BACKGROUND:Immune effector cell (IEC) therapies, including chimeric antigen receptor (CAR)-modified T-cell therapy, have shown efficacy in pediatric B-cell acute lymphoblastic leukemia (B-ALL) and are being investigated for other malignancies. A common toxicity associated with IEC therapy is cytokine release syndrome (CRS), which can lead to cardiovascular decompensation due to systemic inflammation. Data are limited regarding cardiovascular adverse effects in children. This study aims to describe the cardiovascular adverse effect profile of IEC therapies in pediatric patients with hematologic and solid tumor malignancies. METHODS:We retrospectively reviewed patients who received IECs directed towards various targets in patients with hematologic, solid, and brain tumor malignancies from January 2014 to June 2023 at Texas Children's Hospital. The primary end point was hypotension requiring vasoactive support and/or heart failure within 30 days of infusion. RESULTS:A total of 203 patients met inclusion criteria. Pretreatment echocardiogram was available for 142 (70%) pediatric patients, of whom 140 (96%) had normal baseline systolic function. Hypotension requiring vasoactive support occurred in 26 (13%) patients. Hematologic malignancy indications (p = 0.002), total body irradiation (TBI) (p = 0.002), and allogenic hematopoietic stem cell transplants (HCT) (p = 0.035) were associated with increased risk of hypotension requiring vasoactive support. Follow-up echocardiograms were available for 14 patients who met the primary end point, and all showed return to baseline within 6 months. CONCLUSIONS:Significant hemodynamic compromise occurred in a minority of patients treated with IEC therapies. All experiencing cardiac dysfunction had recovery of function, and there was no cardiovascular-related mortality.

OBJECTIVE:Pediatric subspecialty fellows often serve as transport medical control (TMC) for interfacility transports, but assessment of fellow TMC performance is not standardized. In this study, we sought to generate validity evidence for a TMC assessment tool using simulated transport calls. METHODS:We conducted a cross-sectional study among pediatric subspecialty attendings in critical care medicine, emergency medicine, neonatology, and hospital medicine who supervise fellows serving as TMC. We used Messick's framework to evaluate for validity evidence of content, response process, internal structure, and relationship to other variables. Participants listened to simulated transport calls applicable to their subspecialty and completed the 21-item TMC assessment tool, a supervision level scale, and a survey on the relevance, ease, and clarity of the TMC assessment tool. RESULTS:A total of 101 faculty from 54 institutions participated in the study. Nearly all participants (99%, 99/101) indicated that the TMC assessment tool captured the relevant skills and knowledge required for TMC very or somewhat well. Reliability of the TMC assessment tool was high, with a Cronbach's alpha of 0.86 (95% CI 0.84-0.87). The TMC assessment tool also demonstrated outstanding ability to predict if a fellow could perform the role of TMC independently with an area under the curve of 0.91. CONCLUSIONS:This study provides multiple sources of evidence for validity of a TMC assessment tool using simulated interfacility transport calls. This tool could be implemented by pediatric subspeciality fellowship programs to improve TMC training and assessment of fellow performance in the role of TMC.

BackgroundPrimary mediastinal B cell lymphoma (PMBCL) is a rare type of non-Hodgkin's lymphoma, and prompt diagnosis and initiation of chemotherapy are necessary to limit compression of cardiovascular structures.Case reportA 13-year-old patient was diagnosed with PMBCL, resulting in acute hypoxemic respiratory failure and cardiogenic shock with clinical pericardial tamponade. Chemotherapy was initiated after veno-arterial extracorporeal membrane oxygenation and subsequent endovascular stenting of the superior vena cava (SVC) to optimize cardiac output due to malignant SVC syndrome.ConclusionWe discuss the challenges of diagnosis and emergency management of pediatric patients with PMBCL and review the existing relevant literature for SVC syndrome secondary to PMBCL.

