Critical Care Medicine

Perioperative Assessment of Cerebral Oxygen Metabolism in Infants With Functionally Univentricular Hearts Undergoing the Bidirectional Cavopulmonary Connection Objectives: The transition from single-ventricle lesions with surgically placed systemic-to-pulmonary artery shunt to the circulation following a bidirectional cavopulmonary connection results in higher pressure in the superior vena cava when compared with the preceding circulation. The aim of this study was to evaluate the impact of this transition on the perioperative cerebral oxygen metabolism. Design: Prospective observational cohort study. Setting: Pediatric critical care unit of a tertiary referral center. Patients: Sixteen infants after bidirectional cavopulmonary connection. Intervention: Cardiac surgery (bidirectional cavopulmonary connection). Measurements and Main Results: We measured regional cerebral oxygen saturation, amount of hemoglobin, blood flow velocity, and microperfusion immediately before, 12–24 hours, and 36–48 hours following bidirectional cavopulmonary connection. Based on these measurements, we calculated cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen. Mean pressure in the superior vena cava increased significantly (8 vs 17 mm Hg; p < 0.001) following bidirectional cavopulmonary connection. Mean cerebral oxygen saturation increased from 49.0% (27.4–61.0) to 56.9% (39.5–64.0) (p = 0.008), whereas mean cerebral blood flow velocity decreased from 80.0 arbitrary units (61.9–93.0) to 67.3 arbitrary units (59.0–83.3) (p < 0.001). No change was found in the cerebral amount of hemoglobin and in the cerebral microperfusion. Mean cerebral fractional tissue oxygen extraction (0.48 [0.17–0.63] vs 0.30 [0.19–0.56]; p = 0.006) and approximated cerebral metabolic rate of oxygen (5.82 arbitrary units [2.70–8.78] vs 2.27 arbitrary units [1.19–7.35]; p < 0.001) decreased significantly. Conclusions: Establishment of bidirectional cavopulmonary connection is associated with postoperative improvement in cerebral oxygen metabolism. Cerebral amount of hemoglobin did not increase, although creation of the bidirectional cavopulmonary connection results in significant elevation in superior vena cava pressure. Improvement in cerebral oxygen metabolism was due to lower cerebral blood flow velocity and stable microperfusion, which may indicate intact cerebral autoregulation. Drs. Neunhoeffer and Michel are co-first authors and contributed equally to this work. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http:/journals.lww.com/pccmjournal). Supported, in part, by grants from the foundation Stiftung KinderHerz. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: felix.neunhoeffer@med.uni-tuebingen.de ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Decision-Making Around Positive Tracheal Aspirate Cultures: The Role of Neutrophil Semiquantification in Antibiotic Prescribing Objectives: Ventilator-associated infections are a major contributor to antibiotic use in the PICU. Quantitative or semiquantitative assessment of neutrophils (microscopic purulence) is routinely reported in positive cultures from tracheal aspirates. The role of microscopic purulence in guiding antibiotic therapy or its association with symptoms of ventilator-associated infections is less described in children. We examine microscopic purulence as an independent predictor of antibiotic use for positive tracheal aspirate cultures in the PICU. Design: Retrospective cohort study. Setting: Tertiary care pediatric hospital. Patients: Children admitted to the PICU, neuro-PICU, or cardiac PICU with a positive tracheal aspirate culture from January 1, 2016, to December 31, 2016. Interventions: None. Measurements and Main Results: Positive tracheal aspirate cultures were reviewed. The outcome variable was antibiotic treatment that targeted the positive tracheal aspirate culture. The predictor variable was microscopic purulence, defined as moderate or many neutrophils on Gram stain report. Competing predictors included demographics, comorbidities, vital signs changes, respiratory support, and laboratory values. Of 361 positive cultures in the cohort, 81 (22%) were treated with antibiotics. Positive cultures with microscopic purulence were targeted for therapy more frequently (30% vs 11%). Microscopic purulence was the strongest predictor for antibiotic therapy (odds ratio, 3.3; 95% CI, 1.6–6.8) compared with fever (odds ratio, 2.0; 95% CI, 1.0–4.1) or increased respiratory support (odds ratio, 2.3; 95% CI, 1.2–4.3). There was no significant variation in symptomatology between microscopic purulence reported as moderate or many versus other (e.g., fever –24% vs 22%, increased respiratory support –36% vs 28%). Microscopic purulence was less prevalent with longer ventilator durations at the time of sampling. Conclusions: Microscopic purulence was an independent predictor of antibiotic therapy for positive tracheal aspirate cultures in our PICUs. However, microscopic purulence was not associated with clinical symptomatology. