Thank you all for joining us today for the Pediatrics Year in Review for 2021. I've been asked to review the literature for basic science, which is of course an impossible task. So, I chose to focus on advancements in the field of trained immunity because I think this is a very quickly growing field and one that has broad implications for the care of critically ill children. There's growing recognition that the innate immune system is not static, but instead is adapting over time depending on prior exposures and stimuli. Here's a schematic of three different types of adaptations that have been described in the innate immune system. The first is priming, where after the first insult, there's not yet time to return to baseline before the second insult. And there, as a consequence, is an enhanced response to that second insult. This is in contrast to trained immunity, where there is a complete return to baseline after that first insult, but there's some innate immune memory such that with the second insult, there is augmented immune response. The opposite of this is tolerance, where after a return to baseline after the first insult, with the second insult, there is a dampened inflammatory response. Now, you can probably imagine how each of these adaptations might be beneficial or harmful depending on the circumstances. And so, it will be increasingly important that we understand how these might be playing out in our patients such that we can take advantage of tolerance when we need to decrease inflammation, for instance, or take advantage of trained immunity when we need to enhance it. The first manuscript that caught my eye last year was published by Jasmine Belkade's group in the journal Science and looked at trained immunity in the context of prenatal exposures. In this paper, they infected pregnant mice with a self-limited infection of Yersinia. This infection was mild, it did not harm the mice, and it did not reach the fetuses. They then went on to interrogate the offspring in young adulthood. When they looked at all of the barrier sites and all of the various immune cell populations, they found that there was a greatest increase in the Th17 population in the small and large intestine and that this increase in Th17 was limited to the first litter that the mom had while she was infected and not a second litter where there was not an infection. They then took sera from the infected pregnant mice and transferred it to pregnant mice that had not been infected and found that they could recapitulate the Th17 response in the offspring with just the sera. When they investigated what cytokines were present in that sera, they found that there was a biggest increase in IL-6. They tested whether or not just giving IL-6 to the pregnant mice could have the same impact in the Th17 population in the offspring and found that yes, it could. Treatment with the anti-IL-6 antibody prevented the increase in Th17 cells in the population, further supporting that this skewing to the Th17 cells was mediated by IL-6. Then they went on to show that this was happening through the intestinal epithelial cells. They did this by knocking out the IL-6 receptor just in the intestinal epithelial cells and then measuring the Th17 response and found that without the IL-6 receptor, giving IL-6 prenatally did not increase the percentage or number of Th17 cells in the intestines. Finally, to test the functional consequences of this IL-6 training, they infected the offspring with Salmonella and found that there was improved survival in the offspring who had been prenatally exposed to IL-6. Take-homes from this paper for me were that prenatal exposures have the capability of impacting subsequent tissue susceptibility to infection and also auto-inflammatory disorders which I didn't have time to show all the data for. The next paper that caught my eye explored the impact of sequential viral infections on immune response and outcomes. This paper was by Alan Foxman's group and published in the Journal of Experimental Medicine. The first part of this paper explored how the antiviral interferon responses changes over time in response to SARS-CoV-2 infection in people, but I wanted to focus on the second half of the paper. Here they investigated how sequential infection with rhinovirus and then SARS-CoV-2 impacts outcomes. Here they used an epithelial organoid model where they first infected the epithelial cells with rhinovirus and three days later challenged them with SARS-CoV-2. They then assessed the viral load at various time points after infection and the expression of interferon-stimulated genes. First they found that after rhinovirus infection there was an up-regulation of various interferon-stimulated genes known to be important for the control of viral infection. In addition to those being up right before the infection with SARS-CoV-2, the pre-infection with rhinovirus enhanced the expression of these interferon-stimulated genes throughout SARS-CoV-2 infection. As a consequence, there was a dramatic decrease in the viral load of SARS-CoV-2 following rhinovirus infection than there was following mock infection. To demonstrate that the protective effect of rhinovirus infection prior to SARS-CoV-2 is mediated by the transcription factor IRF3 and the up-regulation of interferon-stimulated genes, they treated the cells with an IRF3 inhibitor prior to infection