<p><strong>OBJECTIVES: </strong>To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams.</p>

<p><strong>DESIGN: </strong>Quasi-experimental; three pairs of control/intervention months: June/July; August/October; November/December.</p>

<p><strong>SETTING: </strong>Single-center, urban, quaternary academic children's hospital with three-member rapid response team: critical care fellow or nurse practitioner, nurse, respiratory therapist. Baseline practice: rapid response team leader reviewed each evaluation with an ICU attending physician within 2 hours after return to ICU.</p>

<p><strong>SUBJECTS: </strong>1) Patients evaluated by rapid response team, 2) rapid response team members.</p>

<p><strong>INTERVENTIONS: </strong>Implementation of a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient's bedside and the attending in the ICU.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>As a marker of efficiency, the primary provider outcome was time the rapid response team spent per patient encounter outside the ICU prior to disposition determination. The primary patient outcome was percentage of patients requiring intubation or vasopressors within 60 minutes of ICU transfer. There were three pairs of intervention/removal months. In the first 2 pairs, the intervention was associated with the rapid response team spending less time on rapid response team calls (June/July: point estimate -5.24 min per call; p &lt; 0.01; August/October: point estimate -3.34 min per call; p &lt; 0.01). During the first of the three pairs, patients were significantly less likely to require intubation or vasopressors within 60 minutes of ICU transfer (adjusted odds ratio, 0.66; 95 CI, 0.51-0.84; p &lt; 0.01).</p>

<p><strong>CONCLUSIONS: </strong>Early in the study, more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU, a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer. These findings provide evidence that early ICU attending involvement via telemedicine can improve efficiency of rapid response team evaluations.</p>

<p><strong>OBJECTIVES: </strong>Standard metrics for evaluating rapid response systems (RRSs) include cardiac and respiratory arrest rates. These events are rare in children; therefore, years of data are needed to evaluate the impact of RRSs with sufficient statistical power. We aimed to develop a valid, pragmatic measure for evaluating and optimizing RRSs over shorter periods of time.</p>

<p><strong>METHODS: </strong>We reviewed 724 medical emergency team and 56 code-blue team activations in a children's hospital between February 2010 and February 2011. We defined events resulting in ICU transfer and noninvasive ventilation, intubation, or vasopressor infusion within 12 hours as "critical deterioration." By using in-hospital mortality as the gold standard, we evaluated the test characteristics and validity of this proximate outcome metric compared with a national benchmark for cardiac and respiratory arrest rates, the Child Health Corporation of America Codes Outside the ICU Whole System Measure.</p>

<p><strong>RESULTS: </strong>Critical deterioration (1.52 per 1000 non-ICU patient-days) was more than eightfold more common than the Child Health Corporation of America measure of cardiac and respiratory arrests (0.18 per 1000 non-ICU patient-days) and was associated with &gt;13-fold increased risk of in-hospital death. The critical deterioration metric demonstrated both criterion and construct validity.</p>

<p><strong>CONCLUSIONS: </strong>The critical deterioration rate is a valid, pragmatic proximate outcome associated with in-hospital mortality. It has great potential for complementing existing patient safety measures for evaluating RRS performance.</p>

<p><strong>OBJECTIVES: </strong>Hyperglycemia is common and may be a risk factor for nosocomial infections, including central catheter-associated bloodstream infections in critically ill children. It is unknown whether hyperglycemia at the time of acquiring central catheter-associated bloodstream infections in pediatric critical illness is associated with worse outcomes. We hypothesized that hyperglycemia (blood glucose concentration &gt; 126 mg/dL [&gt; 7 mmol/L]) at the time of acquiring central catheter-associated bloodstream infections (from 4 d prior to the day of first positive blood culture, i.e., central catheter-associated bloodstream infections) in critically ill children is common and associated with ICU mortality.</p>

<p><strong>DESIGN: </strong>Retrospective observational cohort study.</p>

<p><strong>SETTING: </strong>Fifty-five-bed PICU and 26-bed cardiac ICU at an academic freestanding children's hospital.</p>

<p><strong>PATIENTS: </strong>One hundred sixteen consecutively admitted critically ill children from January 1, 2008, to June 30, 2012, who were 0-21 years with central catheter-associated bloodstream infections were included. We excluded children with diabetes mellitus, metabolic disorders, and those with a "do not attempt resuscitation" order.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>The study cohort had an overall ICU mortality of 23%, with 48% of subjects developing hyperglycemia at the time of acquiring central catheter-associated bloodstream infections. Compared with survivors, nonsurvivors experienced more hyperglycemia both at the time of acquiring central catheter-associated bloodstream infections and subsequently. Median blood glucose at the time of acquiring central catheter-associated bloodstream infections was higher in nonsurvivors compared with survivors (139.5 mg/dL [7.7 mmol/L] vs 111 mg/dL [6.2 mmol/L]; p &lt; 0.001) with 70% of nonsurvivors experiencing blood glucose greater than 126 mg/dL (&gt; 7 mmol/L) during the 7 days following central catheter-associated bloodstream infections (in comparison to 45% of survivors; p = 0.03). After controlling for severity of illness and interventions, hyperglycemia at the time of acquiring central catheter-associated bloodstream infections was independently associated with ICU mortality (adjusted odds ratio, 1.9; 95% CI, 1.1-6.4; p = 0.03), in addition to other risk factors for ICU mortality (vasopressor use and severity of organ dysfunction).</p>

<p><strong>CONCLUSIONS: </strong>Hyperglycemia at the time of acquiring central catheter-associated bloodstream infections is common and associated with ICU mortality in critically ill children. Strategies to monitor and control blood glucose to avoid hyperglycemia may improve outcomes in critically ill children experiencing central catheter-associated bloodstream infections.</p>

<p><strong>OBJECTIVES: </strong>Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs.</p>

<p><strong>METHODS: </strong>We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs.</p>

<p><strong>RESULTS: </strong>Patients who had CD cost $99,773 (95% confidence interval, $69,431 to $130,116; P &lt; .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team with concurrent responsibilities to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, equivalent to a reduction of 3.5 CD events.</p>

<p><strong>CONCLUSIONS: </strong>CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.</p>