90% power (alpha=0.05) for the primary outcome, data from 720 recruitments are required. A mixed-methods approach will be employed to explore implementation contexts from the perspective of clinicians and healthcare purchasers.Ethics and dissemination Ethics approval has been provided by Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (HREC/22/QCHQ/81744) and the University of Queensland HREC (2022/HE000196) with subsequent governance approval at all sites. Informed consent is required from the substitute decision-maker or legal guardian prior to participation. In addition, consent may also be obtained from mature minors, depending on the legislative requirements of the study site. The primary trial and substudies will be written by the investigators and published in peer-reviewed journals. The findings will also be disseminated through local health and clinical trial networks by investigators and presented at conferences.Trial registration number ACTRN12622000499785.

BACKGROUND:Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills. OBJECTIVE:The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings. METHODS:The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses. RESULTS:Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes. CONCLUSIONS:Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes. REGISTRATION:PROSPERO Registration Number CRD42020151002. TWEETABLE ABSTRACT:Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.

Objective The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting. Review Methods Used The study utilised scoping review methodology. Data Sources Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers. Review Methods Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories. Results Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support. Conclusions There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

Morbidity and Mortality meetings are conducted in varied clinical contexts including paediatrics. Widely cited as an educational or quality improvement tool, the reality is more complex. In this qualitative study, the aim was to explore the perceived goals of the paediatric acute care Morbidity and Morbidity meeting. This study used semi-structured interviews and observation within a qualitative case study methodology. Data were collected in a large paediatric quaternary hospital. Analysis generated themes related to meeting observations and the participant’s interpretation of meeting goals. A total of 44 interviews were conducted with 14 nurses, 29 doctors, and 1 allied health professional. Thirty-two meetings in six clinical departments were observed. Two themes were developed: complex and nuanced goals; and tensions and contest between and within goals. Meeting goals to evaluate care, learn, support, adhere, and change and respond were sometimes in competition and had varied interpretations. Morbidity and Mortality meetings in this setting are valued and occupy a complex role which reaches beyond identification of measurable patient safety interventions. Understanding goals more fully can lead to optimised conduct and meaningful measurement of efficacy. The strength in these meetings may be the way they promote an embedded safety culture, and an informed and skilled workforce.

Background:Extracorporeal membrane oxygenation (ECMO) is used in children with cardiopulmonary failure. While the majority of ECMO centers use unfractionated heparin, other anticoagulants, including factor XI and factor XII inhibitors are emerging, which may prove suitable for ECMO patients. However, before these anticoagulants can be applied in these patients, baseline data of FXI and FXII changes need to be acquired.Objectives:This study aimed to describe the longitudinal profile of FXI and FXII antigenic levels and function before, during, and after ECMO in children.Methods:This is a prospective observational study in neonatal and pediatric patients with ECMO (<18 years). All patients with venoarterial ECMO and with sufficient plasma volume collected before ECMO, on day 1 and day 3, and 24 hours postdecannulation were included. Antigenic levels and functional activity of FXI and FXII were determined in these samples. Longitudinal profiles of these values were created using a linear mixed model.Results:Sixteen patients were included in this study. Mean FXI and FXII antigenic levels (U/mL) changed from 7.9 and 53.2 before ECMO to 6.0 and 34.5 on day 3 and they recovered to 8.8 and 39.4, respectively, after stopping ECMO. Function (%) of FXI and FXII decreased from 59.1 and 59.0 to 49.0 and 50.7 on day 3 and recovered to 66.0 and 54.4, respectively.Conclusion:This study provides the first insights into changes of the contact pathway in children undergoing ECMO. FXI and FXII antigen and function change during ECMO. Results from this study can be used as starting point for future contact pathway anticoagulant studies in pediatric patients with ECMO.

Figure: Serum TPO levels in pediatric patients with ITP. Conclusion(s):The preliminary results suggest that ITP patients presented with differences in serum TPO levels, while serum TPO levels do not appear to play a critical role in differentiation of T cell subsets.