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Dr. Saiman's institution received grant funding form Merck, and she received funding from TEVA and AB Comm. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work was performed at Morgan Stanley Children's Hospital, New York Presbyterian-Columbia University Irving Medical Center. For information regarding this article, E-mail: sirisha.yalamanchi@rutgers.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Impact of Age of Packed RBC Transfusion on Oxygenation in Patients Receiving Extracorporeal Membrane Oxygenation Objective: To determine the effect of age of packed RBCs on tissue oxygenation in children receiving extracorporeal membrane oxygenation support. Design: A retrospective study was done between March 2013 and August 2015. The following biomarkers were examined 6 hours before and 6 hours after the conclusion of a transfusion: serum and circuit hematocrits, serum and circuit venous saturations, serum lactate levels (mg/dL), and cerebral saturation via near-infrared spectroscopy. Biomarkers were examined with respect to time relative to transfusion using four discrete categories (< 3, –3 to 0, 0–3, and > 3 hr). The association between age of blood transfusion and change in biomarkers was accessed analyzing time relative to transfusion as described above. In addition, the age of blood transfusion was analyzed similarly, using four discrete categories (0–7, 7–14, 14–21, and > 21 d). Setting: Twenty-four bed mixed pediatric medical and cardiac ICU at a tertiary care center. Subjects: Zero- to 18-year-old patients of required extracorporeal membrane oxygenation support. Interventions: None. Measurements and Main Results: Circuit venous saturation demonstrated an increase of 2.5% (p < 0.001) in first 3 hours posttransfusion. This was followed by a 1.4% decrease after the initial 3 hours posttransfusion. Serum venous saturation showed no statistically significant change with relation to transfusions. Neither lactate levels nor near-infrared spectroscopy demonstrated any observed statistical change with relation to transfusion. With regards to the relationship between the age of RBC transfusion and tissue oxygenation biomarkers, none of the biomarkers exhibited a consistent interaction. Conclusions: Our study demonstrates that the age of packed RBC transfusion does not affect the degree tissue oxygenation in children receiving extracorporeal membrane oxygenation support, as measured by mixed venous oxygen saturation, lactate, and near-infrared spectroscopy. In addition, packed RBC transfusion, in general, did not produce any meaningful change in these markers of tissue oxygenation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Dr. Chang received funding from Ortho Clinical Diagnostics. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: sdatta.ucla@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Antithrombin Population Pharmacokinetics in Pediatric Ventricular Assist Device Patients Objectives: Describe the pharmacokinetics of antithrombin in pediatric patients undergoing ventricular assist device therapy and provide dosing recommendations for antithrombin in this population. Design: A retrospective population pharmacokinetic study was designed. Setting: Large tertiary care children's hospital Subject inclusion criteria consisted of less than 19 years old. Patients: Subjects less than 19 years old undergoing therapy with a HeartWare ventricular assist device (HeartWare, Framingham, MA) or Berlin EXCOR ventricular assist device (Berlin GmbH, Berlin, Germany), who received a dose of antithrombin with a postdose antithrombin activity level from January 1, 2011, to June 30, 2017. Interventions: Population pharmacokinetic analysis and simulation using NONMEM v.7.4 (Icon, PLC, Dublin, Ireland). Measurements and Main Results: A total of 41 patients met study criteria (median age, 5.8 years [interquartile range, 1.6–9.9 yr]), and 53.7% underwent therapy with the pulsatile Berlin EXCOR pediatric ventricular assist device (Berlin Heart GmbH, Berlin, Germany). All patients received unfractionated heparin continuous infusion at a mean ± SD dose of 29 ± 14 U/kg/hr. A total of 181 antithrombin doses (44.1 ± 24.6 U/kg/dose) were included, and baseline antithrombin activity levels were 77 ± 12 U/dL. Antithrombin activity levels were drawn a median 19.9 hours (interquartile range, 8.8–41.6 hr) after antithrombin dose. A one-compartment proportional error model best fit the data, with allometric scaling of fat-free mass providing a better model fit than actual body weight. Unfractionated heparin and baseline antithrombin were identified as significant covariates. A 50 U/kg dose of antithrombin had a simulated half-life 13.2 ± 6.6 hours. Conclusions: Antithrombin should be dosed on fat-free mass in pediatric ventricular assist device patients. Unfractionated heparin dose and baseline antithrombin activity level should be considered when dosing antithrombin in pediatric ventricular assist device patients. