Background: Unintended extubation (UE) is a serious risk associated with endotracheal intubation. In the paediatric population, UE can lead to significant patient harm. On average, each UE increases ICU and hospital length of stay by 5.5 and 6.5 days respectively and costs an additional $36 000. The international benchmark rate of UE for quality analysis cited in the literature is < 1 per 100 ventilator days. The United States organization Solutions for Patient Safety (SPS) developed and introduced a bundle to reduce UE with a goal of <= 0.95 per 100 ventilator days. Aim: The aim of this quality improvement project was to determine the baseline rate of UE in a 20-bed mixed medical/surgical PICU in the Pacific Northwest of the United States, implement the SPS bundle for UE prevention, and assess adherence to the bundle, and subsequent rate of UE. Study design: The IHI Model for Improvement Plan-Do-Study-Act (PDSA) was used to guide the development, implementation, and assessment of the SPS UE Bundle standardizing the management of endotracheal tubes. Adherence to the bundle was measured through peer-to-peer audits. Rates of adherence and UE were monitored on line charts. Results: Baseline rate of UE was 1.83 per 100 ventilator days; 23 weeks post implementation of the bundle the rate of UE was reduced to 0.38 UE per 100 ventilator days, F(7, 9) = 4.685, p = 0.027. The mean bundle adherence was 92%. Conclusions: This quality improvement initiative confirms that high adherence to the SPS UE Bundle may significantly reduce rates of UE in PICU settings.

BACKGROUND:Despite mortality benefits, only 19.9% of U.S. adults are fully vaccinated against the coronavirus disease 2019 (COVID-19). The inpatient setting is an opportune environment to update vaccinations, and inpatient electronic health record (EHR) alerts have been shown to increase vaccination rates. OBJECTIVE:Our objective was to evaluate whether an EHR alert could increase COVID-19 vaccinations in eligible hospitalized adults by prompting providers to order the vaccine. METHODS:This was a quasiexperimental pre-post-interventional design study at an academic and community hospital in the western United States between 1 January, 2021 and 31 October, 2021. Inclusion criteria were unvaccinated hospitalized adults. A soft-stop, interruptive EHR alert prompted providers to order COVID-19 vaccines for those with an expected discharge date within 48 hours and interest in vaccination. The outcome measured was the proportion of all eligible patients for whom vaccines were ordered and administered before and after alert implementation. RESULTS:Vaccine ordering rates increased from 4.0 to 13.0% at the academic hospital (odds ratio [OR]: 4.01, 95% confidence interval [CI]: 3.39-4.74, p < 0.001) and from 7.4 to 11.6% at the community hospital (OR: 1.62, 95% CI: 1.23-2.13, p < 0.001) after alert implementation. Administration increased postalert from 3.6 to 12.7% at the academic hospital (OR: 3.21, 95% CI: 2.70-3.82, p < 0.001) but was unchanged at the community hospital, 6.7 to 6.7% (OR: 0.99, 95% CI: 0.73-1.37, p = 0.994). Further analysis revealed infrequent vaccine availability at the community hospital. CONCLUSION:Vaccine ordering rates improved at both sites after alert implementation. Vaccine administration rates, however, only improved at the academic hospital, likely due in part to vaccine dispensation inefficiency at the community hospital. This study demonstrates the potential impact of complex workflow patterns on new EHR alert success and provides a rationale for subsequent qualitative workflow analysis with alert implementation.

