Crow, Sheri

Introduction As part of the Society of Critical Care Medicine's Pediatric ICU Liberation Campaign Collaborative, Mayo Clinic developed a daily physician-led rounding checklist to promote timely de-escalation of ICU support and proactive measures to prevent iatrogenic conditions. We hypothesized that implementing this checklist would be feasible and would reduce missed opportunities to optimize care through both de-escalation and initiation of key preventive tasks. Methods We conducted a prospective study in a 16-bed medical/surgical PICU at a quaternary academic center over a 300-day period from May 2017 to March 2018. A 15-task daily rounding checklist was integrated into standard patient-centered rounds for every admitted patient to prompt physicians to address common de-escalation and preventive care tasks. For each task, physicians documented whether it had already been addressed during rounds, was not applicable to the patient, or the checklist directly prompted a plan modification. Trends in checklist compliance and the frequency/type of plan modifications were assessed in 60-day intervals to evaluate sustainability over time. Results 1,710 rounding checklists were completed across 2,424 patient-days (71% compliance). The checklist prompted 198 documented plan modifications from 9% of all completed checklists. The most frequent modifications involved initiating a bowel regimen ( n = 47), converting intravenous to enteral medications ( n = 32), initiating gastrointestinal prophylaxis ( n = 30), consulting rehabilitation services ( n = 18), and restarting home medications ( n = 18), which together accounted for 73% (145/198) of all modifications. Discussion Implementation of a daily rounding checklist was feasible, achieved acceptable compliance, and identified 198 opportunities for timely de-escalation and proactive care in a complex PICU environment. Although overall compliance did not meet the a priori >75% target across the entire study period, early adoption exceeded this threshold and later decline highlighted sustainability challenges. This initiative demonstrates the potential of structured physician-led checklists to standardize care and reduce iatrogenic risk in pediatric critical care.

Objective: The Society of Critical Care Medicine PICU Liberation ABCDEF (A–F) Campaign Collaborative aimed to implement best practices for analgesia (A), breathing (B), comfort/consciousness (C), delirium (D), early mobilization (E), and family engagement and empowerment (F). Our post hoc study of Mayo Clinic data sought to compare the pre-implementation rounding process, which used a nursing script organized by organ systems, with a novel, liberation-focused rounding process emphasizing A–F bundle elements. Design: Secondary analysis of pre- vs. post-implementation surveys collected by independent observers during rounds. Setting: Medical/surgical PICU in a quaternary-care, academic medical center during April to July 2017. Subjects: The observed participants included PICU physicians, nurses, respiratory therapists, pharmacists, and dietitians. Interventions: None. Measurements and Main Results: Survey responses from 145 team members pre-implementation and 67 post-implementation showed improved team satisfaction, communication, and understanding of daily plans (all p < 0.05). Respondents reported an increased frequency of discussions on bundle components A–E (all p < 0.01). Observations of 41 pre-implementation and 46 post-implementation rounds showed an increase in the frequency of discussion of all components of the bundle (all p < 0.01). However, this finding was not at the expense of increased duration of individual rounds since we failed to find a difference in pre- vs. post-implementation duration per patient (480 vs. 544 s per patient, p = 0.20). Conclusions: In 2017, around the time of introducing the nurse-led PICU Liberation rounding process to our practice, we found that after implementation, there was an associated increase in discussions about bundle elements and improved communications and satisfaction in team members.

Objectives:Nutrition support is essential in improving outcome and survival in children on extra corporal membranous support (ECMO). We aim to evaluate the association between the timing of enteral nutrition (EN) initiation and its impact on outcome.Methods:We retrospectively reviewed the electronic health records of children (≤18 years) from November 2014 to November 2019 who were on veno‐arterial ECMO for ≥48 hours. Abstracted data included demographics, ECMO indication and duration, timing of EN initiation, change in weight‐for‐age z score (WAZ), and survival rate. The vasoactive‐inotropic score (VIS) was calculated to assess illness acuity.Results:We identified 76 children with median age (interquartile range [IQR]) of 0.3 years (0–2.6), 46 of which were infants (59%) who required ECMO for a median (IQR) of 10 days (6–22). Thirty‐six (47%) survived to hospital discharge. EN was initiated in 55 (72%) of patients while on ECMO. EN initiation by day 3 of ECMO was positively associated with survival (P = 0.0438). VIS at the time of EN initiation was lower in surviving infants (P = 0.022). Children who achieved enteral autonomy were more likely to survive (P = 0.0024). Survivors had greater WAZs at ECMO completion (P = 0.0004).Conclusions:Initiation of EN by day 3 of ECMO and at a lower VIS is associated with greater likelihood of survival.