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http:/journals.lww.com/pccmjournal). Dr. Moffett disclosed off-label product use of antithrombin in pediatric ventricular assist device patients. Dr. Teruya received funding from STAGO (reagent company for coagulation, Advisory committee), Evaheart, and Octapharma. Dr. Adachi serves as consultant and proctor for Berlin Heart and Medtronic and consultant for Sony-Olympus Medical Solutions. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: bsmoffet@texaschildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Cardiopulmonary Resuscitation in the Pediatric Cardiac Catheterization Laboratory: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry Objectives: Hospitalized children with underlying heart disease are at high risk for cardiac arrest, particularly when they undergo invasive catheterization procedures for diagnostic and therapeutic interventions. Outcomes for children experiencing cardiac arrest in the cardiac catheterization laboratory remain under-reported with few studies reporting survival beyond the catheterization laboratory. We aim to describe survival outcomes after cardiac arrest in the cardiac catheterization laboratory while identifying risk factors associated with hospital mortality after these events. Design: Retrospective observational study of data from a multicenter cardiac arrest registry from November 2005 to November 2016. Cardiac arrest in the cardiac catheterization laboratory was defined as the need for chest compressions greater than or equal to 1 minute in the cardiac catheterization laboratory. Primary outcome was survival to discharge. Variables analyzed using generalized estimating equations for association with survival included age, illness category (surgical cardiac, medical cardiac), preexisting conditions, pharmacologic interventions, and event duration. Setting: American Heart Association's Get With the Guidelines-Resuscitation registry of in-hospital cardiac arrest. Patients: Consecutive patients less than 18 years old experiencing an index (i.e., first) cardiac arrest event reported to the Get With the Guidelines-Resuscitation. Interventions: None. Measurements and Main Results: A total of 203 patients met definition of index cardiac arrest in the cardiac catheterization laboratory composed primarily of surgical and medical cardiac patients (54% and 41%, respectively). Children less than 1 year old comprised the majority of patients, 58% (117/203). Overall survival to hospital discharge was 69% (141/203). No differences in survival were observed between surgical and medical cardiac patients (p = 0.15). The majority of deaths (69%, 43/62) occurred in patients less than 1 year old. Bradycardia (with pulse) followed by pulseless electrical activity/asystole were the most common first documented rhythms observed (50% and 27%, respectively). Preexisting metabolic/electrolyte abnormalities (p = 0.02), need for vasoactive infusions (p = 0.03) prior to arrest, and use of calcium products (p = 0.005) were found to be significantly associated with lower rates of survival to discharge on multivariable regression. Conclusions: The majority of children experiencing cardiac arrest in the cardiac catheterization laboratory in this large multicenter registry analysis survived to hospital discharge, with no observable difference in outcomes between surgical and medical cardiac patients. Future investigations that focus on stratifying medical complexity in addition to procedural characteristics at the time of catheterization are needed to better identify risks for mortality after cardiac arrest in the cardiac catheterization laboratory. