OBJECTIVES:The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years. DESIGN:Retrospective multicenter cohort study. SETTING:Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021. PATIENTS:Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time (p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis (p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge. CONCLUSIONS:ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).

Unhurried conversations are necessary for careful and kind care that is responsive and responsible to both patients and clinicians. Adequate conceptual development is an important first step in being able to assess and measure this important domain of quality of care. In this article, we expand on a preliminary model to identify the key microlevel communication practices that support an unhurried conversation, defined as an ongoing, mutual accomplishment between patient and clinician that proceeds through a range of verbal and nonverbal communication practices wherein one or more participants (mutually) regulate the sequence, spacing (temporal and spatial), and speed of interaction to make themselves available to the other and remove or suspend distractions from the environment in order to improve care. We draw from the rich, qualitative descriptions found in earlier work that point to specific, observable practices in clinical encounters and identified empirical and theoretical work across a range of disciplines to expand our understanding of these practices. Ultimately, we identify and elaborate on 10 observable indicators of patient-clinician communication: engaging in shared turn taking, establishing rapport through discussion of off-task topics, pausing to allow the other ample time to speak, moderating the pace of spoken language, avoiding conversational interruptions, minimizing external interruptions, triaging topics as needed to create adequate time, expressing emotions, encouraging participation through inviting questions, and displaying open body language. These indicators work together to cocreate unhurried conversations.

OBJECTIVE:Given the importance of unhurried conversations for providing careful and kind care, we sought to create, test, and validate the Unhurried Conversations Assessment Tool (UCAT) for assessing the unhurriedness of patient-clinician consultations. METHODS:In the first two phases, the unhurried conversation dimensions were identified and transformed into an assessment tool. In the third phase, two independent raters used UCAT to evaluate the unhurriedness of 100 randomly selected consultations from 184 videos recorded for a large research trial. UCAT's psychometric properties were evaluated using this data. RESULTS:UCAT demonstrates content validity based on the literature and expert review. EFA and reliability analyses confirm its construct validity and internal consistency. The seven formative dimensions account for 89.93% of the variance in unhurriedness, each displaying excellent internal consistency (α > 0.90). Inter-rater agreement for the overall assessment item was fair (ICC = 0.59), with individual dimension ICCs ranging from 0.26 (poor) to 0.95 (excellent). CONCLUSION:UCAT components comprehensively assess the unhurriedness of consultations. The tool exhibits content and construct validity and can be used reliably. PRACTICE IMPLICATIONS:UCAT's design and psychometric properties make it a practical and efficient tool. Clinicians can use it for self-evaluations and training to foster unhurried conversations.

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) has been associated with improved outcomes compared to conventional CPR (CCPR) in children with underlying cardiac disease. There are limited data on ECPR survival outcomes in the non-cardiac population. Hypothesis: ECPR will be associated with improved survival to discharge in children without underlying cardiac disease with prolonged CPR. Methods: Retrospective cohort study using the AHA Get With The Guidelines® - Resuscitation registry of children (<18 years) without cardiac disease who received ≥30 minutes of CPR for in-hospital cardiac arrest between 2000-2020. Weighted propensity scores were used to balance ECPR and CCPR groups based on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model was used to estimate the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR relative to the index year of 2000. Results: Of 875 patients, 159 received ECPR and 716 received CCPR (median age 1 year, primary diagnosis respiratory insufficiency, median CPR duration 45 minutes for full cohort). Survival to discharge was similar between the ECPR group (21.4%) compared to the CCPR group (16.2%) in both the univariable analysis (p= 0.13) and the propensity-weighted multivariable logistic regression (aOR 1.44 [CI 0.85-2.44, p= 0.173]. The Bayesian model estimated an 85.1% probability of a positive effect of ECPR on survival to discharge. ECPR use increased over time (test for trend p<0.001). Conclusion: In children without cardiac disease who required ≥30 minutes of CPR, ECPR usage significantly increased in the last 20 years. Compared to CCPR, ECPR was not associated with a statistically significant increase in survival to discharge. However, a Bayesian model estimated weak evidence of a positive survival effect of ECPR.

1 Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 2 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 4 Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD *See also p. 3. Dr. Su disclosed that she is the cofounder and author for chddoodles LLC. Dr. Kudchadkar has disclosed that she does not have any potential conflicts of interest.