with rhinovirus. Inhibiting IRF3 successfully decreased the transcription of interferon-stimulated genes and it also inhibited the beneficial effects of rhinovirus such that the SARS-CoV-2 viral load was no longer decreased following rhinovirus infection. In addition, inhibiting IRF3 also increased the viral load of rhinovirus. So sequential rhinovirus than SARS-CoV-2 infection was only protective and improved viral clearance if the interferon response was intact. The authors to conclude that there's a period of time after a viral infection that we are protected from a subsequent viral infection, but only if the interferon response is intact. If the interferon response is not intact, then sequential viral infections are actually harmful. In this third paper, they did a deep exploration into the epigenomic and transcriptional consequences of influenza vaccination. This was published by Bali Palendran's group in Cell. In this study, volunteers were vaccinated with a seasonal influenza vaccine, TIV, and avian influenza vaccine, H5N1, or an avian influenza vaccine plus an adjuvant, HSO3. Following vaccination, their peripheral blood mononuclear cells were isolated at various time points and all these different measurements were obtained to fully assess the impact of vaccination on the PBMC. In these first set of experiments, they took the isolated peripheral blood mononuclear cells and exposed them to various bacterial or viral ligands and measured cytokine secretion. Here you can see that over many days following vaccination, there is a decrease in cytokine secretion in response to both bacterial and viral ligands and that this decrease in cytokine secretion is not fully reversed by day 180. This decrease in cytokine secretion was associated with a decrease in chromatin accessibility of these genes, which they went on to show was likely mediated by a decrease in the AP1 family of transcription factors. Moving on to the H5N1 vaccinations, they also showed that there was a decrease in cytokine secretion up to 42 days after the vaccination. Similar to the seasonal influenza vaccine, this decrease in cytokine secretion was associated with a decrease in chromatin accessibility of the AP1 family of transcription factors, including Fos and Jun here. Interestingly and unlike the seasonal influenza vaccine or the non-adjuvanted H5N1 vaccine, the adjuvanted H5N1 vaccine showed an increase in chromatin accessibility of the IRF family of transcription factors, which are responsible for the transcription of interferon-stimulated genes. When they looked at the interferon-stimulated gene transcription, they found that they were in fact increased in response to vaccination with the adjuvanted H5N1 and its booster, but not increased in the non-adjuvanted H5N1 vaccine. They then tested how these epigenomic modifications that they found after vaccination might impact the response to other viruses. So they infected the PBMCs isolated from people who were vaccinated with the adjuvanted H5N1 vaccine with either dengue or Zika virus. And they found that there was decreased viral load in the folks who had been vaccinated with the adjuvanted vaccine compared to those who had not. In addition, they found that the decrease in viral load was inversely proportional to the increase in IRF1, suggesting that an increase in IRF1 was improving the ability to combat these viruses. So vaccination can modify the inflammatory response to unrelated stimuli and careful choice of immune stimulants like adjuvants can tune the immune system to dampen inflammation while also increasing antiviral potential. Finally, I wanted to touch briefly on this article published in Nature by Kirsten Meyers group looking at the local and systemic responses to SARS-CoV-2 in both children and adults. In this study, they performed single cell RNA sequencing on samples from the nose and the blood from healthy children and adults and those infected with SARS-CoV-2. They found some interesting age-related differences shown here in the nose between children and adults with infants having a higher proportion of innate immune cells in the nose compared to older children and adults, which transitions to an increase in adaptive immune cells with time. So not surprising, but fun to see this switch from innate immunity, a dependence on innate immunity in the youngest children, to a more prominent adaptive immune response in the older kids. Intriguingly, when they compared healthy children to adults, they found an increase in baseline antiviral interference signaling in both the nose and the blood. So here shown in red, indicating that these processes were upregulated in children compared to adults at baseline. However, this increased signature only persisted in the immune cell population and not the epithelial cell population in response to SARS-CoV-2. So the consequences of this preexisting antiviral interferon signature in children is unclear. I realize that was a whirlwind tour of some very complicated papers with broad implications for our understanding of innate immunity and its development over childhood. I didn't have time to go through all of the data in all of the papers, so I hope that you have the opportunity to go back and read them for yourself, because there is definitely some very interesting aspects that we didn't discuss today. But for me, the take-home points that I