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by grant from the Texas Children's Hospital departmental funds were used for this study. The scientific advisory board of the American Heart Association (AHA) provided review and approval of the article, and the Executive Database Steering Committee of the AHA provided additional peer review of the article before submission. Part of the content of this article was presented in poster abstract format at the American Heart Association's Scientific Sessions, November 12, 2017, Anaheim, CA. The authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Javier J. Lasa, MD, FAAP, Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, Texas Children's Hospital/Baylor College of Medicine, MC: E1420, 6651 Main Street, Houston, TX 77030. E-mail: jjlasa@texaschildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Superiority of Dynamic Needle Tip Positioning for Ultrasound-Guided Peripheral Venous Catheterization in Patients Younger Than 2 Years Old: A Randomized Controlled Trial Objectives: This study evaluated whether the dynamic needle tip positioning technique increased the success rate of ultrasound-guided peripheral venous catheterization in pediatric patients with a small-diameter vein compared with the static ultrasound-guided technique. Design: Randomized controlled study. Setting: Single institution, Osaka Women's and Children's Hospital. Patients: The study population included 60 pediatric patients less than 2 years old who required peripheral venous catheterization in the PICU. Interventions: Patients were randomly divided into the dynamic needle tip positioning (n = 30) or static group (n = 30). Each group received ultrasound-guided peripheral venous catheterization with or without dynamic needle tip positioning, respectively. The Fisher exact test, Kaplan-Meier curve plots, log-rank tests, and Mann-Whitney U test were used in the statistical analysis. Measurements and Main Results: The first-attempt success rate was higher in the dynamic needle tip positioning group than in the static group (86.7% vs 60%; p = 0.039; relative risk = 1.44; 95% CI, 1.05–2.0). The overall success rate within 10 minutes was higher in the dynamic needle tip positioning group than in the static group (90% vs 63.3%; p = 0.03; relative risk = 1.42; 95% CI, 1.06–1.91). Significantly fewer attempts were made in the dynamic needle tip positioning group than in the static group (median [interquartile range, range] = 1 [1–1, 1–2] vs 1 [1–2, 1–3]; p = 0.013]). The median (interquartile range) catheterization times were 51.5 seconds (43–63 s) and 71.5 seconds (45–600 s) in the dynamic needle tip positioning and static groups, respectively (p = 0.01). Conclusions: Dynamic needle tip positioning increased the first-attempt and overall success rates of ultrasound-guided peripheral venous catheterization in pediatric patients less than 2 years old. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. This work was performed at Osaka Women's and Children's Hospital. For information regarding this article, E-mail: t-k-s-t@koto.kpu-m.ac.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Trauma Bay Disposition of Infants and Young Children With Mild Traumatic Brain Injury and Positive Head Imaging Objectives: To describe the disposition of infants and young children with isolated mild traumatic brain injury and neuroimaging findings evaluated at a level 1 pediatric trauma center, and identify factors associated with their need for ICU admission. Design: Retrospective cohort. Setting: Single center. Patients: Children less than or equal to 4 years old with mild traumatic brain injury (Glasgow Coma Scale 13–15) and neuroimaging findings evaluated between January 1, 2013, and December 31, 2015. Polytrauma victims and patients requiring intubation or vasoactive infusions preadmission were excluded. Interventions: None. Measurements and Main Results: Two-hundred ten children (median age/weight/Glasgow Coma Scale: 6 mo/7.5 kg/15) met inclusion criteria. Most neuroimaging showed skull fractures with extra-axial hemorrhage/no midline shift (30%), nondisplaced skull fractures (28%), and intracranial hemorrhage without fractures/midline shift (19%). Trauma bay disposition included ICU (48%), ward (38%), intermediate care unit and home (7% each). Overall, 1% required intubation, 4.3% seizure management, and 4.3% neurosurgical procedures; 15% were diagnosed with nonaccidental trauma. None of the ward/intermediate care unit patients were transferred to ICU. Median ICU/hospital length of stay was 2 days. Most patients (99%) were discharged home without neurologic deficits. The ICU subgroup included all patients with midline shift, 62% patients with intracranial hemorrhage, and 20% patients with skull fractures. Across these imaging subtypes, the only clinical predictor of ICU admission was trauma bay Glasgow Coma Scale less than 15 (p = 0.018 for intracranial hemorrhage; p < 0.001 for skull fractures). A minority of ICU patients (18/100) required neurocritical care and/or neurosurgical interventions; risk factors included neurologic