Citations

Background: Central line-associated bloodstream infections (CLABSIs) remain a challenge in pediatric intensive care units (PICUs); central line days have been directly correlated with risk of CLABSI. The Mayo Clinic PICU is a 23-bed multidisciplinary unit including dedicated bone marrow transplant beds with an average of 1048 admissions annually. In 2024, the unit’s CLABSI rate was 0.82 per 1,000 central line days or approximately 1–3 CLABSIs per year. Weekly multidisciplinary CLABSI Prevention Rounds were piloted from August 2024 to March 2025 with the aim of reducing central line device utilization rate as a method to reduce CLABSI risk. Methods: A multidisciplinary team of Clinical Nurse Specialists (CNS), Nurse Managers, and off-service PICU physicians conducted weekly CLABSI rounds on PICU beds (excluding 4 BMT beds), meeting with each bedside nurse as well as the on-service providers. The CLABSI team assessed central line necessity using a standard questionnaire and provided education to physicians and nurses regarding central line care and CLABSI prevention. Monthly data were compared for the same 8 calendar months pre versus post intervention for central line days, patient days, and device utilization rate (DUR; central line days/patient days), both unadjusted and adjusted for PRISM (Pediatric Risk of Mortality) 3 severity of illness score. Pre- and post-implementation staff surveys assessed confidence in line management and interdisciplinary communication using Likert scales. Results: Thirty-two CLABSI rounds with a total of 118 individual patients and 45 discrete interventions were noted over 8 months and compared to the 8 pre-intervention corresponding months. Pre versus post monthly DUR was 0.42 [0.32–0.57] vs 0.46 [0.30–0.55], p = 0.49 (PRISM 3–adjusted p = 0.97). Nursing confidence in ‘discussing central line need’ significantly improved post-implementation, 5 [4–5] vs 5 [5–5], p = 0.035. Nurses also positively perceived third-party involvement in need assessment, 4 [3–4] vs 4 [3–4], p = 0.06. All surveyed clinicians trended toward being less likely to think a central line was left in too long, 3 [3–4] vs 3 [2–4], p = 0.06. Conclusion: Structured weekly multidisciplinary CLABSI rounds are a feasible intervention that empowers bedside nurses and improves confidence in line maintenance and interdisciplinary communication. Median DUR was not significantly altered by the intervention, but nursing perception of central line management improved qualitatively in pre- versus post-implementation surveys. Continued expansion of multidisciplinary initiatives addressing central line necessity and management is needed to further evaluate overall effects on DUR and CLABSI incidence.

ABSTRACT Intrinsic Acinetobacter -derived cephalosporinases (ADCs) in Acinetobacter baumannii are AmpC-type β-lactamases that confer resistance to β-lactam agents, typically through insertion sequence (IS) element-driven overexpression. However, the contribution of ADCs to resistance against advanced β-lactam agents has not been systematically investigated. Given the increasing clinical use of these agents, including cefiderocol, we analyzed the diversity and function of ADC variants in a global collection of carbapenem-resistant A. baumannii (CRAb) isolates. We identified 52 distinct ADC variants in a collection of 428 CRAb clinical isolates from the United States. Among these, variants carrying both a valine substitution at position 292 in the R2 loop and an alanine duplication (ADUP) in the Ω loop consistently conferred stable resistance to cefiderocol. Biochemical and crystallographic analyses demonstrated that ADC-227, which harbors a V292W substitution with an ADUP at position 218a in the Ω loop, exhibits enhanced catalytic efficiencies for ceftazidime and cefiderocol and moderately reduced inhibition by avibactam, leading to resistance not only to cefiderocol but also to ceftazidime–avibactam. Structural studies revealed conformational flexibility of the R2 loop, allowing dynamic accommodation of substrates. Collectively, the findings identify Val292, in combination with an ADUP in the Ω loop, as a mutational “hot spot” for ADCs evolution that may undermine the efficacy of newer β-lactams, including cefiderocol. These results underscore the need for ongoing molecular surveillance of A. baumannii isolates to detect and track the emergence of such variants in clinical settings. IMPORTANCE Carbapenem-resistant Acinetobacter baumannii (CRAb) has been designated as a critical priority pathogen by the World Health Organization (WHO). Cefiderocol has been introduced as a novel therapy against CRAb; however, recent clinical data highlight concerning treatment failures and excess mortality. Understanding resistance mechanisms is therefore essential to preserve the clinical utility of this agent. This study addresses a critical knowledge gap by investigating the role of intrinsic Acinetobacter -derived cephalosporinases (ADCs), which are ubiquitous in A. baumannii and diverse in sequence. By defining specific mutational patterns that endanger cefiderocol activity, this work highlights how chromosomally encoded enzymes can evolve to erode the effectiveness of newer β-lactams such as cefiderocol. These insights underscore the importance of integrating molecular surveillance into clinical practice and antimicrobial stewardship to ensure timely detection of emerging resistance in clinical A. baumannii isolates, ultimately informing treatment strategies and guiding future drug development.

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.

