Designing and maintaining a rescue extracorporeal life support program: A holistic simulation approach.

Rescue Extracorporeal Life Support Programs based at non-cardiac surgery centers have unique needs to be able to ensure successful outcomes despite low patient volumes. In this paper we describe the important role simulation had in each stage of development, implementation, and maintenance of our pediatric Rescue ECLS Program. Systems-focused simulations were used to develop robust workflows, processes, and bundles. Simulation-based education targeted the acquisition and maintenance of clinical skills for individual team members, bringing together a multidisciplinary team of local clinicians who do not routinely perform pediatric cannulation related tasks. Translational simulation ensured continued improvement by addressing adverse events or latent safety threats observed during system-focused or educational simulations. Realism of all simulations was our priority, and was achieved through in situ simulations, participation of multidisciplinary teams, use of real equipment and medical supplies, and use of a high-fidelity cannulation manikin. This holistic simulation approach allowed us to overcome the barriers to high quality care, and maintain outcomes comparable to high volume centers. A similar approach can help other centers design simulation for their own Rescue ECLS Program, and can be translated to other high-risk and high-acuity critical care programs.

Video Review of Simulated Pediatric Cardiac Arrest to Identify Errors/Latent Safety Threats: A Mixed Methods Study.

INTRODUCTION: Outcomes from pediatric in-hospital cardiac arrest depend on the treatment provided as well as resuscitation team performance. Our study aimed to identify errors occurring in this clinical context and develop an analytical framework to classify them. This analytical framework provided a better understanding of team performance, leading to improved patient outcomes. METHODS: We analyzed 25 video recordings of pediatric cardiac arrest simulations from the pediatric intensive care unit at the Alberta Children's Hospital. We conducted a qualitative-dominant crossover mixed method analysis to produce a broad understanding of the etiology of errors. Using qualitative framework analysis, we identified and qualitatively described errors and transformed the data coded into quantitative data to determine the frequency of errors. RESULTS: We identified 546 errors/error-related actions and behaviors and 25 near misses. The errors were coded into 21 codes that were organized into 5 main themes. Clinical task-related errors accounted for most errors (41.9%), followed by planning, and executing task-related errors (22.3%), distraction-related errors (18.7%), communication-related errors (10.1%), and knowledge/training-related errors (7%). CONCLUSIONS: This novel analytical framework can robustly identify, classify, and describe the root causes of errors within this complex clinical context. Future validation of this classification of errors and error-related actions and behaviors on larger samples of resuscitations from various contexts will allow for a better understanding of how errors can be mitigated to improve patient outcomes.

"We Aren't Meant to Go Through the Hardest Parts of Our Lives Alone": Family Experience With Restricted PICU Presence During the COVID-19 Pandemic.

CONTEXT: PICUs across Canada restricted family presence (RFP) in response to the COVID-19 pandemic from allowing two or more family members to often only one family member at the bedside. The objective of this study was to describe the experiences and impact of RFP on families of critically ill children to inform future policy and practice. HYPOTHESIS: RFP policies negatively impacted families of PICU patients and caused moral distress. METHODS AND MODELS: National, cross-sectional, online, self-administered survey. Family members of children admitted to a Canadian PICU between March 2020 and February 2021 were invited to complete the survey. RFP-attributable distress was measured with a modified distress thermometer (0-10). Closed-ended questions were reported with descriptive statistics and multivariable linear regression assessed factors associated with RFP-attributable distress. Open-ended questions were analyzed using inductive content analysis. RESULTS: Of 250 respondents who experienced RFP, 124 (49.6%) were restricted to one family member at the bedside. The median amount of distress that families attributed to RFP policies was 6 (range: 0-10). Families described isolation, removal of supports, and perception of trauma related to RFP. Most families (183, 73.2%) felt that policies were enforced in a way that made them feel valued by PICU clinicians, which was associated with less RFP-attributable distress. Differential impact was seen where families with lower household income indicated higher RFP-attributable distress score (2.35; 95% CI, 0.53-4.17; p = 0.03). Most respondents suggested that future policies should allow at least two family members at the bedside. INTERPRETATIONS AND CONCLUSIONS: Families of children admitted to PICUs during the COVID-19 pandemic described increased distress, trauma, and removal of supports due to RFP policies. Vulnerable families showed an increased odds of higher distress. Healthcare professionals played an important role in mitigating distress. Allowance of at least two family members at the bedside should be considered for future policy.

Setting up a Rescue Extracorporeal Life Support Program.