deficit, loss of consciousness/seizures, and extra-axial hemorrhage (especially epidural hematoma). Conclusions: Nearly half of our cohort was briefly monitored in the ICU (with disposition mostly explained by trauma bay imaging, rather than clinical findings); however, less than 10% required ICU-specific interventions. Although ICU could be used for close neuromonitoring to prevent further neurologic injury, additional research should explore if less conservative approaches may preserve patient safety while optimizing healthcare resource utilization. Drs. Noje and Jackson had equal contributions to this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http:/journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: cnicule1@jhmi.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Short- and Long-Term Outcomes of Extremely Preterm Infants in Japan According to Outborn/Inborn Birth Status Objectives: Outborn (born outside tertiary centers) infants, especially extremely preterm infants, are at an increased risk of mortality and morbidity in comparison to inborn (born in tertiary centers) infants. Extremely preterm infants require not only skilled neonatal healthcare providers but also highly specialized equipment and environment surroundings. Maternal transport at an appropriate timing must be done to avoid the delivery of extremely preterm infants in a facility without the necessary capabilities. Cases of unexpected deliveries at birth centers or level I maternity hospitals need to be attended emergently. We compared the differences in short- and long-term outcomes between outborn and inborn infants to improve our regional perinatal system. Design: Retrospective cohort study. Setting: Neonatal Research Network of Japan database. Patients: Extremely preterm infants (gestational age between 22 + 0 and 27 + 6 wk) in the Neonatal Research Network of Japan database between 2003 and 2011. Interventions: None. Measurements and Main Results: A total of 12,164 extremely preterm infants, who were divided into outborn (n = 785, 6.5%) and inborn (n = 11,379, 93.5%) groups, were analyzed. Significant differences were observed in demographic and clinical factors between the two groups. Outborn infants had higher short-term odds of severe intraventricular hemorrhage (adjusted odds ratio, 1.49; 95% CI, 1.11–2.00; p < 0.01), necrotizing enterocolitis (adjusted odds ratio, 1.49; 95% CI, 1.11–2.00; p < 0.01), and focal intestinal perforation (adjusted odds ratio, 1.58; 95% CI, 1.09–2.30; p = 0.02). There were no significant differences in long-term outcomes between the two groups, except in the rate of cognitive impairment (adjusted odds ratio, 1.49; 95% CI, 1.01–2.20; p = 0.04). Conclusions: The frequency of severe intraventricular hemorrhage, necrotizing enterocolitis or focal intestinal perforation, and cognitive impairment was significantly higher in outborn infants. Thus, outborn/inborn birth status may play a role in short- and long-term outcomes of extremely preterm infants. However, more data and evaluation of improvement in the current perinatal environment are needed. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: yoshihitosasaki@hotmail.co.jp ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Healthcare Provider Perceptions of Cardiopulmonary Resuscitation Quality During Simulation Training Objectives: To assess the relationship between quantitative and perceived cardiopulmonary resuscitation performance when healthcare providers have access to and familiarity with audiovisual feedback devices. Design: Prospective observational study. Setting: In situ simulation events throughout a pediatric quaternary care center where the use of continuous audiovisual feedback devices during cardiopulmonary resuscitation is standard. Subjects: Healthcare providers who serve as first responders to in-hospital cardiopulmonary arrest. Interventions: High-fidelity simulation of resuscitation with continuous audiovisual feedback. Measurements and Main Results: Objective data was collected using accelerometer-based measurements from a cardiopulmonary resuscitation defibrillator/monitor. After the simulation event but before any debriefing, participants completed self-evaluation forms to assess whether they believed the cardiopulmonary resuscitation performed met the American Heart Association guidelines for chest compression rate, chest compression depth, chest compression fraction, chest compression in target, and duration of preshock pause and postshock pause. An association coefficient (kappa) was calculated to determine degree of agreement between perceived performance and the quantitative performance data that was collected from the CPR defibrillator/monitor. Data