BACKGROUND:Multidisciplinary patient care rounds are increasingly seen as a vital complement to patient care management. Family engagement in these rounds, especially in the paediatric population, is important to treatment and outcomes, but there is little information about family experience in the Paediatric Intensive Care Unit (PICU). AIMS:To develop a process using family care journals (FCJ) to systematically evaluate family experience in the PICU and identify needed supportive resources that will enhance their critical care stay. STUDY DESIGN:This is a single-centre quasi-experimental design conducted at a large urban quaternary level freestanding children's hospital. A family care journal (FCJ) was distributed to families upon admission to PICU to serve as a resource tool during their stay. An electronic point of care (POC) questionnaire was used to assess families' experiences in the PICU. RESULTS:Three hundred sixty-six questionnaires were completed (100% response rate) and analysed. Overall, there was an improvement in all phases post FCJ implementation compared with the baseline. Seventy five percent of families found it a useful tool for communication with the PICU team. Open-ended comments revealed improvement opportunities related to communication, environment, and delay in care. Almost all commented on excellent nursing care. CONCLUSIONS:Introducing FCJ in a paediatric ICU is a practical approach, providing a cost-effective method to assess family experiences and gain insights for ongoing quality improvement efforts. Collaboration among all care team members, including nursing, medical, and administrative leaders, is crucial for empathetically addressing parental needs during hospitalization. RELEVANCE TO CLINICAL PRACTICE:Combining the use of journals and questionnaires provides the clinical team with an efficient means of collecting valuable feedback from parents regarding their experience in the PICU and the factors that foster ongoing commitment from families. Nurses play a crucial role in encouraging the adoption of these journals, as they promote greater parent involvement in their children's care.

Introduction: We describe a unique case of a pediatric patient diagnosed with a diffuse large B cell lymphoma causing acute superior vena cava (SVC) syndrome and cardiogenic shock. She required veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and endovascular SVC stent placement to optimize cardiac output prior to completing her first two rounds of chemotherapy. Description: A 13-year-old girl was admitted to the pediatric intensive care unit (PICU) with acute hypoxemic respiratory failure following three weeks of cough and progressive shortness of breath, initially presumed to be secondary to community acquired pneumonia with a right sided pleural effusion. After escalating respiratory support to endotracheal intubation, she developed acute hypotension and tachycardia with rising lactic acidosis. Further diagnostic workup revealed a large anterior mediastinal mass compressing the SVC, right upper pulmonary vein, right pulmonary artery, and distal trachea. She underwent femoral cannulation to initiate VA-ECMO, but the degree of obstruction of venous return resulted in persistent poor cardiac output with biventricular systolic dysfunction and elevated central venous pressure. To bypass the obstruction, she underwent endovascular stenting of her superior vena cava, resulting in a dramatic improvement in cardiac output while awaiting histopathology results and initiating chemotherapy for a presumed lymphoma. Discussion: This case is the first report of a pediatric patient with an oncologic process who underwent endovascular stent placement while simultaneously requiring VA-ECMO. Pediatric oncology patients had previously been considered relative contraindications to ECMO, but recent reports have described the utility of ECMO as a bridge to initiation of chemotherapy, especially in a setting of a mediastinal mass with vascular invasion or compression. Additionally, SVC syndrome in adults typically is treated with endovascular stenting as first line therapy, often as a palliative procedure in malignant causes of SVC obstruction. Pediatric patients are undergoing endovascular therapy for SVC syndrome more commonly, and this case demonstrates the feasibility of completing an endovascular intervention to augment venous return in a pediatric patient with a mediastinal mass.

Point-of-care ultrasound (POCUS) is increasingly accepted in pediatric critical care medicine as a tool for guiding the evaluation and treatment of patients. POCUS is a complex skill that requires user competency to ensure accuracy, reliability, and patient safety. A robust competency-based medical education (CBME) program ensures user competency and mitigates patient safety concerns. A programmatic assessment model provides a longitudinal, holistic, and multimodal approach to teaching, assessing, and evaluating learners. The authors propose a fit-for-purpose and modifiable CBME model that is adaptable for different institutions' resources and needs for any intended competency level. This educational model drives and supports learning, ensures competency attainment, and creates a clear pathway for POCUS education while enhancing patient care and safety.

Clinician educators (CEs) play a vital role in helping academic institutions achieve the missions of patient care, education and research. The driving forces that motivate pediatric CEs in professional growth and personal satisfaction remain unexplored. An exploratory survey research to investigate the job characteristics and factors that motivate CEs to pursue professional growth with personal satisfaction. Using the Job Characteristics Model (JCM) as a framework, we developed a 22-item survey comprised of the JCM derived Job Diagnostic Survey, Global Job Satisfaction scales and demographics. We collected data from January 2020 to March 2020 from self-identified pediatric CEs (with and without educational leadership roles) through a survey recruitment service. Given no data on total number of CEs in the survey pool, response rate was unknown. Job characteristics in the core job dimensions of meaningfulness, autonomy, and performance feedback, as well as, the derived Motivating Potential Score (MPS), were analyzed using descriptive statistics and regression models. From 201 respondents, including 55 education leaders, >70% were satisfied with patient care, teaching, and mentoring while <40% were satisfied with administrative and scholarly activities. Meaningfulness (in some areas), autonomy (patient care/teaching), and internal feedback (all areas) had significant effects on job satisfaction. In regression analysis, skill variety, feedback, and years of experience were associated with higher job satisfaction, and the MPS was a predictor of total job satisfaction. The JCM can be utilized to understand CE's motivations and needs within their workplace and guide professional development via job enrichment efforts.