thought were most interesting from each paper are listed here. The first being that prenatal exposure might impact postnatal inflammatory responses to pathogens or environmental stimuli. That sequential viral infection might be protective if the interferon response is intact, but if it's not, they might be harmful. That immune cell activation by vaccination can modify the subsequent immune response to unrelated viral infections. We've known this for a while, but seeing how that subsequent response may be tuned depending on how the vaccination was given and with what adjuvants, I think it's really fascinating. And that children might have a preactivated interferon response compared to adults that could be protective in things like SARS-CoV-2 infection, but why it's not clearly protective in other viral infections like influenza and RSV, which we know impact children to a more significant degree than adults, is unclear. And I think all of these papers leave us with the question of how can we harness trained immunity to improve disease tolerance and outcomes, and how can we use this knowledge to both protect our patients from critical illness, to help them recover from critical illness more quickly, or to protect them from the side effects of prolonged critical illness like immunoparalysis and hospital-acquired infections. With that, I'd like to thank you for your attention, and I really hope that we have the opportunity to discuss these papers. Hello, and welcome to the 51st Critical Care Congress. My name is Dr. Mallory Perry, and I'll be presenting to you the pediatric year-in-review looking at clinical research. Again, my name is Mallory Perry. I am a PhD-prepared nurse scientist and postdoctoral fellow currently funded by NIH-NIGMS, and I'm employed with Children's Hospital of Philadelphia Research Institute. While I wish that we could be in sunny Puerto Rico enjoying this talk in person, I'm about to settle with this virtual world, and so I hope you can join me today as we kind of discuss what we went through in 2021 and the important publications that graced us during this time period. I would like to first say that I have no financial disclosures of interest, but I would like to acknowledge my funding sources, which include NIH-NIGMS, where I'm funded by K99R00, as well as the American Association of Critical Nurses. The methodology that I used to do this 2021 year-in-review was an in-depth OVID and SCOPUS search of the literature. This looked at terms such as pediatric or children and critical care, intensive care, or critical illness. I limited my search to 2021 to get a really comprehensive view of the year and publications and original investigations and summaries. Journals of emphasis included Pediatric Critical Medicine, Critical Care Medicine, the Blue Journal, New England Journal of Medicine as well, JAMA, and Lancet. I then hand-searched each of the table of contents of some of the most cited articles and then looked at those as well and limited to 2021. Of note in this virtual world where we are, Twitter had a lot of emphasis in a lot of these articles and the way they were the most cited and the way they were most downloaded, so I also included those as well. In 2021, there were three major themes that came out of the research, and not shockingly, COVID-19 was one of the large ones. Not only COVID-19 and severe COVID-19 infection leading to critical illness, but also the surgence of multi-inflammatory syndrome in children or MIS-C and differentiating between the two, as well as big data and public health approaches to understanding the impact of COVID-19 in our pediatric intensive care units. Additionally, there's discussion of paradigm shift, particularly looking at blood culturing in the pediatric ICU and ventilation and sedation strategies in the PICU. Also, PICU outcomes had its time in 2021, looking at the installation of post-PICU clinics and then firearms and how firearms may impact a child's recovery and firearm injuries. So to get started, I'm going to talk about COVID-19 and multi-inflammatory syndrome in children and how we got here. So in early 2020, obviously, COVID-19 took stage, and MIS-C kind of came a little bit later, but we're trying to tease between the two. So one of the most downloaded in pediatric critical care medicine was this article by Drs. Remesberg et al., looking at caring for critically ill children suspected or proven COVID-19 infection, recommendations by the Scientific Sections Collaborative of the European Society of Pediatric and Neonatal Intensive Care, or ESNIC as they're better known, and it gives a European perspective. They synthesized existing literature and an in-depth search from July 2020, and they found some practice implications and recommendations for COVID-19 and mechanical ventilation. They proposed treatment options for COVID-19, and the interesting thing of this was in the early days, they differentiated between COVID-19 and MIS-C and the therapies for those, as well as recommendations to reduce clotting, particularly in CRRT, nutritional support, and anti-inflammatory viral and bacterial treatments, as well as a holistic approach using nursing, spiritual, and transport special considerations. Of note, this is one of their main figures from the article, differentiating between COVID-19 and multi-inflammatory syndrome in children infection. As you can