OBJECTIVES: Postoperative patients after congenital cardiac surgery are at high risk of fluid overload (FO), which is known to be associated with poor outcomes. "Fluid creep," or nonresuscitation IV fluid in excess of maintenance requirement, is recognized as a modifiable factor associated with FO in the general PICU population, but has not been studied in congenital cardiac surgery patients. Our objective was to characterize fluid administration after congenital cardiac surgery, quantify fluid creep, and the association between fluid creep, FO, and outcome.DESIGN: Retrospective, observational cohort study.SETTING: Single-center urban mixed-medical and cardiac PICU.PATIENTS: Patients admitted to the PICU after cardiac surgery between January 2010 and December 2020.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: There were 1,459 postoperative encounters with 1,224 unique patients. Total fluid intake was greater than maintenance requirements on 3,103 of 4,661 patient days (67%), with fluid creep present on 2,624 patient days (56%). Total nonresuscitation intake was higher in patients with FO (defined as cumulative fluid balance 10% above body weight) versus those without. Fluid creep was higher among patients with FO than those without for each of the first 5 days postoperatively. Each 10 mL/kg of fluid creep in the first 24 hours postoperatively was associated with 26% greater odds of developing FO (odds ratio [OR] 1.26; 95% CI, 1.17-1.35) and 17% greater odds of mortality (OR 1.17; 95% CI, 1.05-1.30) after adjusting for risk of mortality based on surgical procedure, age, and day 1 resuscitation volume. Increasing fluid creep in the first 24 hours postoperatively was associated with increased postoperative duration of mechanical ventilation and PICU length of stay.CONCLUSIONS: Fluid creep is present on most postoperative days for pediatric congenital cardiac surgery patients, and fluid creep is associated with higher-risk procedures. Fluid creep early in the postoperative PICU stay is associated with greater odds of FO, mortality, length of mechanical ventilation, and PICU length of stay. Fluid creep may be under-recognized in this population and thus present a modifiable target for intervention.

Introduction:With persistent incidence, incomplete vaccination rates, confounding respiratory illnesses, and few therapeutic interventions available, COVID-19 continues to be a burden on the pediatric population. During a surge, it is difficult for hospitals to direct limited healthcare resources effectively. While the overwhelming majority of pediatric infections are mild, there have been life-threatening exceptions that illuminated the need to proactively identify pediatric patients at risk of severe COVID-19 and other respiratory infectious diseases. However, a nationwide capability for developing validated computational tools to identify pediatric patients at risk using real-world data does not exist. Methods:HHS ASPR BARDA sought, through the power of competition in a challenge, to create computational models to address two clinically important questions using the National COVID Cohort Collaborative: (1) Of pediatric patients who test positive for COVID-19 in an outpatient setting, who are at risk for hospitalization? (2) Of pediatric patients who test positive for COVID-19 and are hospitalized, who are at risk for needing mechanical ventilation or cardiovascular interventions? Results:This challenge was the first, multi-agency, coordinated computational challenge carried out by the federal government as a response to a public health emergency. Fifty-five computational models were evaluated across both tasks and two winners and three honorable mentions were selected. Conclusion:This challenge serves as a framework for how the government, research communities, and large data repositories can be brought together to source solutions when resources are strapped during a pandemic.

Background/Objective: Pediatric intensive care unit (PICU) survivors risk significant cognitive morbidity, particularly those with acquired brain injury (ABI) diagnoses. Studies show sedative and analgesic medication may potentiate neurologic injury, but few studies evaluate impact on survivor outcomes. This study aimed to evaluate whether exposures to analgesic and sedative medications are associated with worse neurocognitive outcome. Methods: A retrospective cohort study was conducted of 91 patients aged 8 to 18 years, undergoing clinical neurocognitive evaluation approximately 1 to 3 months after PICU discharge. Electronic health data was queried for sedative and analgesic medication exposures, including opioids, benzodiazepines, propofol, ketamine, and dexmedetomidine. Doses were converted to class equivalents, evaluated by any exposure and cumulative dose exposure per patient weight. Cognitive outcome was derived from 8 objective cognitive assessments with an emphasis on executive function skills using Principal Components Analysis. Then, linear regression was used to control for baseline cognitive function estimates to calculate a standardized residualized neurocognitive index (rNCI) z-score. Multivariable linear regression evaluated the association between rNCI and medication exposure controlling for covariates. Significance was defined as P < .05. Results: Most ( n = 80; 88%) patients received 1 or more study medications. Any exposure and higher cumulative doses of benzodiazepine and ketamine were significantly associated with worse rNCI in bivariate analyses. When controlling for Medicaid, preadmission comorbid conditions, length of stay, delirium, and receipt of other medication classes, receipt of benzodiazepine was associated with significantly worse rNCI ( β-coefficient = −0.48, 95% confidence interval = −0.88, −0.08). Conclusions: Exposure to benzodiazepines was independently associated with worse acute phase cognitive outcome using objective assessments focused on executive function skills when controlling for demographic and illness characteristics. Clinician decisions regarding medication regimens in the PICU may serve as a modifiable factor to improve outcomes. Additional inquiry into associations with long-term cognitive outcome and optimal medication regimens is needed.