BACKGROUND AND OBJECTIVE:Pediatric interfacility transport teams facilitate access to subspecialty care, and physicians often guide management remotely as transport medical control (TMC). Pediatric subspecialty fellows frequently perform TMC duties, but tools assessing competency are lacking. Our objective was to develop content validity for the items required to assess pediatric subspecialty fellows' TMC skills. METHODS:We conducted a modified Delphi process among transport and fellow education experts in pediatric critical care medicine, pediatric emergency medicine, neonatal-perinatal medicine, and pediatric hospital medicine. The study team generated an initial list of items on the basis of a literature review and personal experience. A modified Delphi panel of transport experts was recruited to participate in 3 rounds of anonymous, online voting on the importance of the items using a 3-point Likert scale (marginal, important, essential). We defined consensus for inclusion as ≥80% agreement that an item was important/essential and consensus for exclusion as ≥80% agreement that an item was marginal. RESULTS:The study team of 20 faculty drafted an initial list of items. Ten additional experts in each subspecialty served on the modified Delphi panel. Thirty-six items met the criteria for inclusion, with widespread agreement across subspecialties. Only 1 item, "discussed bed availability," met the criteria for inclusion among some subspecialties but not others. The study team consolidated the final list into 26 items for ease of use. CONCLUSIONS:Through a consensus-based process among transport experts, we generated content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

Introduction: Multiple competency assessment tools exist for CVC insertion, but there is no standardized approach for use. A direct observation, competency checklist tool (CT) for pediatric CVC placement was developed and validity evidence obtained in simulated encounters but not clinical environments. This study aimed to evaluate how the CT performs in a clinical environment and compare it with a global rating scale (GRS) and an entrustment scale (ES), two competency assessments commonly used. Methods: 12-month (7/21-6/22), prospective, multi-site, observational study. With each CVC inserted, supervisors completed 3 assessments of competency (1. CT: 15 steps with dichotomous (Complete/Not Complete) options; 2. GRS: a dichotomous (Competent/Not Competent) assessment; 3. ES: 5-level supervision rating from ‘observe only’ to ‘able to perform procedure unsupervised’). CT inter-item reliability was evaluated with Cronbach’s alpha. CT, GRS, and ES assessments were compared using partial correlations adjusting for clustering of observations in fellows and fellows in programs. Mixed-effects linear, ordinal, and logistic regressions were used to model the effect of fellow year on scales. Results: 17 sites participated with 339 CVC insertions completed by 116 unique fellows. Overall, the CT had an acceptable internal reliability (alpha=0.66 [95% CI 0.6-0.71]). The CT had minimal correlation with the other assessments (GRS R=0.38, ES R=0.29). GRS and ES (R=0.54) were moderately correlated. For the CT, 2nd year fellows had higher scores than 1st year fellows (0.29 [0.08-0.51] points, p=0.008). 3rd year fellows did not have higher scores than 2nd year fellows (p=0.243). For GRS and ES, trainees had higher competency scores with each year of training (year 1 to 2 [(p< 0.001] and year 2 to 3 [p=0.009]). Conclusions: The checklist tool performed acceptably during real-world competency assessment and correlated with fellow year of training from year 1 to 2 but not year 2 to 3, reflecting its strength in assessing competency for novice trainees. Current assessment tools (ES and GRS) did not correlate well with the CT; different competency assessment tools may serve different purposes based on level of training. Further evaluation of these assessment tools is warranted to determine optimal approach to competency assessment.