Extracorporeal life support (ECLS) is a high-risk, lifesaving medical treatment that is typically limited to centers that can support a comprehensive ECLS program. Rescue programs can bridge the gap in care between ECLS centers and other tertiary pediatric centers without cardiac surgical and comprehensive ECLS support. We describe how our pediatric center without cardiac surgery successfully partnered with an established ECLS center to develop a Rescue ECLS Cannulation Program. This formalized program provides cannulation and stabilization by a specialized team at the presenting hospital before being transported to a partner hospital. This article outlines how we established our unique Rescue ECLS Cannulation program. We outline the planning, development, and implementation of the program and describe the unique aspects contributing to successful implementation including longitudinal training, staged program evolution, and a bundled approach to care. We also describe the patients who we have cannulated since its inception. Rescue ECLS Cannulation Programs provide access to consistent, high-quality, and lifesaving care to critically ill patients at sites without the resources to support a full ECLS program.

Key Considerations in Establishing a Pediatric Rescue Extracorporeal Life Support Program: A Multi Methods Review.

Extracorporeal life support (ECLS) is generally limited to centers with cardiac surgery. However, pediatric centers without cardiac surgery can still provide potentially lifesaving ECLS through a Rescue Program, allowing a local team to cannulate and stabilize patients before they are transported to a center with cardiac surgery support for ongoing care. This multimethod study provides an exploration of pediatric ECLS team insights regarding program implementation and offers recommendations for other centers wishing to develop a similar program. We performed surveys and semi-structured interviews to gather perspectives from ECLS team members. Demographics and preliminary perspectives were obtained from surveys. Interviews were transcribed and coded using thematic analysis to identify key considerations, facilitators, and barriers related to rescue program implementation. Our multidisciplinary ECLS team perceived great value in the rescue program and identified elements critical to successful program development and implementation, including barriers that might exist for any center wishing to set up a similar program. Participants emphasized that the initial design and continued maintenance of any Rescue ECLS Program be a comprehensive, multidisciplinary initiative. Clear communication, a mechanism for debriefing and feedback, and a strategy allowing for flexible program evolution are essential.

Facial shape manifestations of growth faltering in Tanzanian children.

Variation in the shape of the human face and in stature is determined by complex interactions between genetic and environmental influences. One such environmental influence is malnourishment, which can result in growth faltering, usually diagnosed by means of comparing an individual's stature with a set of age-appropriate standards. These standards for stature, however, are typically ascertained in groups where people are at low risk for growth faltering. Moreover, genetic differences among populations with respect to stature are well established, further complicating the generalizability of stature-based diagnostic tools. In a large sample of children aged 5-19 years, we obtained high-resolution genomic data, anthropometric measures and 3D facial images from individuals within and around the city of Mwanza, Tanzania. With genome-wide complex trait analysis, we partitioned genetic and environmental variance for growth outcomes and facial shape. We found that children with growth faltering have faces that look like those of older and taller children, in a direction opposite to the expected allometric trajectory, and in ways predicted by the environmental portion of covariance at the community and individual levels. The environmental variance for facial shape varied subtly but significantly among communities, whereas genetic differences were minimal. These results reveal that facial shape preserves information about exposure to undernourishment, with important implications for refining assessments of nutritional status in children and the developmental-genetics of craniofacial variation alike.

Isotopic reconstruction of the weaning process in the archaeological population of Canímar Abajo, Cuba: A Bayesian probability mixing model approach.

The general lack of well-preserved juvenile skeletal remains from Caribbean archaeological sites has, in the past, prevented evaluations of juvenile dietary changes. Canímar Abajo (Cuba), with a large number of well-preserved juvenile and adult skeletal remains, provided a unique opportunity to fully assess juvenile paleodiets from an ancient Caribbean population. Ages for the start and the end of weaning and possible food sources used for weaning were inferred by combining the results of two Bayesian probability models that help to reduce some of the uncertainties inherent to bone collagen isotope based paleodiet reconstructions. Bone collagen (31 juveniles, 18 adult females) was used for carbon and nitrogen isotope analyses. The isotope results were assessed using two Bayesian probability models: Weaning Ages Reconstruction with Nitrogen isotopes and Stable Isotope Analyses in R. Breast milk seems to have been the most important protein source until two years of age with some supplementary food such as tropical fruits and root cultigens likely introduced earlier. After two, juvenile diets were likely continuously supplemented by starch rich foods such as root cultigens and legumes. By the age of three, the model results suggest that the weaning process was completed. Additional indications suggest that animal marine/riverine protein and maize, while part of the Canímar Abajo female diets, were likely not used to supplement juvenile diets. The combined use of both models here provided a more complete assessment of the weaning process for an ancient Caribbean population, indicating not only the start and end ages of weaning but also the relative importance of different food sources for different age juveniles.