BACKGROUND:The use of electronic health records has generated an increase in after-hours and weekend work for providers. To alleviate this situation, the hiring of medical scribes has rapidly increased. Given the lack of scribe industry standards and the wide variance in how providers and scribes work together, it could potentially create new patient safety-related risks.OBJECTIVE:The purpose of this paper was to identify how providers can optimize the effective and safe use of scribes.DESIGN:The research team conducted a secondary analysis of qualitative data where we reanalyzed data from interview transcripts, field notes, and transcribed group discussions generated by four previous projects related to medical scribes.PARTICIPANTS:Purposively selected participants included subject matter experts, providers, informaticians, medical scribes, medical assistants, administrators, social scientists, medical students, and qualitative researchers.APPROACH:The team used NVivo12 to assist with the qualitative analysis. We used a template method followed by word queries to identify an optimum level of scribe utilization. We then used an inductive interpretive theme-generation process.KEY RESULTS:We identified three themes: (1) communication aspects, (2) teamwork efforts, and (3) provider characteristics. Each theme contained specific practices so providers can use scribes safely and in a standardized way.CONCLUSION:We utilized a secondary qualitative data analysis methodology to develop themes describing how providers can optimize their use of scribes. This new knowledge could increase provider efficiency and safety and be incorporated into further and future training tools for them.

Objective While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training. Materials and Methods A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team’s analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists. Results The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired. Conclusion We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.

BACKGROUND: For almost 50 years, pediatricians used adult guidelines to diagnose ARDS. In 2015, specific criteria for pediatric ARDS were defined. However, it remains unclear how frequently providers recognize pediatric ARDS and whether recognition affects adherence to consensus recommendations. METHODS: This was a mixed-method, retrospective study of mechanically ventilated pediatric subjects after the release of the pediatric ARDS recommendation statement. Pediatric ARDS cases were identified according to the new criteria. Provider recognition was defined by documentation in the medical record. Pediatric ARDS subjects with and without provider recognition were compared quantitatively according to clinical characteristics, adherence to lung-protective ventilation (LPV), adjunctive therapies, and outcomes. A qualitative document analysis (QDA) was performed to evaluate knowledge and beliefs surrounding the Pediatric Acute Lung Injury Consensus Conference recommendations. RESULTS: Of 1,983 subject encounters, pediatric ARDS was identified in 321 (16%). Provider recognition was present in 97 (30%) cases and occurred more often in subjects who were older, had worse oxygenation deficits, or were bone marrow transplant recipients. Recognition rates increased each studied year. LPV practices did not differ based on provider recognition; however, subjects who received it were more likely to experience permissive hypoxemia and adherence to extrapulmonary recommendations. Ultimately, there was no differences in outcomes between the provider recognition and non-provider recognition groups. Three themes emerged from the QDA: (1) pediatric ARDS presents within a complex, multidimensional context, with potentially competing organ system failures; (2) similar to historical conceptualizations, pediatric ARDS was often considered a visual diagnosis, with measures of oxygenation unreferenced; and (3) emphasis was placed on non-evidence-based interventions, such as pulmonary clearance techniques, rather than on consensus recommendations. CONCLUSIONS: Among mechanically ventilated children, pediatric ARDS was common but recognized in a minority of cases. Potential opportunities, such as an opt-out approach to LPV, may exist for improved dissemination and implementation of recommended best practices.

Parents are increasingly using online physician rating sites to select a pediatrician. However, no studies have examined the role of social media in influencing parents' choice of a pediatrician. The objective of this study was to qualitatively analyze what factors influence the choice of a pediatrician in an online peer support community. We retrieved retrospective data of all threads made to 4 subreddits on the Reddit social media platform between January 1, 2018 and December 31, 2019. We performed qualitative analysis using an inductive approach on threads related to choosing a pediatrician. We identified several codes which were grouped into subcategories/categories and finally abstracted into themes.We retrieved a total of 179 threads and included 30 for qualitative analysis. Thematic analysis led to identification of four major themes that influence how parents choose pediatricians on a social media platform—pediatrician-specific factors, office-related factors, parent/patient factors, and social factors. An online peer support community can serve as an important source of information for parents when searching for a pediatrician. Pediatric practices should focus on providing unmet information needs to parents that will ease the burden of the search process.