CONTEXT: Sepsis-induced coagulopathy leading to disseminated microvascular thrombosis is associated with high mortality and has no existing therapy. Despite the high prevalence of Gram-positive bacterial sepsis, especially methicillin-resistant Staphylococcus aureus (MRSA), there is a paucity of published Gram-positive pediatric sepsis models. Large animal models replicating sepsis-induced coagulopathy are needed to test new therapeutics before human clinical trials. HYPOTHESIS: Our objective is to develop a pediatric sepsis-induced coagulopathy swine model that last 70 hours. METHODS AND MODELS: Ten 3 weeks old piglets, implanted with telemetry devices for continuous hemodynamic monitoring, were IV injected with MRSA (n = 6) (USA300, Texas Children's Hospital 1516 strain) at 1 x 109 colony forming units/kg or saline (n = 4). Fluid resuscitation was given for heart rate greater than 50% or mean arterial blood pressure less than 30% from baseline. Acetaminophen and dextrose were provided as indicated. Point-of-care complete blood count, prothrombin time (PT), activated thromboplastin time, d-dimer, fibrinogen, and specialized coagulation assays were performed at pre- and post-injection, at 0, 24, 48, 60, and 70 hours. Piglets were euthanized and necropsies performed. RESULTS: Compared with the saline treated piglets (control), the septic piglets within 24 hours had significantly lower neurologic and respiratory scores. Over time, PT, d-dimer, and fibrinogen increased, while platelet counts and activities of factors V, VII, protein C, antithrombin, and a disintegrin and metalloproteinase with thrombospondin-1 motifs (13th member of the family) (ADAMTS-13) decreased significantly in septic piglets compared with control. Histopathologic examination showed minor focal organ injuries including microvascular thrombi and necrosis in the kidney and liver of septic piglets. INTERPRETATIONS AND CONCLUSIONS: We established a 70-hour swine model of MRSA sepsis-induced coagulopathy with signs of consumptive coagulopathy, disseminated microvascular thrombosis, and early organ injuries with histological minor focal organ injuries. This model is clinically relevant to pediatric sepsis and can be used to study dysregulated host immune response and coagulopathy to infection, identify potential early biomarkers, and to test new therapeutics.

OBJECTIVES:Characterize transport medical control education in Pediatric Critical Care Medicine fellowship.DESIGN:Cross-sectional survey study.SETTING:Pediatric Critical Care Medicine fellowship programs in the United States.SUBJECTS:Pediatric Critical Care Medicine fellowship program directors.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:We achieved a 74% (53/72) response rate. A majority of programs (85%) require fellows to serve as transport medical control, usually while carrying out other clinical responsibilities and sometimes without supervision. Fellows at most programs (80%) also accompany the transport team on patient retrievals. Most respondents (72%) reported formalized transport medical control teaching, primarily in a didactic format (76%). Few programs (25%) use a standardized assessment tool. Transport medical control was identified as requiring all six Accreditation Council for Graduate Medical Education competencies, with emphasis on professionalism and interpersonal and communication skills.CONCLUSIONS:Transport medical control responsibilities are common for Pediatric Critical Care Medicine fellows, but training is inconsistent, assessment is not standardized, and supervision may be lacking. Fellow performance in transport medical control may help inform assessment in multiple domains of competencies. Further study is needed to identify effective methods for transport medical control education.

OBJECTIVE:To create and validate a checklist for high-quality documentation and pilot a multi-modal, immersive educational module across multiple institutions. We hypothesized that this module would improve knowledge, skills, and attitudes in medical documentation.METHODS:Module design was grounded in an established curriculum design framework. We conducted the study across 12 pediatric critical care fellowship programs between September 2017 and January 2018. Workshops were allotted 90 minutes for completion. We utilized a pre-/post- study design to determine the workshop's impact. Changes in knowledge were assessed through pre and post testing. Changes in skills were evaluated with a validated checklist for inclusion of key documentation elements. Changes in attitudes were determined through learner self-assessment RESULTS: 83 of 138 eligible fellows (60%) started the module and 62 of 83 (75%) completed data sets for analysis. Immediate post-testing demonstrated modest statistically significant improvement in knowledge, skills, and attitudes. The workshop was easily disseminated and deployed CONCLUSIONS: This study demonstrates that a multi-modal educational intervention can lead to improvement in medical documentation knowledge, skills, and attitudes in a cohort of PCCM fellows and be easily disseminated for use by other specialties and types of clinicians.