see on the left-hand side, many of the associated features of COVID-19 were increased CRP, some white cell, blood cell counts, but again, non-obligatory in these children, and clinical features were mainly respiratory in presentation. As you can see, a lot of bronchopneumonia, and there was normal cardiac function. As we get into multi-inflammatory syndrome in children, we see here that there are a host of symptoms that happen in these children, and viral testing can be in the absence of SARS-CoV-2 swabs. They could be negative or they could be positive by IgG antibody. As we can see here, laboratory features, there's widespread inflammation, not only identified by CRP and neutrophilia, lymphothenia, and then clinical features are widespread. Particularly, this article highlights the involvement of cardiogenic shock, looking at heart failure and left ventricular dysfunction with or without coronary dilation, looking at vasoplegic shock, which is normal cardiac function, again, with or without coronary dilation, and then normal cardiac function with coronary artery dilation or aneurysm. As you can see here, compared to COVID-19, which looked at recommendations for remdesivir or corticosteroids, there is a plethora, including IVIG, corticosteroids, interleukin inhibitors, that may help with these treatment therapies. Moving on, we move on to differentiating MIS-C versus non-MIS-C COVID-19 PICU patients. Again, this is another one of those PCCM, most downloaded from July 2020 by Tripathi et al., looking at COVID-19-associated PICU admissions, a report from the Society of Critical Care Medicine Discovery Network, Viral Infection and Respiratory Illness, Universal Registry Study. The idea here was to compare clinical characteristics and outcomes of severe COVID-19 with or without multi-inflammatory syndrome in children. This was a retrospective cohort study of 38 PICUs who were enrolled in this registry. And ideally, again, it was to compare the clinical characteristics of these two related illnesses. The secondary objective was to identify explanatory factors associated with the outcome of critical illness defined by a composite index of in-hospital mortality score and organs of system support. This index included positive pressure ventilation, vasoactive inotropic support, also looked at pulmonary vasodilator therapies and extracorporeal life support, and then also new renal replacement therapies. What was found in this study is about 43% of children had multi-inflammatory syndrome, and overall mortality was about 4%. MIS-C patients were more likely to be a younger cohort. They were black and presented with fever, abdominal pain, and they were less likely to have comorbidities as the COVID-19 patients did. About 42% of these children experienced critical illness requiring a PICU admission, and more than two comorbidities was associated with the greater odds of critical illness in this cohort. Moving on, a study by Dr. Feldstein et al. characterized outcomes of U.S. children and adolescents with multi-system inflammatory syndrome in children, compared again with severe acute COVID-19 infection. This was to compare clinical characteristics and outcomes of severe MIS-C versus COVID-19, and this was a cross-sectional study of COVID-19 patients from March 14 to April 3, 2020, in the inception of COVID, with a follow-up at 46 hospitals. Follow-up occurred through April 10, so about a week after. What was found here was that about 52% of the participants were male, the median age was 13, and 73% had respiratory involvement, whereas about a quarter of them had more than just pulmonary involvement and failure. Therapies included about a third of them having mechanical ventilation, only 2% requiring ECMO. Targeted therapies were received by about 61% of these children, and the most commonly used therapy was hydrochloroquine at 75%. Of those, 11 of them received hydrochloroquine alone, whereas 10 received it in combination. And the outcomes were that mortality rate overall between MIS-C and the COVID-19 population was 4%. 31% were still hospitalized at the follow-up on March, sorry, April 10th. And of those that were still hospitalized, 20% required mechanical ventilation, and less than 1% required ECMO. Multi-inflammatory syndrome in children, this was by Sun et al. And this was actually included in the New England Journal of Medicine, and it was to compare clinical characteristics and outcomes of COVID as well. It was a case series of children hospitalized from March to October 2020 at 66 hospitals, a little over 1,000 children. And of these children, 48% were diagnosed with MIS-C. So as you can see a trend here, it's kind of half and half between who was COVID-19 and who was MIS-C. MIS-C patients were likely between 6 to 12 years old and had more cardio-respiratory, cardiovascular, amicocutaneous, without great respiratory involvement, some left ventricular failure, and coronary artery aneurysm normalized within 30 days of initial infection. In MIS-C patients, there was increased neutrophil to lymphocyte ratio, and CRP and platelets were decreased. About 75% of these patients with MIS-C and about 2% with COVID-19 were made to the PICU. And again, mortality remains low with about 2% in both groups in this cohort. Now getting into data-driven therapies and trying to identify different phenotypes and sub-phenotypes, GIVA et