Faculty Bibliography

OBJECTIVES/SPECIFIC AIMS: To build a multisite de-identified database of female adolescents, aged 12-21 years (January 2011-December 2012), and their subsequent offspring through 24 months of age from electronic health records (EHRs) provided by participating Community Health. METHODS/STUDY POPULATION: We created a community-academic partnership that included New York City Community Health Centers (n=4) and Hospitals (n=4), The Rockefeller University, The Sackler Institute for Nutrition Science and Clinical Directors Network (CDN). We used the Community-Engaged Research Navigation model to establish a multisite de-identified database extracted from EHRs of female adolescents aged 12-21 years (January 2011-December 2012) and their offspring through 24 months of age. These patients received their primary care between 2011 and 2015. Clinical data were used to explore possible associations among specific measures. We focused on the preconception, prenatal, postnatal periods, including pediatric visits up to 24 months of age. RESULTS/ANTICIPATED RESULTS: The analysis included all female adolescents (n=122,556) and a subset of pregnant adolescents with offspring data available (n=2917). Patients were mostly from the Bronx; 43% of all adolescent females were overweight (22%) or obese (21%) and showed higher systolic and diastolic blood pressure, blood glucose levels, hemoglobin A1c, total cholesterol, and triglycerides levels compared with normal-weight adolescent females (p<0.05). This analysis was also performed looking at the nonpregnant females and the pregnant females separately. Overall, the pregnant females were older (mean age=18.3) compared with the nonpregnant females (mean age=16.5), there was a higher percentage of Hispanics among the pregnant females (58%) compared with the nonpregnant females (43.9%). There was a statistically significant association between the BMI status of mothers and infants' birth weight, with underweight/normal-weight mothers having more low birth weight (LBW) babies and overweight/obese mothers having more large babies. The odds of having a LBW baby was 0.61 (95% CI: 0.41, 0.89) lower in obese compared with normal-weight adolescent mothers. The risk of having a preterm birth before 37 weeks was found to be neutral in obese compared with normal-weight adolescent mothers (OR=0.81, 95% CI: 0.53, 1.25). Preliminary associations are similar to those reported in the published literature. DISCUSSION/SIGNIFICANCE OF IMPACT: This EHR database uses available measures from routine clinical care as a "rapid assay" to explore potential associations, and may be more useful to detect the presence and direction of associations than the magnitude of effects. This partnership has engaged community clinicians, laboratory, and clinical investigators, and funders in study design and analysis, as demonstrated by the collaborative development and testing of hypotheses relevant to service delivery. Furthermore, this research and learning collaborative is examining strategies to enhance clinical workflow and data quality as well as underlying biological mechanisms. The feasibility of scaling-up these methods facilitates studying similar populations in different Health Systems, advancing point-of-care studies of natural history and comparative effectiveness research to identify service gaps, evaluate effective interventions, and enhance clinical and data quality improvement.

A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).

BACKGROUND: To introduce an updated version of the original Therapeutic Intervention Scoring System (TISS) applicable to critically ill children (TISS-C). This version was designed to assess patient acuity and nursing workload (NW) and to determine a relationship between such assessment and the incidence of adverse events. METHODS: Reviewing previous versions of TISS, an updated TISS-C was developed. Items inapplicable to pediatric critical care were eliminated; items current to critical care were added; and items still valid were edited. The point system accounts for the wide range of care provided. Random patients from a predetermined period had TISS-C scores calculated. The TISS-C scores were also calculated on patients with documented adverse events. Baseline scores were compared with scores of patients in whom adverse events had occurred. We determined the pediatric intensive care unit (PICU) NW to be the product of the TISS-C score and the patient-nurse ratio (PNR). RESULTS: One hundred twenty-five random patients had a mean TISS-C of 14.6 +/- 11.8. Patients with any adverse event (98) had a TISS-C of 19.9 +/- 11.6 (P < .05). Using our PICU mean PNR of 1.4 (20 patients/14 nurses), the NW for patients with more severe events was 33.6 +/- 15.9. CONCLUSIONS: Critically ill pediatric patients are more vulnerable to experience adverse events when their derived NW values are high. It is postulated that a critical NW exists, where adverse events are more likely to occur.