Good, Ryan1; Zurca, Adrian2; Turner, David3; Bjorklund, Ashley4; Krennerich, Emily5; Petrillo, Toni6; Rozenfeld, Ranna7; Sasser, William8; Schuette, Jennifer9; Tcharmtchi, M. Hossein10; Watson, Christopher11; Czaja, Angela1 Author Information

McCabe, Megan1; Mason, Katherine2; Mink, Richard3; Werner, Jason4; Schneider, James5; Tcharmtchi, M. Hossein6; Armijo-Garcia, Veronica7; Winkler, Margaret8; Baker, David1; Nassar, Dina1; Turner, David9 Author Information

OBJECTIVES:To develop a competency-based educational tool for cardiac point-of-care ultrasound image interpretation using the design-based research approach.DESIGN:In accordance with design-based research, multiple methods were used to determine that learners would benefit from achieving competency in cardiac point-of-care ultrasound image interpretation before they attempted it at the bedside. A competency-based educational tool was designed and underwent a rapid prototyping process with experts. Evaluative data was used to redesign and reevaluate the educational tool with a new group of learners to improve its effectiveness.SETTING:Large, university-based children's hospital.SUBJECTS:Pediatric critical care attending physicians, fellow physicians and advanced practice providers, and pediatric resident physicians.INTERVENTIONS:Integrating mastery learning and deliberate practice as theoretical frameworks, the authors designed an online "Image Library" composed of 90 questions of cardiac point-of-care ultrasound image clips with varying degrees of pathology that were organized into three levels of difficulty. Learners answered a set of 10 questions, learned from feedback, and repeated an additional set in the same difficulty until achieving a predefined level of mastery.MEASUREMENTS AND MAIN RESULTS:Two learning cycles were implemented with a total of 41 learners. Forty learners (98%) were able to demonstrate mastery on the Image Library and required a range of 30 to 210 questions to do so. On a 10-question final assessment, learners scored an average of 72%, while experts and novices scored 83% and 17%, respectively. On a 5-point scale, learners rated the quality of the Image Library for facilitation of learning (median 5), enjoyment of learning (5), and useful knowledge and skills to improve clinical practice (5).CONCLUSIONS:An effective and innovative tool for teaching cardiac point-of-care ultrasound image interpretation was developed using the design-based research approach. Our results demonstrate the importance of individualized learning timelines for ultrasound image interpretation.

There is limited evidence on the effectiveness of conventional point of care ultrasound “weekend workshops.” We aimed to develop and evaluate an educational program for pediatric critical care providers to achieve competency in focused cardiac ultrasound (FoCUS). Five-unit FoCUS training