BACKGROUND:Children hospitalized following hematopoietic stem cell transplantation (HSCT) experience complex and prolonged pain in response to the intensity of this treatment. OBJECTIVES:To describe how pain was managed for children during HSCT therapy and how contextual factors related to the clinical environment influenced healthcare providers' and parents' pain management practices. METHODS:A qualitative case study was conducted and involved semi-structured interviews at two time points following transplantation (30 and 90 days) with parents (n = 10) and naturalistic observations of pain-related care provided to children (n = 29) during HSCT therapy by their healthcare providers (n = 10). Semi-structured interviews were also conducted with healthcare providers (n = 14). RESULTS:The effectiveness of pain management interventions was hindered by the multifactorial nature of pain children experienced, a gap in the provision of psychosocial interventions for pain and a lack of evidence-based guidelines for the sustained, and often long-term, administration of opioids and adjuvant medications. Misconceptions were demonstrated by healthcare providers about escalating pain management according to pain severity and differentiating between opioid tolerance and addiction. Parents were active in the management of pain for children, especially the provision of nonpharmacological interventions. Collaboration with external pain services and the impact of caring for children in protective isolation delayed timely management of pain. CONCLUSIONS:There is a pressing need to create evidence-based supportive care guidelines for managing pain post transplantation to optimize children's relief from pain. If parents and children are to be involved in managing pain, greater efforts must be directed toward building their capacity to make informed decisions.

Background Children undergoing hematopoietic stem cell transplantation (HSCT) are vulnerable to pain. Objective This study aimed to examine how healthcare providers and parents assessed pain and what contextual factors influenced their pain assessment practices for children hospitalized after allogeneic HSCT therapy. Methods A qualitative case study was conducted in a tertiary level pediatric HSCT unit in 2 phases. Semistructured interviews with parents were conducted at 30 and 90 days after HSCT therapy. Healthcare providers participated in naturalistic observations of pain-related care provided to children during their hospitalization for HSCT therapy and a semistructured interview. Results The assessment of pain after transplantation by healthcare providers and parents was predominantly reliant on the observation of children for behaviors indicative of pain, rather than the application of validated pain assessment tools. Without formal measures of the pain experience, judgments regarding the severity of children’s pain were influenced by the context of high acuity of care posttransplantation and the emotional responses of healthcare providers and parents from bearing witness to children’s pain. Conclusion Pain assessments mostly reflected children’s ability to tolerate pain, rather than a genuine measurement of how significantly pain impacted the child. Implication for Practice This study has emphasized how the assessment of pain for children hospitalized during HSCT therapy is limited by the complexity of the clinical environment. It is recommended that validated methods of assessing pain by healthcare providers and parents be implemented into clinical practice to ensure children’s pain is visible.

Background:Many children taking warfarin perform their international normalized ratio (INR) at home, with results phoned to a clinician who instructs warfarin dosing. Data suggest that parents can be supported to make warfarin dosing decisions themselves, a process known as patient self-management (PSM). Objectives:This study aimed to determine the suitability and acceptability of warfarin PSM in children using the Epic Patient Portal. Methods:Children currently performing INR patient self-testing were eligible. Participation involved an individualized education session, adherence to the PSM program, and participation in phone interviews. Clinical outcomes (INR time in therapeutic range and safety outcomes), patient portal functionality, and family experience were assessed. The hospital human research ethics committee approved the study and consent was obtained from parents/guardians. Results:Twenty-four families undertook PSM. The median age of children was 11 years and all children had congenital heart disease. A median of 13 INRs was uploaded to the portal per family (range, 8-47) across a 10-month period. Before PSM, the mean time the INR was in therapeutic range was 71%; this increased to 79.9% during PSM (difference: P < .001). No adverse events were encountered. Eight families participated in a phone interview. The major theme identified was empowerment; minor themes that emerged included "gaining knowledge," "trust and responsibility builds confidence," "saving time," and "resources as a safety net." Conclusion:This study demonstrates that communication via the Epic Patient Portal is satisfactory to families and offers a suitable option for PSM for children. Importantly, PSM empowers and builds confidence in families to facilitate management of their child's health.