BACKGROUND:Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric patients undergoing cardiopulmonary resuscitation (CPR). METHODS:Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes [ROSC]) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects. RESULTS:Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 [95% CI: 0.55-2.36]), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 [0.43, 1.77]), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26). CONCLUSIONS:In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.

conceptualization Assimilative (think and watch) Convergent (think and do) Accommodative (feel and do) Divergent (feel and watch) Active experimentation Fig. 18.1 Kolb’s four-stage experiential learning cycle and styles [13]. (Permission granted from Elsevier, Ref. [4]) R. L. Hales and D. L. Rodgers

Theoretical constructs and theories applied in experiments in decision making have challenges, when applied to actual healthcare, where data and time are limited. This chapter describes some alternative decision making theories that can be applied in the messy “real” world of healthcare professionals. The chapter covers several cognitive processes such as sensemaking and team reflection that are relevant to healthcare simulation and its use for system improvements. The chapter explores how these models can inform simulation practice in terms of design, conduct, and debriefing. It also describes how simulation can be used to analyze meta-cognitive processes.

•In subclavian artery isolation, a subclavian artery arises from a pulmonary artery.•Subclavian artery isolation with d-TGA has unique findings on physical examination.•Subclavian artery isolation with d-TGA is often a missed diagnosis on echocardiogram.•Diagnosis is made more often using CCT, CMR, or invasive angiography.•Preoperative diagnosis enables surgical correction during arterial switch operation.

Simulation-based training (SBT) is often evaluated based on the transfer of specific knowledge and skills. In contrast, the degree to which reflective practice is inculcated by SBT is rarely considered. Because reflection is a pillar of adult learning theories, we sought to examine the degree to which participation in SBT was associated with increased reflective practice. Eighty-one healthcare professionals completed a survey which included the number of SBTs they participated in during the past 2 years, content-related and administrative-related features of those SBTs and a key aspect of reflective practice (ie, self-appraisal). The number of SBTs healthcare professionals participated in during the past 2 years was positively associated with reflective self-appraisal. This relationship was neither moderated by the inclusion of reflection components in SBTs nor by the voluntary/mandatory nature of participation in SBTs. Furthermore, the facilitator was ranked as the most important feature of the overall learning experience in SBTs. Also, no significant differences were found between the number of technical skills based and non-technical skills based SBTs. These findings demonstrate the importance of evaluating SBTs for facilitating reflective learning mindsets that healthcare practitioners can apply beyond the specific skills trained by SBTs.

Introduction: The transition from residency to subspecialty fellowship in pediatric cardiology is challenging, with the daunting requirement to rapidly acquire a broad scope of knowledge and skill. In 2015, a pediatric cardiology boot camp was designed as an educational tool to help prepare trainees for this transition. Hypothesis: A national pediatric cardiology boot camp consistently improves knowledge and decreases anxiety for prospective fellows. Methods: In late spring each year (2015-2019), a 2.5-day intensive program was provided for trainees prior to beginning fellowship in July. Hands-on, simulation-based experiences were provided on topics including anatomy, auscultation, echocardiography, catheterization, cardiovascular intensive care, electrophysiology, heart failure, pulmonary hypertension, and cardiac surgery. Knowledge based exams and surveys were completed by each participant pre- and post-training. Pre- and post-training exam results were compared via paired t-tests and survey results were compared via Wilcoxon rank sum. Results: Over 5 years 144 participants (72 female, 50%) completed the course, representing 40 fellowship programs in the United States and Canada. In aggregate, significant improvement was seen in participants’ knowledge assessment (pre 45 ± 11% vs. post 71 ± 9%; p<0.0001). Post-intervention tests showed significant increases in knowledge every year, with a similar mean rate of improvement from year to year (25±10%; p=0.15). Participants in 2015 did score higher on both pre and post testing (pre 55±10%, post 85±7%; p<0.0001), but the improvement rate remained consistent. Pre- and post-program surveys showed significant improvement in 38 of 38 domains assessing comfort and anxiety (p<0.001 for each domain). All participants strongly agreed (97%) or agreed (3%) that the boot camp was a valuable learning experience and 98% strongly agreed (66%) or agreed (32%) that boot camp alleviated anxieties about starting fellowship. Conclusions: The Pediatric Cardiology Boot Camp provides a significant and reproducible educational benefit to participants nationwide. This intensive program simultaneously improves learners’ knowledge and alleviates anxiety as they transition to subspecialty training.