al. in a data-driven clustering identifies features distinguishing multisystem inflammatory syndrome from acute COVID-19 infection in children and adolescents. This was in Lancet and Big Data in August 2021 to discover these sub-phenotypes using unsupervised clustering of children less than 21 years of age with COVID-19 from March to December 2020. They revealed three separate clusters looking at MIS-C and COVID-19. In cluster one, 92% of patients had MIS-C. They were previously healthy, had a mean age of 72 years, and there was CV and or mucotinous involvement. Inflammatory biomarkers were elevated, and they had negative PCR. Whereas cluster two, 27% of these children had MIS-C. They did have preexisting conditions. They were a similar age, so they're similar to be about seven years old. They had chest X-ray infiltrates, whether that be bilateral or unilateral, and they had a positive PCR. In cluster three, there were about 19% that were labeled as having MIS-C. They were a younger cohort where the mean age was 2.8 years of age, had positive PCR, and had decreased inflammation compared to the other two clusters. Such information could help find sub-phenotypes early, looking at treatment courses and therapies. An article by Dr. Maddox et al. looks at the impact of strict public health restrictions on pediatric critical illness. This looked at the overall framework and characteristics of the PICU during COVID-19 infection, not just those who were COVID-19 infected. So they characterized the impact of public health interventions, such as masking and social distancing, on the volume and characteristics of the PICU. It was a retrospective cohort study of six PICUs in the early COVID days from February to May 2020, compared to baseline statistics from 2017 to 2019. They found that admission rates in patient days during stay-at-home orders had a younger, there was less younger children who were admitted. There was less respiratory illness or an infectious illness that were admitted during this time. Increased incidence of poisoning and endocrinopathies. And decreased patients' need for required noninvasive ventilation. Overall, reductions in PICU admissions suggest that much of pediatric critical illness in younger children may be preventable through targeted public health strategies, especially those for respiratory and infectious illnesses. Moving on to paradigm shifts, we know that there has been some changes in practice, as there is yearly, but particularly I'm going to highlight some in sedation ventilation and blood cultures. In an original article by Blackwood et al., we look at in JAMA the effect of sedation and ventilation liberation protocol versus usual care and duration of invasive mechanical ventilation in pediatric intensive care units, or the SANDWICH trial. This is a randomized controlled trial. It included 18 pediatric ICUs in the UK, looking at the protocolized intervention of sedation and ventilation liberation management and protocol versus usual care. As you can see here, the primary outcome was duration of invasive mechanical ventilation. And as you can see, the protocol intervention, children experienced about 64.8 hours time in extubation versus usual care, which is 66.2 hours. This adjusted mean difference was significant. It was less than 6.1 hours. So, this is very significant to know that the sedation and ventilation liberation protocols may be useful in duration of mechanical ventilation. Blood culture guidelines, this was published in PCCM, looking by Woods Hill et al., consensus recommendations for blood culture use in critically ill children using a modified Delphi approach. They created a consensus recommendation on when to avoid blood cultures and prevent overuse in the PICU. The recommendations found are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children. It used 14 PICUs enrolled in the Bright Start Collaborative, and they included 19 recommendations, as you can see here, based on an algorithm of whether or not the child has fever without signs of sepsis, or if they do have signs of sepsis, whether it's a new fever or persistent fever, with guidelines for institutions. And lastly, outcomes research had its say in 2021 as well. Namely, one of the most downloaded in PCCM in November 21 was outcomes of children with firearm injuries by Dr. Baggio et al. in the United States. The goal of this study was to analyze outcomes of children admitted to the PICU with firearm injury, and it was a retrospective review using the virtual PICU system, or VPS, from January 2009 to December 2017 of children admitted to the PICU. What was found here was that about 12% of children died in the PICU, and 55% of those who were admitted were about 13 to 18 years old, so they were of adolescent age. Cause of firearms is majorly unintentional, with assault at about one in five children in suicide ideation, about 7%. Demographics were majorly males, and Black was about 45%, with White being 27%, Hispanic 12%. Children who died in the PICU are more likely to be admitted for suicidal ideation, and high morbidity at discharge, as evidenced by POPC and PCPC changes, including neurological changes. It's feasible to understand the impact of health conditions, like firearm injury on the society, and more research has been done by this team that may help pediatric victims of firearm violence. Moving forward, by