Objective: Provider burnout is a crisis in healthcare and leads to medical errors, a decrease in patient satisfaction, and provider turnover. Many feel that the increased use of electronic health records contributes to the rate of burnout. To avoid provider burnout, many organizations are hiring medical scribes. The goal of this study was to identify relevant elements of the provider-scribe relationship (like decreasing documentation burden, extending providers' careers, and preventing retirement) and describe how and to what extent they may influence provider burnout. Materials and Methods: Qualitative methods were used to gain a broad view of the complex landscape surrounding scribes. Data were collected in 3 phases between late 2017 and early 2019. Data from 5 site visits, interviews with medical students who had experience as scribes, and discussions at an expert conference were analyzed utilizing an inductive approach. Results: A total of 184 transcripts were analyzed to identify patterns and themes related to provider burnout. Provider burnout leads to increased provider frustration and exhaustion. Providers reported that medical scribes improve provider job satisfaction and reduce burnout because they reduce the documentation burden. Medical scribes extend providers' careers and may prevent early retirement. Unfortunately, medical scribes themselves may experience similar forms of burnout. Conclusion: Our data from providers and managers suggest that medical scribes help to reduce provider burnout. However, scribes are not the only solution for reducing documentation burden and there may be potentially better options for preventing burnout. Interestingly, medical scribes sometimes suffer from burnout themselves, despite their temporary roles.

Background With the use of electronic health records (EHRs) increasing and causing unintended negative consequences, the medical scribe profession has burgeoned, but it has yet to be regulated. The purpose of this study was to describe scribe workflow as well as identify the threats and opportunities for the future of the scribe industry. Methods The first phase of the study used ethnographic methods consisting of interviews and observations by a multi-disciplinary team of researchers at five United States sites. In April 2019, a two-day conference of experts representing different stakeholder perspectives was held to discuss the results from site visits and to predict the future of medical scribing. An interpretive content analysis approach was used to discover threats and opportunities for the future of medical scribes. Results Threats facing the medical scribe industry were related to changes in the documentation model, EHR usability, different payment structures, the need to acquire disparate data during clinical encounters, and workforce-related changes relevant to the scribing model. Simultaneously, opportunities for medical scribing in the future included extension of their role to include workflow analysis, acting as EHR-related subject-matter-experts, and becoming integrated more effectively into the clinical care delivery team. Experts thought that if EHR usability increases, the need for medical scribes might decrease. Additionally, the scribe role could be expanded to allow scribes to document more or take on more informatics-related tasks. The experts also anticipated an increased use of alternative models of scribing, like tele-scribing. Conclusion Threats and opportunities for medical scribing were identified. Many experts thought that if the scribe role could be expanded to allow scribes to document more or take on more informatics activities, it would be beneficial. With COVID-19 continuing to change workflows, it is critical that medical scribes receive standardized training as tele-scribing continues to grow in popularity and new roles for scribes as medical team members are identified.

Drury, Kurt1; Hall, Trevor2; Leonard, Skyler3; Orwoll, Benjamin2; Williams, Cydni1 Author Information

Objective: Hiring medical scribes to document in the electronic health record (EHR) on behalf of providers could pose patient safety risks because scribes often have no clinical training. The aim of this study was to investigate the effect of scribes on patient safety. This included identification of best practices to assure that scribe use of the EHR is not a patient safety risk. Materials and Methods: Using a sociotechnical framework and the Rapid Assessment Process, we conducted ethnographic data gathering at 5 purposively selected sites. Data were analyzed using a grounded inductive/hermeneutic approach. Results: We conducted site visits at 12 clinics and emergency departments within 5 organizations in the US between 2017 and 2019. We did 76 interviews with 81 people and spent 80 person-hours observing scribes working with providers. Interviewees believe and observations indicate that scribes decrease patient safety risks. Analysis of the data yielded 12 themes within a 4-dimension sociotechnical framework. Results about the "technical" dimension indicated that the EHR is not considered overly problematic by either scribes or providers. The "environmental" dimension included the changing scribe industry and need for standards. Within the "personal" dimension, themes included the need for provider diligence and training when using scribes. Finally, the "organizational" dimension highlighted the positive effect scribes have on documentation efficiency, quality, and safety. Conclusion: Participants perceived risks related to the EHR can be less with scribes. If healthcare organizations and scribe companies follow best practices and if providers as well as scribes receive training, safety can actually improve.