SESSION TITLE: Wednesday Electronic Posters 3 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Respiratory failure is often present at the time of pediatric sepsis recognition and contributes to morbidity and mortality of a septic child. The diaphragm plays a vital role in respiratory mechanics and the degree of diaphragm dysfunction determines the severity of respiratory failure. There is a paucity of data on the pathophysiology of Sepsis Induced Diaphragm Dysfunction (SIDD) independent of mechanical ventilation. The main objective of this study was to determine the structural and molecular derangements in the diaphragm of a non-mechanically ventilated pediatric swine model of MRSA MODS. METHODS: Eight 5-week old pigs (8 kg) were implanted with jugular and carotid catheters and a telemetry device in a femoral artery for continuous hemodynamic monitoring. Four days later, 6 pigs were injected intravenously with MRSA (USA300, TCH 1516 strain; dose of 1x109 CFU/kg) and 2 pigs were injected with saline and acted as non- septic controls (sham). Diaphragm thickness was assessed as a surrogate for function with ultrasonography (U/S) at baseline, at 48 and 66 hours after MRSA administration. At 70hr, all pigs were euthanized and necropsied. Changes in diaphragm thickness (Tdi) were obtained and compared to their baseline and within groups (septic pigs vs sham). Structural and molecular assessment of the diaphragm was further analyzed by histology and Western-blot. Protein expressions of Protein Kinase B (AKT) and Ser473 phosphorylated AKT in the diaphragm was standardized to GAPDH and analyzed by Western-blot using Optical Density (OD). Statistics: Mixed linear model procedure of SAS with group (septic versus sham) as the fix effect and pig as the random effect of the model. Results: Mean ± SD. RESULTS: Thickness (Tdi) in the septic diaphragms significantly decreased over time (3.6 ± 0.1, 2.9 ±0.03, and 2.3 ± 0.1 at 0, 48, and 66hr respectively) (n=6; p = 0.018). Tdi in sham diaphragm did not change over time. Qualitative decrease in diaphragm muscle fibers at 70hr in septic pigs compared to sham. We found a ∼ 50% decrease in phosphorylation of AKT as evidenced by decreased ratio of Ser473 pAKT/total AKT [0.43 ±0.2 vs 0.84 ± 0.1] in septic diaphragms (n=2) compared to sham (n=2). CONCLUSIONS: Diaphragms of septic pigs were significantly thinner at 48 and 66hr compared to sham. In addition, the diaphragm muscle fiber bundles were qualitatively smaller at 70hr compared to sham. Importantly, these effects were independent of mechanical ventilation. Furthermore, we found evidence of decreased activation (phosphorylation) of AKT in the diaphragm muscle of septic pigs, which is known to cause muscle atrophy. CLINICAL IMPLICATIONS: Data from our clinically relevant pediatric swine model of sepsis show that changes in diaphragm muscle mass and structure occur independent of mechanical ventilation. Investigations on the pathophysiologic mechanism of SIDD are ongoing and warranted. DISCLOSURES: no disclosure on file for Miguel Cruz; No relevant relationships by Moreshwar Desai, source=Web Response No relevant relationships by Inka Didelija, source=Web Response No relevant relationships by Saul Flores, source=Web Response No relevant relationships by Bobby Guillory, source=Web Response Grant relationship with Pfizer Please note: >$100000 Added 03/14/2019 by Kristina Hulten, source=Web Response, value=Grant/Research Support Grant relationship with RedHill Biopharma Please note: >$100000 Added 03/14/2019 by Kristina Hulten, source=Web Response, value=Grant/Research Support service relationship with Me-med Please note: $1001 - $5000 Added 03/14/2019 by Kristina Hulten, source=Web Response, value=fee-for service No relevant relationships by Safiya Joseph, source=Web Response no disclosure on file for Sheldon Kaplan; No relevant relationships by Fong Lam, source=Web Response No relevant relationships by Linda Lamberth, source=Web Response No relevant relationships by Ayisha Mahama, source=Web Response No relevant relationships by Juan Marini, source=Web Response no disclosure on file for Marina Martinez-Vargas; no disclosure on file for Trung Nguyen; No relevant relationships by Renán Orellana, source=Web Response no disclosure on file for Arun Saini; no disclosure on file for Barbara Stoll; No relevant relationships by M. Hossein Tcharmtchi, source=Web Response No relevant relationships by Vinod Vijayan, source=Web Response no disclosure on file for Christian Villadolid; No relevant relationships by Manpreet Virk, source=Web Response

Objectives: To describe the current approach to initial training, ongoing skill maintenance, and assessment of competence in central venous catheter placement by pediatric critical care medicine fellows, a subset of trainees in whom this skill is required. Design: Cross-sectional internet-based survey with deliberate sampling. Setting: United States pediatric critical care medicine fellowship programs. Subjects: Pediatric critical care medicine program directors of Accreditation Council for Graduate Medical Education-accredited fellowship programs. Interventions: None. Measurements and Main Results: A working group of the Education in Pediatric Intensive Care Investigators research collaborative conducted a national study to assess the degree of standardization of training and competence assessment of central venous catheter placement across pediatric critical care medicine fellowship programs. After piloting, the survey was sent to all program directors ( n = 67) of Accreditation Council for Graduate Medical Education-accredited pediatric critical care medicine programs between July 2017 and September 2017. The response rate was 85% (57/67). Although 98% of programs provide formalized central venous catheter placement training for first-year fellows, only 42% of programs provide ongoing maintenance training as part of fellowship. Over half (55%) of programs use a global assessment tool and 33% use a checklist-based tool when evaluating fellow central venous catheter placement competence under direct supervision. Only two programs (4%) currently use an assessment tool previously published and validated by the Education in Pediatric Intensive Care group. A majority (82%) of responding program directors believe that a standardized approach to assessment of central venous catheter competency across programs is important. Conclusions: Despite national mandates for skill competence by many accrediting bodies, no standardized system currently exists across programs for assessing central venous catheter placement. Most pediatric critical care medicine programs use a global assessment and decisions around the ability of a fellow to place a central venous catheter under indirect supervision are largely based upon subjective assessment of performance. Further investigation is needed to determine if this finding is consistent in other specialties/subspecialties, if utilization of standardized assessment methods can improve program directors’ abilities to ensure trainee competence in central venous catheter insertion in the setting of variable training approaches, and if these findings are consistent with other procedures across critical care medicine training programs, adult and pediatric.