Ducharme-Criviar, we have PICU follow-up clinic patient and family outcomes two months after discharge. And this was looking at, as we know, post-intensive care syndrome, looking to understand in a cohort at two months after discharge of children who were either mechanically ventilated with, they were meant to be PICU for more than four, equal, sorry, four or more days, and they were receiving mechanical ventilation invasively for more than two days or more, and then, or they were receiving non-invasive mechanical ventilation for four days or more. Findings found that the average length of stay was 28.5 days, the median of seven days, and of these children, about 61% were intubated. Post-PICU symptoms included sleep disturbance in about one in five of them, feeding difficulties, fatigue, and voice change in Schrader were common as well. Neurocognitively, there was about a quarter of them that had school delays, nearly half had gross motor function, fine motor dysfunction, delays in problem solving, and about a third in personal social function, about half. And as we know, post-intensive care syndrome and overall the PICU hospitalization very much affects families as much as it does children, and what we found is, and what they found, sorry, is that 14% had financial issues, nearly half had anxiety, and about a third had depression. So, that wraps up our three main themes of COVID-19, MISC, paradigm shifts, as well as post-PICU, and I want to get into the rapid fire round to just kind of to discuss some notable mentions that may have not been in the most downloaded or the most cited, but were frequently used and have helped to shift the way our PICUs operate. Deep et al. created a hybrid model of pediatric and adult critical care during the COVID-19 surge, the experience of two tertiary hospitals in London and New York. As you'll recall, a lot of pediatric ICUs and practitioners had to shift to taking care of adult patients and vice versa. King's College Hospital in the UK and Morgan Stanley, they created a model which allowed for adult critical care to be happening in the PICU while maintaining essential services for critically ill children. Yang et al. did the implementation of an analgesic sedation protocol, which is associated with midazolam usage in the PICU. What they found was primary agents of dex with intermittent opioids significantly decreased midazolam use in mechanically ventilated patients, though there was no difference in ventilator free days, length of stay, unplanned or failed extubations, and cardiorespiratory events. In Chuang et al., the prevalence of acute rehabilitation for kids in the PICU, a Canadian multi-centre point prevalence study, which is PARCC PICU, and mobility, what they found was mobility was most often facilitated by the nurse or family. They're looking at interdisciplinary care, and family presence alone was independently associated with out of bed in these children. Carsey et al. did compliance with antibiotic guidelines for suspected ventilator-associated infection, or the VANE2 study, which found that there's poor adherence to guidelines in 22 New England PICUs. After guideline implementation, only about 27% of those recommended to stop antibiotics therapy actually stopped the therapy. So, we know that this did not improve outcomes or increased length of stay. And then Black et al. did the timing and clinical significance of fluid overload and pediatric acute respiratory distress syndrome. Looked at fluid overload after day four of R associated with worst outcomes, which increased angiopoietin-2, which predicted fluid overload. And lastly, I'd be remiss in not mentioning Dr. Hector Wong, who his lifetime's work looking at biomarkers for existing risk of hospitalizations and long-term quality of life morbidity after surviving pediatric septic shock. He used his preserved biomarkers looking at the LAP study, and what was found that preserved biomarkers estimated risk of persistent serious deterioration of health-related quality of life up to three months. And Van Lurchen et al. the diaphragm activity pre- and post-extubation and ventilated critically ill infants and children measured with transcutaneous electromyography. And what was found here was that failed extubation led to increased level of diaphragm activity pre- and post-extubation was associated with. And I want to leave you with that, and this has been a great year for pediatric critical care. There's been a lot of research and a lot of interest and a lot of different topics. And I'm just so excited that, you know, we are moving in a forward direction, and I look forward to seeing you all at SCCM in 2023 in New Orleans. And as they say, les say les, bon tour, roulez. Thank you. Hi, my name is Nora Coleman. I am a pediatric intensivist at Children's Healthcare of Atlanta with a passion for quality improvement and simulation. I'm excited to be here today to talk about quality, safety, and education in pediatric critical care medicine. The role of quality improvement has been long recognized as a strategy to drive change and impact patient outcomes. Quality improvement requires a collaborative and combined effort of healthcare professionals, especially frontline workers, as well as patients, their families, researchers, leaders, and educators. In the past decade, there's been a large increase in PICU quality improvement