from 27 mock codes and 236 participants was analyzed. Average cardiopulmonary resuscitation performance was chest compression rate 106 ± 10 compressions per minute; chest compression depth 2.05 ± 0.6 in; chest compression fraction 74% ± 10%; chest compression in target 22% ± 21%; preshock pause 8.6 ± 7.2 seconds; and postshock pause 6.4 ± 8.9 seconds. When all healthcare providers were analyzed, the association coefficient (κ) for chest compression rate (κ = 0.078), chest compression depth (κ = 0.092), chest compression fraction (κ = 0.004), preshock pause (κ = 0.321), and postshock pause (κ = 0.40) was low, with no variable achieving moderate agreement (κ > 0.4). Conclusions: Cardiopulmonary resuscitation performance during mock codes does not meet the American Heart Association's quality recommendations. Healthcare providers have poor insight into the quality of cardiopulmonary resuscitation during mock codes despite access to and familiarity with continuous audiovisual feedback. This work was performed at the Lucile Packard Children's Hospital Stanford. Supported, in part, by grant from the Laerdal Foundation and from the Jackson Vaughan Critical Care Research Fund. Dr. Su's institution received funding from Laerdal Foundation for Acute Medicine and Jackson Vaughan Critical Care Research Fund. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: lindsey.troy@hsc.utah.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Telemedicine for Interfacility Nurse Handoffs Objective: To compare nurse preparedness and quality of patient handoff during interfacility transfers from a pretransfer emergency department to a PICU when conducted over telemedicine versus telephone. Design: Cross-sectional nurse survey linked with patient electronic medical record data using multivariable, multilevel analysis. Setting: Tertiary PICU within an academic children's hospital. Participants: PICU nurses who received a patient handoff between October 2017 and July 2018. Interventions: None. Main Results and Measurements: Among 239 eligible transfers, 106 surveys were completed by 55 nurses (44% survey response rate). Telemedicine was used for 30 handoffs (28%), and telephone was used for 76 handoffs (72%). Patients were comparable with respect to age, sex, race, primary spoken language, and insurance, but handoffs conducted over telemedicine involved patients with higher illness severity as measured by the Pediatric Risk of Mortality III score (4.4 vs 1.9; p = 0.05). After adjusting for Pediatric Risk of Mortality III score, survey recall time, and residual clustering by nurse, receiving nurses reported higher preparedness (measured on a five-point adjectival scale) following telemedicine handoffs compared with telephone handoffs (3.4 vs 3.1; p = 0.02). There were no statistically significant differences in both bivariable and multivariable analyses of handoff quality as measured by the Handoff Clinical Evaluation Exercise. Handoffs using telemedicine were associated with increased number of Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver components (3.3 vs 2.8; p = 0.04), but this difference was not significant in the adjusted analysis (3.1 vs 2.9; p = 0.55). Conclusions: Telemedicine is feasible for nurse-to-nurse handoffs of critically ill patients between pretransfer and receiving facilities and may be associated with increased perceived and objective nurse preparedness upon patient arrival. Additional research is needed to demonstrate that telemedicine during nurse handoffs improves communication, decreases preventable adverse events, and impacts family and provider satisfaction. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The telemedicine infrastructure for this study was developed with funds from grant number G01RH27872 from the Health Resources and Services Administration (HRSA), Federal Office of Rural Health Policy, Office for the Advancement of Telehealth and from grant number H3AMC24073 from HRSA, Maternal and Child Health Bureau, Emergency Medical Services for Children Program, and State Partnership Regionalization of Care. Ms. Lieng's institution received funding from National Center for Advancing Translational Sciences (NCATS) and National Institutes of Health (NIH)—grant number UL1 TR001860 and linked award TL1 TR001861 and KL2 TR001859. Ms. Lieng and Dr. Rosenthal received support for article research from the NIH. Dr. Rosenthal's institution received funding from NCATS and NIH—grant number UL1 TR001860 and linked award KL2 TR001859. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: mlieng@ucdavis.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Alexandros Sfakianakis
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