BACKGROUND: Severe pediatric asthma, if not immediately and aggressively treated, may progress to acute respiratory failure requiring mechanical ventilation in the pediatric intensive care unit (PICU). Intravenous (IV) terbutaline, a beta2 agonist, is dispensed when the initial treatment does not improve the clinical condition. OBJECTIVE: To investigate the influence of early initiation of IV terbutaline on the incidence of acute respiratory failure requiring mechanical ventilation in severe pediatric asthma. METHODS: A retrospective chart review was conducted of 120 subjects (35 patients from an outside hospital emergency department [ED] with late start of terbutaline and 85 patients from the authors' hospital ED with early initiation of IV terbutaline) admitted to the PICU with severe asthma treated with continuous IV terbutaline. Responses to terbutaline treatment and outcomes were evaluated. RESULTS: Patients transported from outlying hospital EDs had shorter pre-PICU mean durations of IV terbutaline than those transferred from the authors' ED (0.69 +/- 1.38 and 2.91 +/- 2.47 hours, respectively, P = .001). Twenty-one of 35 patients (60%) from outlying EDs required mechanical ventilation compared with 14 of 85 patients (16%) from the authors' ED (P = .001). Durations of pre-PICU terbutaline infusion for patients requiring mechanical ventilation were significantly shorter than those with no such requirement (P = .015). CONCLUSION: The results of the present study, conducted in the largest number of subjects to date, suggest that early administration of continuous terbutaline in the ED may decrease acute respiratory failure and the need for mechanical respiratory (invasive and noninvasive) support in severe pediatric asthma.

Mortality rates for sepsis and septic shock have not improved in the past decade. The Surviving Sepsis Campaign (SSC) guidelines released in 2012 emphasize early recognition and treatment of sepsis, in an effort to reduce the burden of sepsis worldwide. This series of review articles will discuss the pathophysiology of sepsis; comorbidities, such as multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and endocrine issues; and finally, management of sepsis and septic shock.

Introduction: Severe pediatric asthma, if not immediately and aggressively treated, may progress to acute respiratoryfailure requiring mechanical ventilation in the PICU. Hypothesis: Timely initiation of IV terbutaline infusion in severe asthma reduces the incidence of acute respiratory failure. Methods: A retrospective chart review of patients admitted to the PICU with severe asthma and received continuous intravenous infusion of terbutaline was conducted. The patients were divided into 2 categories; patients who were transported to our PICU from outlying emergency departments (ED) and patients who were transferred from our ED to the PICU. We evaluated these patients' responses to terbutaline and outcome. Results: One hundred and twenty (120) patients were studied, 42 females and 78 males with a mean age of 6.8 y +/- 4.2 y. One hundred eighteen (118) patients survived and 2 patients died (brain death) in the PICU from an earlier episode of cardiac arrest at home. Thirty-five (35) patients were transferred from outlying ED(s) and 85 patients from our own ED. Seventy-six patients (76) had their terbutaline infusion started prior to their arrival in PICU and 44 patients had it started after. Seventy-six patients (63%) did not require respiratory mechanical support and were breathing spontaneously throughout their course, 21 patients (17%) received BiPAP and 23 patients (19%) required tracheal intubation and mechanical ventilation. The periods of Pre-PICU terbutaline infusion were 2.61 h +/- 2.47 h, 2.04 h +/- 2.54 h and 0.97 h +/- 1.59 h, respectively (p = 0.015). Patients transported from outlying hospitals' ED(s) had shorter mean durations of IV terbutaline than those transferred from our ED, measuring 0.69 h +/- 1.38 h and 2.91 h +/- 2.47 h, respectively (p = 0.000). Conclusions: Early administration of continuous infusion of terbutaline in ED may reduce the need for mechanical respiratory (invasive and non-invasive) support in severe pediatric asthma. Patients who were transferred from outlyi!

Purpose: Children are frequently the victims of both natural disasters and specific acts of terror; however there is a lack of organized pediatric emergency preparedness planning for mass casualty incidents (MCI). To address these gaps, a large urban Department of Health (DOH) established a federal grant funded Pediatric Disaster Coalition (PDC), which established guidelines for creating Pediatric Critical Care (PCC) surge plans and is currently assisting hospitals in implementing them. This city with a population of over 8 million people (approximately 25% of whom are < 18 years of age) has 25 hospitals with PCC services with a total of 235 PICU beds. Recently, there was a failed attempt to detonate a car bomb on a Saturday evening in the center of this large city. Had the bomb exploded, given the location and time of day, it is probable that many of the critically injured victims would have been children. Methods: One week following the event we conducted a telephone survey of PCC leadership at 9 hospitals with PCC capability in the immediate area to determine the number of vacant PCC beds at the time of the event, before activation of any surge plans. Results: At the time the car bomb was discovered, these 9 hospitals with a total of 141 PCC beds (60% of cities total 235 beds) had 29 vacant pediatric critical care beds. Had the event resulted in many pediatric casualties, the existing PCC vacant beds at these hospitals would not have been sufficient. Activating newly developed PDC surge plans at 5 of these hospitals would have added 92 surge beds to the 29 available PCC beds for a total of 121. Conclusion: In order to provide PCC to a large number of victims following an MCI it is crucial that hospitals prepare PCC surge plans. Once all 25 hospitals in this city complete surge plans it is estimated there should be an ability to add over 200 PCC surge beds, potentially increasing PCC surge capacity by 85%. Plans are currently being developed to drill and evaluate these PDC surge plans