work. These interventions cover a wide range of approaches with a variety of targets. Steepe describes six characteristics of quality. These improvements should be safe, timely, effective, efficient, equitable, and patient-centered. As described in a recent paper by Inada et al., the most common clinical targets of QI interventions were healthcare-associated infections, handoffs, rounds, sedation and pain delirium, and medication safety, as well as unplanned excavations. Many studies were related to the safety effectiveness of these interventions. Few addressed timeliness and patient-centeredness, and almost none published in PEDCCM addressed equity. The PICU environment is a highly complex environment and is challenged by constantly changing workflows and the complex interactions between people and elements of their work system. Ability to maintain high safety and quality of care requires a level of adaptive expertise to meet the demands of a high-stress environment where there are rapid changes in patient care needs and many competing priorities. In such a complex clinical environment, there are many challenges and barriers to implementing and sustaining improved quality of care. These barriers include team members that resist new and innovative quality improvement initiatives. There also is a requirement to change professional practice. It is important to understand how interprofessional staff perspectives impact the ability to sustain quality improvement initiatives. Understanding things like staff buy-in, family engagement, the limitations in practical implementation and ability to safely and effectively integrate into workflow, how to bundle initiatives with other care elements, ability to understand resource constraints and utilizations, and ability to establish consistency across provider care delivery. Work as imagined does not always equate to work as done, and understanding these limitations and nuances in unit-specific culture and the micro-work system is essential to optimally implement and effectively integrate QI initiatives. Elucidating barriers early on are essential to the facilitation of solutions that address barriers in implementation and promote sustainability and success. There are also many challenges in reporting of QI research. The publication of quality improvement research studies has increased in peds' critical care medicine over the past 10 years. However, the quality and reporting of QI-focused research is variable, highlighting an opportunity for the community to improve upon our approach to reporting quality and work. Limitations to extrapolate learning, improve patient outcomes, and demonstrate return on investment are impacted by failure to apply rigorous methodology, address the local problem in context, failure to describe problem drivers and PDSA cycles, and incorporate statistical analysis. In a study also done by Inada et al. in 2021 PED-CCM, there was a conduction of extensive review of published QI work. In 2,400 published manuscripts, 6.5% of PED-CCM papers qualified as legitimate QI based on the quality improvement minimum quality criteria set, and only 6% of those papers referenced SQUIRE guidelines. This study by Bartman et al. published in PED-CCM in 2021 discusses that we must improve quality-focused research by raising the quality of QI project execution, manuscript writing, and peer review. With a focus on what should be and how we get there, our patients everywhere will benefit. Below are some of the requirements for QI research described in this paper. First, we'll talk about problem description. QI projects must include the rationale and discuss where we are and where we are going. Next, it's important in the context to consider and report individual specifics at the institution where the QI initiative was being implemented. It is important to apply the model for understanding success in quality, ensuring that the context is high-quality research. It is also important to discuss that how we measure quality improvement data. There should be a precise description of what is and what is not accounted for. This requires at least one process and one outcome measure to link intervention with outcome. In the analysis portion of manuscript writing, we must analyze and report QI data using things like interrupted time series or process control charts to display normal variation in system performance over time. And finally, in the interpretation of data, we must discuss why the intervention did or did not work, why the change magnitude was larger or smaller than observed, what was the degree of improvement, what the degree of improvement reveals about the interplay between interventions and system. In order to raise the bar on the quality of published QI data, there's three components, QI execution, writing, and peer review. Many institutions are now offering training options for practicing faculty. Institutions without such programs should consider developing internal courses or send PICU staff to external courses. All QI publications should adhere to the SQUIRE guidelines and incorporate the majority of the components. Peer reviewers are also instrumental in driving improvement in manuscript quality. Reviewers should critique papers and look for significant work that can be generalizable, work that is novel even when placed in the context of previous work, a well-designed