SESSION TITLE: Pediatrics Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Acute respiratory distress syndrome (ARDS) is a significant cause of morbidity and mortality in critically ill patients. In 2015, the Pediatric Acute Lung Injury Consensus Conference (PALICC) group published diagnostic criteria for pediatric ARDS (PARDS) and consensus-based treatment guidelines. In adults, provider recognition (PR) of ARDS has been associated with improved adherence to clinical guidelines. In pediatric populations, patterns of PARDS recognition since the publication of the PALICC guidelines are unknown. The purpose of this study is to determine the rate of PARDS recognition and examine clinical factors that may be associated with making the diagnosis. METHODS: A chart review of all patients admitted to the pediatric intensive care unit (PICU) at Oregon Health and Science University who received mechanical ventilation (MV) from 2015-2020 was conducted. Congenital cardiac surgery patients (CCS) were excluded. Investigators retroactively diagnosed PARDS cases by the PALICC criteria. PR was defined as the presence of the term “ARDS” in the medical record. The primary outcome was the fraction of cases in which PARDS was recognized. Mann-Whitney U test was used to compare age, race, sex, oxygenation index (OI), oxygenation saturation index (OSI), and pediatric index of mortality 3 (PIM) scores in patients with PR to those without. RESULTS: There were 1983 PICU encounters. Excluding CCS, PARDS was present in 391 (20%). 121 (31%) of patients with PARDS had PR. Patients with PR were younger (Median 2.7 years [IQR 0.51-10.7] versus 10.2 years [IQR 3.1-14.5], p<0.001), had a lower max OI (Median 9.7 [IQR 7.2-16.8] versus 30.7 [IQR 15.1-46.5], p<0.001), and had a lower max OSI (Median 10.1 [IQR 6.7-16.2] versus 25.7 [IQR 17.8-33.4], p<0.001). Sex, race, and PIM scores did not differ significantly between groups. CONCLUSIONS: Among children receiving MV, PARDS was common but recognized in a minority of cases. PR was more common in patients who were older and had more severe oxygenation deficits. CLINICAL IMPLICATIONS: We speculate that failure to diagnose PARDS may result in decreased utilization of the PALICC recommended treatment guidelines. Further investigation is required to confirm these findings in other settings, to identify other factors that may affect PARDS recognition, and to investigate the impact of PARDS recognition on patient outcomes. DISCLOSURES: No relevant relationships by Avi Kopstick, source=Web Response No relevant relationships by Benjamin Orwoll, source=Web Response No relevant relationships by Christina Rufener, source=Web Response

1Health and Hospitals Corp, Portland, OR 2Oregon Health and Science University-Doernbecher Children’s Hospital, Portland, OR 3N/A, Portland, OR

Rationale: MMPs (Matrix metalloproteinases) and their endogenous tissue inhibitors may contribute to lung injury through extracellular matrix degradation and modulation of inflammation and fibrosis. Objectives: To test for an association between MMP pathway proteins and inflammation, endothelial dysfunction, and clinical outcomes. Methods: We measured MMPs in plasma collected on acute respiratory distress syndrome (ARDS) Day 1 from 235 children at five hospitals between 2008 and 2017. We used latent class analysis to identify patients with distinct MMP profiles and then associated those profiles with markers of inflammation (IL‐1RA, ‐6, ‐8, ‐10, and ‐18; macrophage inflammatory protein‐1&agr; and ‐1&bgr;; tumor necrosis factor‐&agr; and ‐R2), endothelial injury (angiopoietin‐2, von Willebrand factor, soluble thrombomodulin), impaired oxygenation (PaO2/FiO2 [P/F] ratio, oxygenation index), morbidity, and mortality. Measurements and Main Results: In geographically distinct derivation and validation cohorts, approximately one‐third of patients demonstrated an MMP profile characterized by elevated MMP‐1, ‐2, ‐3, ‐7, and ‐8 and tissue inhibitor of metalloproteinase‐1 and ‐2; and depressed active and total MMP‐9. This MMP profile was associated with multiple markers of inflammation, endothelial injury, and impaired oxygenation on Day 1 of ARDS, and conferred fourfold increased odds of mortality or severe morbidity independent of the P/F ratio and other confounders (95% confidence interval, 2.1‐7.6; P < 0.001). Logistic regression using both the P/F ratio and MMP profiles was superior to the P/F ratio alone in prognosticating mortality or severe morbidity (area under the receiver operating characteristic curve, 0.75; 95% confidence interval, 0.68‐0.82 vs. area under the receiver operating characteristic curve, 0.66; 95% confidence interval, 0.58‐0.73; P = 0.009). Conclusions: Pediatric patients with ARDS have specific plasma MMP profiles associated with inflammation, endothelial injury, morbidity, and mortality. MMPs may play a role in the pathobiology of children with ARDS.