Ontogeny of sexual size dimorphism and environmental quality in Guatemalan children.

OBJECTIVES: Human growth data from Guatemalan school children were analyzed to test the hypothesis that the degree of sexual size dimorphism (SSD) in height is reduced for people living under more adverse environmental quality. METHODS: The sample consists of 2,560 girls and 3,262 boys, 6-16.99 years of age, from the two major Guatemalan ethnic groups, Maya of very low socioeconomic status (SES) and Ladino of high, middle, and low SES. SES was estimated by questionnaire and ethnographic observation. All data are from the Longitudinal Study of Child Development of the Universidad del Valle de Guatemala. Significance of SSD was tested within each whole year age category (e.g., 6.0-6.9 years) by SES for Ladinos and Maya. Ethnic groups were then compared for each age category to determine whether the SSD values were significantly different between groups. RESULTS: Statistically significant height SSD was found for 10 of the 11 age categories for the high SES Ladinos, 8 of the 11 age categories for middle SES Ladinos, 3 of the 11 low SES Ladino age categories, and 0 of the 11 very low SES Maya age categories. For all SES and ethnic groups SSD tended to decrease between 6 and 11 years of age and then increase after age 12 years. CONCLUSIONS: A poor quality environment for growth and development, as estimated by SES, was found to reduce or eliminate statistically significant SSD. Patterns of biological maturation before and after puberty also seem to contribute to age changes in SSD.

Juvenile elbow dislocation from the prehistoric site of Josipovac-Gravinjak, Croatia.

This paper examines a rare case of juvenile elbow dislocation in the human skeletal remains from the Eneolithic (Copper Age) site of Josipovac-Gravinjak in Croatia, dated to 3500-2780 BC. Although dislocations from the archaeological context have been previously reported in adults, they are rarely diagnosed in juveniles. The skeletal remains of a 7.5-8.5 year old juvenile were examined using gross observation and radiography. Analyses of the skeletal remains confirm the absence of a fracture, while comparison with clinical studies suggests that the observed lesions are indicative of a radial head dislocation. The severity of the injury and bone remodelling suggest that the injury occurred more than 6 months prior to death and that it was left untreated.

Infant and juvenile growth in ancestral Pueblo Indians.

The present study examines patterns of infant and juvenile growth in a diachronic sample of ancestral Pueblo Indians (AD 1300-1680) from the American Southwest. An assessment of growth patterns is accompanied by an evaluation of pathological conditions often considered to be indicators of nutritional deficiencies and/or gastrointestinal infections. Growth patterns and the distribution of pathological conditions are interpreted relative to culturally relevant age categories defined by Puebloan rites of passage described in the ethnographic literature. A visual comparison of growth distance curves revealed that relative to a modern comparative group our sample of ancestral Pueblo infant and juveniles exhibited faltering growth beginning soon after birth to about 5 years of age. A comparison of curves describing growth relative to adult femoral length, however, indicated reduced growth occurring later, by around 2 years of age. Similar to previous studies, we observed a high proportion of nonsurvivors exhibiting porotic cranial lesions during the first 2 years of life. Contrary to expectations, infants and juveniles without evidence of porotic cranial lesions exhibited a higher degree of stunting. Our study is generally consistent with previous research reporting poor health and high mortality for ancestral Pueblo Indian infants and juveniles. Through use of a culturally relevant context defining childhood, we argue that the observed poor health and high mortality in our sample occur before the important transition from young to older child and the concomitant initial incorporation into tribal ritual organization.

Brief communication: Sexual dimorphism of the juvenile basicranium.

The purpose of this article is to examine the level of sexual dimorphism exhibited in the foramen magnum and occipital condyles of juveniles, and to test the utility of this sexual dimorphism for estimating sex. Using five basicranial measurements taken from 36 juveniles of known sex and age from the Lisbon documented collection (Portugal), we evaluated sexual dimorphism in the juvenile cranial base. Our application of a method previously applied solely to adults indicated that the basicranium is sexually dimorphic in juveniles, with larger foramen magnum and occipital condyle dimensions observed in males. Significant univariate differences between males and females were found for length and breadth of the foramen magnum, and breadth of the left occipital condyle. Using these measurements, multivariate discriminant analysis indicated that sex was correctly assigned 75.8% of time. Obtained accuracy, however, was lower than reported by previous studies of adult samples. We suggest that this discrepancy is a result of population variability rather than age.