project that incorporates QI science tools and methods, and the SQUIRE guidelining formatting. To review the quality and simulation studies published in PCCM in 2021, I will be focusing on the three papers below and quickly provide a short review of each paper. This study, eSimpler, a dynamic electronic health record integrated checklist for clinical decision support during PICU daily rounds, was this quality improvement study that occurred in a quaternary PICU in an academic freestanding children's hospital. The goal of this study was to design, implement, and evaluate a rounding checklist that was embedded into the electronic health record. This new dynamic checklist was compared to a former static checklist that was used in 2011. Dynamic checklists, as opposed to static ones, not only display data appropriate to a patient's clinical context, such as is the endotracheal tube position relevant for intubated patients, but also provides electronic health record data relevant to the checklist item. These dynamic checklists enhance situational awareness by allowing the comparison of patient's intended care plan with actual care ordered and document. The eSimpler tool was a clinical decision support tool with prompts that displayed relevant data automatically pulled from the electronic health record. eSimpler was implemented for 49,000 patient days over six months. Several checklist-driven processes were measured and studied. These included increased prescription of mechanical or pharmacologic VTE prophylaxis, recognition of renal dysfunction, and central catheter utilization. In conclusion, eSimpler was a dynamic electronic health record informed checklist that required less time to complete and improved certain care process compared with the prior static checklist with limited electronic health record data. In this study, early mobilization in a PICU, a qualitative sustainability analysis of PICU-UP, presented a semi-structured phone interviews to characterize interprofessional staff perspectives of the PICU-UP program. Following data saturation, thematic analysis was performed on interview transcripts. The purpose of this study was to identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program in the PICU. Fifty-two staff members across multiple disciplines were interviewed. Three themes emerged. Those were factors influencing the implementation process, staff perceptions of PICU-UP, and improvements in program integration. In conclusion, three years after implementation, the PICU-UP remained well-received by staff, although there were several barriers that remained relevant, and those were consistent with execution of early mobility, challenges with resource management, sedation decisions, and patient heterogeneity. This study highlights the importance of understanding staff perception in order to identify barriers and develop solutions that can grow and strengthen PICU mobility initiatives. The COVID-19 pandemic influenced medical education and simulation training worldwide. This study, Readiness for and Response to Coronavirus Disease 2019 Among Pediatric Healthcare Providers, the Role of Simulation for Pandemics and Other Disasters, was an international survey study aimed to characterize self-reported efforts by the pediatric simulation community. The survey was sent to 555 individual members of three large international pediatric simulation societies. The study highlighted differences between the intercontinental geographic regions in terms of COVID-19-based simulations and continuation of non-COVID-19 education-based sims. Although most participants in the American region and India initiated educational activities for the care of COVID-19 patients, this was only true for 47% of European respondents. Frequent modifications to existing simulation programs included the use of telesimulation and virtual reality training. Forty-nine percent of institutions discontinued non-coronavirus 2019-related simulation training. In situ simulation was the most prevalent training mode for COVID-19 simulations. This focused on airway management and cardiopulmonary resuscitation. The differences in the use of telesimulation were striking as many resource-rich regions did not adopt their approach as frequently as expected. In conclusion, the swift incorporation of disease-specific sessions and the transition of standard education to virtual or hybrid simulation training modes occurred frequently. This approach depended heavily on local requirements, limitations, and circumstances. In particular, the use of telesimulation allowed education to continue while maintaining social distancing requirements. In summary, quality improvement plays a major role in the outcomes of our pediatric patients. Implementations of quality initiatives depends on understanding local barriers and staff perception and unit-based culture and addressing those limitations to ensure success and sustainability of QI initiatives. As the pediatric critical care community continues to engage in QI-based research, there is an opportunity to raise the bar aiming for higher quality, project execution, rigorous data analysis reporting, and critical peer review.

pediatric critical care medicine

quality improvement initiatives

patient outcomes

barriers and limitations

staff buy-in

family engagement

consistency in care delivery

quality improvement research