Because of increased electronic health record use, many organizations are hiring medical scribes as a way to alleviate provider burnout and increase clinical efficiency. The providers and scribes have unique relationships and thus, this study's purpose was to examine the scribe-provider interaction/relationship through the perspectives of scribes, providers, and administrators utilizing qualitative research techniques. Participants included 81 clinicians (30 providers, 27 scribes, and 24 administrators) across five sites. Analysis of the scribe-provider interaction data generated six subthemes: characteristics of an ideal scribe, characteristics of a good provider, provider variability, quality of the scribe-provider relationship, negative side of the scribe-provider relationship, and evaluation and supervision of scribes. Future research should focus on additional facets of the scribe-provider relationship including optimal ergonomic considerations to allow for scribes and providers to work together harmoniously.

Objectives: As acute kidney injury and elevated cumulative fluid balance commonly co-occur in pediatric acute respiratory distress syndrome, we aimed to identify risk factors for their development and evaluate their independent relationships with mortality. We hypothesized that acute kidney injury and elevated cumulative fluid balance would be associated with markers of inflammation and that children with elevated cumulative fluid balance and concomitant acute kidney injury would have worse outcomes than other children. Design: Prospective observational study using the pediatric Risk, Injury, Failure, Loss, End-Stage acute kidney injury classification. Setting: Five academic PICUs. Patients: Two-hundred sixty patients 1 month to 18 years old meeting the Berlin definition of acute respiratory distress syndrome between 2008 and 2014. Interventions: None. Measurements and Results: PICU mortality was 13% (34/260). Relative to survivors, nonsurvivors had greater cumulative fluid balance on day 3 of acute respiratory distress syndrome (+ 90.1 mL/ kg; interquartile range 26.6-161.7 vs + 44.9 mL/kg; interquartile range 10.0-111.3; p = 0.008) and also had higher prevalence of acute kidney injury on day 3 of acute respiratory distress syndrome (50% vs 23%; p = 0.001). On stratified analysis, greater cumulative fluid balance on day 3 of acute respiratory distress syndrome was associated with mortality among patients with concomitant acute kidney injury (+ 111.5 mL/kg for nonsurvivors; interquartile range 82.6-236.8 vs + 58.5 mL/kg for survivors; interquartile range 0.9-176.2; p = 0.041) but not among patients without acute kidney injury (p = 0.308). The presence of acute kidney injury on acute respiratory distress syndrome day 3 was associated with mortality among patients with positive cumulative fluid balance (29.1% vs 10.4% mortality; p = 0.001) but not among patients with even or negative cumulative fluid balance (p = 0.430). Day 1 plasma interleukin-6 levels were associated with the development of day 3 positive cumulative fluid balance, day 3 acute kidney injury, and PICU mortality and the association between elevated day 1 interleukin-6 and PICU mortality was partially mediated by the interval development of day 3 positive cumulative fluid balance and day 3 acute kidney injury (p < 0.001). Conclusions: In pediatric acute respiratory distress syndrome, elevated cumulative fluid balance on day 3 of acute respiratory distress syndrome is associated with mortality specifically in patients with concomitant acute kidney injury. Plasma interleukin-6 levels are associated with the development of positive cumulative fluid balance and acute kidney injury, suggesting a potential mechanism by which inflammation might predispose to mortality.

Central line–associated bloodstream infections (CLABSIs) cause major patient harm, preventable through attention to line care best practice standards. The objective was to determine if a digital self-assessment application (CLABSI App), bundling line care best practices with social gamification and in-context microlearning, could engage nurses in CLABSI prevention. Nurses caring for children with indwelling central venous catheters in 3 high-risk units were eligible to participate. All other units served as controls. The intervention was a 12-month nonrandomized quality improvement study of CLABSI App implementation with interunit competitions. Compared to the preceding year, the intervention group (9886 line days) CLABSI rate decreased by 48% (P = .03). Controls (7879 line days) did not change significantly. In all, 105 unique intervention group nurses completed 673 self-assessments. Competitions were associated with increased engagement as measured by self-assessments and unique participants. This model could be extended to other health care–associated infections, and more broadly to process improvement within and across health care systems.