Abstract Abstract 2273 Background: Continuous flow left ventricular assist device (CF-LVAD) recipients have high tendency of post-surgical gastrointestinal (GI) bleeding. We previously described the loss of high molecular weight VWF multimers (HMWM), due to either an accelerated clearance or enhanced cleavage of the HMWM, in most CF-LVAD recipients (Ann Thorac Surg. 90:1263–9). However, besides the tedious plasma VWF multimer analysis, neither VWF ristocetin cofactor nor collagen binding activity assay provides sufficient sensitivity for detecting such an acquired VWF abnormality (AVWA). In this study, we examined a new automated latex particle-enhanced immunoturbidimetric VWF activity assay (VWF:Lx) for its ability of detecting CF-LVAD-AVWA. We also analyzed the VWF pro-peptide (VWF:pp) to explored the potential mechanism of CF-LVAD-AVWA. Design: As part of an on-going prospective multicenter study, pre- and post-CF-LVAD implantation (7, 30 days and 5–7 months) blood samples were collected from 15 LVAD recipients (median age 52 years; 10 male and 5 female; 2008∼2009). Plasma VWF antigen (VWF:Ag), VWF:Lx activity, VWF:pp/Ag ratios were measured; and plasma VWF multimer analyses were performed on all available plasma samples. Standard statistical analyses were employed. Result: Loss of VWF HMWM was observed in 3 patients prior to CF-LVAD implantation and virtually all patients after surgery. VWF:Ag, VWF:Lx or VWF:pp/Ag ratios of the pre- and post-implantation samples were not significantly different (P> 0.1). However, VWF:Lx/Ag ratios of the post-implantation samples were significantly decreased (P<0.05). At a cut off of 0.8, the VWF:Lx/Ag ratio has a 90% sensitivity and specificity for detecting AVWA. Conclusions: VWF:Lx/Ag ratio has excellent sensitivity and specificity in detecting CF-LVAD-AVWA, and its impact on predicting post-surgical bleeding tendency in CF-LVAD recipients is being investigated. The distinct CF-LVAD-AVWA is most likely caused by enhanced cleavage, rather than clearance, of the HMWM. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 1122 Background: Continuous flow left ventricular assist device (CF-LVAD) recipients have increased tendency of post-surgical bleeding. We have previously described a universal loss of high molecular weight VWF multimers (HMWM), likely due to enhanced cleavage of the HMWM in CF-LVAD recipients. Among various VWF laboratory tests, VWF multimer analysis remains the reference method for detecting such an acquired VWF abnormality (AVWA). We hypothesize that the severity of AVWA is a predictor for bleeding tendency. In this study, using our in-gel VWF multimer electrophoresis method, we measured the severity of HMWM loss in CF-LVAD recipients by infra-red densitometry analysis and examined its association with other VWF activity test results and patients' bleeding tendency. Design: As part of an on-going prospective multicenter study, pre- and/or post-CF-LVAD implantation (7, 30 days and 5–7 months) blood samples were collected from 20 LVAD recipients during 2008 and 2009. Their clinically significant bleeding episodes were recorded. Plasma VWF antigen (VWF:Ag), VWF:Lx activity [Chen D, et al. J Thromb Haemost. 2011;9(10):1993–2002] and plasma VWF multimer analyses [Pruthi RK, et al. Thromb Res. 2010;126(6):543–9] were performed on all available plasma samples. VWF multimers were quantified by infra-red fluorescent densitometry analysis using Odyssey Infrared Imager version 2.0. VWF:multi ratio defined by density ratio between the high molecular weight multimer (HMWM, bands 11 and above) and low and intermediate molecular weight multimer (band 2 to 9) was calculated. Normal range of VWF:multi ratio was determined from 16 normal donor plasma and 4 pooled normal plasma. Statistical analyses including t-test and kappa test were employed. Result: The normal range of VWF:multi ratio is 0.4–0.76. The CV of VWF:multi ratio of a pooled normal plasma tested in 21 gel runs is 12%. Loss of VWF HMWM is present in three patients before CF-LVAD implantation and all patients after implantation. All samples with loss of HMWM show decreased VWF:multi ratio (<0.4). At a cut-off value of 0.4, the sensitivity and specificity of VWF:multi ratio for detecting HMWM loss are 100% and 95.5% respectively (n=67). Decrease of VWF:multi ratio is observed after implantation (0.41±0.07 pre- vs. 0.29±0.07 post-implantation, P<0.00001). In four patients who received heart transplantation, normalization of VWF multimer pattern and VWF:multi ratio (0.54±0.06) is observed. Ten patients had significant post-implantation bleeding episodes that are associated with significantly decreased VWF:multi ratio (0.26±0.04 bleeding vs. 0.32±0.09 non-bleeding, P=0.002) and VWF Lx/Ag ratio (0.72±0.10 bleeding vs 0.80±0.09 non-bleeding, P=0.001). At a cut-off of 0.26, VWF:multi ratio demonstrates a sensitivity of 64% and specificity of 85.7% for predicting clinically significant bleeding. The VWF:multi ratio shows moderate agreement with VWF:Lx/Ag ratio (Kappa value 0.42). Conclusions: Severity of VWF HMWM losses can be quantitatively measured by the new in-gel infra-red densitometry method (VWF:multi ratio). Severity of VWF HMWM losses defined by the VWF:multi ratios, along with VWF:Lx/Ag ratios are significantly associated with bleeding tendency in LVAD recipients. Disclosures: Milano: Thoratec: Consultancy.

OBJECTIVES:Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited.METHODS:In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999–2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population.RESULTS:Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background.CONCLUSIONS:Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.