ECMO is a team sport and requires a sophisticated understanding of team science to optimize outcomes. This chapter provides an overview of the latest understanding of advances in team science and concepts applicable to ECMO teams. Concepts such as coordination and sensemaking will be reviewed. There will also be a review of newer techniques to improve team performance including 10 for 10, use of a boundary spanner, team reflectivity, as well as techniques to increase a team’s psychological safety.

BACKGROUND:The continued need for improved teamwork in all areas of health care is widely recognized. The present article reports on the application of a hackathon to the teamwork problems specifically associated with ad hoc team formation in rapid response teams.PURPOSES:Hackathons-problem-solving events pioneered in computer science-are on the rise in health care management. The focus of these events tends to be on medical technologies, however, with calls for improvements in management practices as general recommendations. The hackathon reported here contributes to health care management practice by addressing improvements in teamwork as the focal problem.METHODOLOGY:The hackathon event took place over 2.5 days in conjunction with an academic conference focused on group research. Three teams comprised of practicing healthcare professionals, academic researchers and students developed solutions to problems of ad hoc team formation in rapid response teams.FINDINGS:The event fulfilled several goals. The teams produced three distinct, yet complementary solutions that were backed by both field-based experience and solid research evidence. The event provided the opportunity for two-way translation of research and practice through direct collaboration among key stakeholders. The hackathon produced long term effects through establishing or strengthening collaborations, dissemination of the ideas through presentations, workshops, and publications, and changes in participantsâ work practices.PRACTICE IMPLICATION:The event demonstrated that hackathons, classically focused on technology, can also offer a spur to innovation around organizational processes. The article provides advice for organizing other hackathons focused on similar topics. The solutions offered by the participants in the event yields the clear insight that multipronged solutions for emergency-oriented teamwork are needed. The hackathon highlighted the scaled of collaboration and effort needed to tackle the many complexities in health care that impact outcomes for providers, patients, and health organizations.

At the 14th Annual International Meeting for the Pediatric Cardiac Intensive Care Society, the authors presented a simulation workshop for junior multidisciplinary providers focused on cardiopulmonary interactions. We provide an overview of educational theories of particular relevance to curricular design for simulation-based or enhanced activities. We then demonstrate how these theories are applied to curriculum development for individuals to teams and for novice to experts. We review the role of simulation in cardiac intensive care education and the education theories that support its use. Finally, we demonstrate how a conceptual framework, SIMZones, can be applied to design effective simulation-based teaching.

This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.

Department of Pediatrics, Northwestern University, Chicago, IL Department of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA Department of Cardiology, Harvard Medical School Boston Children’s Hospital, Boston, MA *See also p. 564. Dr. Allan received funding from UpToDate (author royalties). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Background: Postoperative care delivered in the pediatric cardiac intensive care unit (CICU) relies on providers’ understanding of patients’ congenital heart defects (CHDs) and procedure performed. Novel, bedside use of virtual, three-dimensional (3D) heart models creates access to patients’ CHD to improve understanding. This study evaluates the impact of patient-specific virtual 3D heart models on CICU provider attitudes and care delivery. Methods: Virtual 3D heart models were created from standard preoperative cardiac imaging of ten patients with CHD undergoing repair and displayed on a bedside tablet in the CICU. Providers completed a Likert questionnaire evaluating the models’ value in understanding anatomy and improving care delivery. Responses were compared using two-tailed t test and Mann-Whitney U test and were also compared to previously collected CICU provider responses regarding use of printed 3D heart models. Results: Fifty-three clinicians (19 physicians, 34 nurses/trainees) participated; 49 (92%) of 53 and 44 (83%) of 53 reported at least moderate to high satisfaction with the virtual 3D heart’s ability to enhance understanding of anatomy and surgical repair, respectively. Seventy-one percent of participants felt strongly that virtual 3D models improved their ability to manage postoperative problems. The majority of both groups (63% physicians, 53% nurses) felt that virtual 3D heart models improved CICU handoffs. Virtual 3D heart models were as effective as printed models in improving understanding and care delivery, with a noted provider preference for printed 3D heart models. Conclusions: Virtual 3D heart models depicting patient-specific CHDs are perceived to improve understanding and postoperative care delivery in the CICU.