ABSTRACT The COVID‐19 pandemic underscored the critical need to strengthen healthcare systems and optimize resource allocation planning during times of disruption and crisis. This retrospective, single‐center, cross‐sectional study included 33,158 admissions for patients ≤ 17 years old admitted to the Children's Hospital (CH) between January 1, 2017, and December 31, 2021. Data was abstracted using Vizient Clinical Data Base and the internal data warehouse. A Poisson regression model was implemented to compare admission diagnosis patterns during the pre‐ and intra‐pandemic phases. CH SARS‐CoV‐2 prevalence rate was 0.1% in 2020 and 0.5% in 2021. There was a decrease in overall admissions to the CH ( p < 0.01) and PICU ( p < 0.01) at the onset of the pandemic. There were significant and variable differences in admission patterns for certain infectious and seizure‐related diagnoses. The CH experienced an increase in certain specific mental health diagnoses. Seasonality was noted for viral bronchiolitis during the pre‐pandemic phase, but was disrupted during the intra‐pandemic phase. The COVID‐19 pandemic had a significant impact on the number and pattern of admissions, despite low prevalence of SARS‐CoV‐2 in our hospital. These changes may be secondary to COVID‐19 community mitigation strategies. Results can inform anticipated patterns during future pandemics.

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: Many PICU admissions start with presentation in the emergency department (ED). However, we do not know whether there are any ED-related factors associated with the subsequent development of pediatric delirium (PD) within 24 hours of PICU admission. DESIGN: Retrospective cohort study. SETTING: Single-center ED and PICU serving a quaternary referral center in the United States. PATIENTS: Children younger than 18 years old presenting to the ED between January 2022 and December 2023 who required direct admission to the PICU, and who had at least one positive delirium screening within 24 hours of the admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of delirium in the PICU was defined as a Cornell Assessment of Pediatric Delirium (CAPD) score of 9 and higher. We identified 138 patients for the final analysis. Overall, 51 of 138 patients (37%) developed PD within 24 hours of admission. The majority of delirium cases were classified as hypoactive (53%, 27/51) and mixed (31%, 16/51) subtypes, while only 16% (8/51) were identified as hyperactive delirium. Factors associated with greater odds (95% CI) of delirium in the PICU in multivariable analysis were use of mechanical ventilation (odds ratio [OR], 3.42 [95% CI, 1.09–10.78]; p = 0.04) and intermittent urinary catheterization (OR, 3.7 [95% CI, 1.21–11.30]; p = 0.02). Initial CAPD score positively correlated with PICU length of stay (LOS; r = 0.32; p < 0.01), Pediatric Index of Mortality 3 (PIM 3) score ( r = 0.26; p < 0.01), and negatively correlated with emergency severity index (ESI) in the ED ( r = –0.35; p < 0.01). CONCLUSIONS: Mechanical ventilation and intermittent urinary catheterization in the ED are associated with greater odds of PD within 24 hours of PICU admission. CAPD at admission positively correlates with PICU LOS, PIM 3 scores, and negatively correlates with ESI in the ED.

In the published publication [...]

Background : The COVID-19 pandemic profoundly impacted healthcare, emphasizing the need to strengthen future pandemic responses and optimize resource allocation planning and deployment during times of disruption and crisis. Methods : This retrospective, single-center, cross-sectional study included participants ≤17 years-old admitted to the Children’s Hospital (CH) between 01/01/2017 and 12/31/2021. Clinical data was abstracted using Vizient ® Clinical Data Base and the internal data warehouse. Using the International Classification of Disease, 10 th Revision, Clinical Modification (ICD-10-CM) admit diagnosis, frequency and pattern of total admissions during the pre-pandemic phase (2017 Q1-2019 Q4) and intra-pandemic phase (2020 Q1-2021 Q4) were compared. Results : The study included 33,158 admissions. CH SARS-CoV-2 prevalence rate was 0.1% in 2020 and 0.5% in 2021. There was a decrease in overall admissions to the CH (p <0.01) and PICU (p <0.01) at the start of the pandemic. There were significant and variable differences in admission patterns for certain infectious, mental health, and seizure related diagnoses. Seasonality was noted for viral bronchiolitis during the pre-pandemic phase but was disrupted during the intra-pandemic phase with significantly lower admission rates for viral bronchiolitis in 2020 Q4 (p <0.05) and 2021 Q1 (p <0.01), followed by a significant early increase in viral bronchiolitis admissions in 2021 Q3 (p <0.01). Conclusion : The COVID-19 pandemic significantly impacted the number and pattern of admissions despite low SARS-CoV-2 prevalence in our hospital. These changes may be secondary to COVID-19 mitigation strategies implemented in the community. Results can inform anticipated patterns during future pandemics.

Pediatric delirium (PD) is an acute neuropsychiatric syndrome marked by fluctuating disturbances in attention and cognition, frequently observed in pediatric intensive care units (PICUs) and associated with increased morbidity, mortality, and long-term cognitive impairment. Despite its clinical significance, PD remains underdiagnosed due to challenges inherent in assessing consciousness and cognition in children at varying developmental stages. Several bedside tools have been developed and validated in recent years, including the Cornell Assessment of Pediatric Delirium (CAPD), PreSchool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU); Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Sophia Observation Withdrawal Symptoms—Pediatric Delirium Scale (SOS-PD), enhancing early recognition and management of PD in critically ill children. This narrative review explores the historical background, epidemiology, risk factors, pathophysiology, clinical subtypes, diagnostic tools, and current prevention and treatment strategies for PD from newborns to 21 years old. The screening tools available and the integration of non-pharmacological interventions, such as environmental modifications and family-centered care, as well as cautious and selective pharmacological management, are emphasized in this review. Early identification and targeted interventions are essential to mitigate the adverse outcomes associated with PD.