e6 SECTION XV Pediatric Critical Care Board Review Questions Rationale Addressing disruptive behavior directly can be uncomfortable and challenging but is essential in maintaining morale and mo mentum[.]
e6 S E C T I O N XV Pediatric Critical Care: Board Review Questions Rationale Addressing disruptive behavior directly can be uncomfortable and challenging but is essential in maintaining morale and momentum when leading and implementing change initiatives Depending on the situation, the specific approach can be preventative and informal (answer B), accusatory (answer D), or punitive (answers A and E) However, in a situation in which the disruptive individual has cancelled previously scheduled meetings, has not commented on the strengths and weaknesses of the guideline, and is interfering with constructive interprofessional team communication and collaboration, a direct confrontation that emphasizes a shared common goal (improving patient care) and outlines unacceptable behavior that still leaves room for education (review of the guideline development process and observed outcomes) and dialogue (specific solicitation of guideline critique) can preserve relationships and avenues for partnership on future projects Chapter 7: Fostering a Learning Healthcare Environment in the Pediatric Intensive Care Unit Which of the following elements provides a foundation for a learning healthcare environment? A Best practice B Clinical research C Professionalism D Shared educational model Preferred response: C Rationale The elements of professionalism, namely accountability, respect, and teamwork, need to be consistently present in order for best practice, clinical research, and shared education to occur Which of the following accurately characterizes gender disparity in the medical workspace? A About 10% of female physicians have experienced sexual harassment B A significant gender pay gap persists in medicine C Male and female physicians are both likely to be introduced as “doctor.” D Women receive similar research start-up funding when compared to men Preferred response: B Rationale 30% of female physicians have experienced sexual harassment Women receive significantly less research start-up funding when compared to men Male physicians are more likely to be introduced as “doctor,” compared to female physicians In addition, women are less likely to be first authors in top tier journals; women are less likely to be included on expert guideline consensus panels; there are fewer women in leadership positions, even in pediatrics; and there are fewer women full professors as compared to men 3 Which of the following characteristics of clinical standard work is correct? A Amplifies occurrence of nuisance variables B Complicates communication among providers C Establishes a baseline for continuous improvement D Increases waste transiently with implementation Preferred response: C Rationale Standardization utilizing clinical standard work facilitates identifying and eliminating waste, communicating between providers, establishing a baseline for continuous improvement, and minimizing noise/controlling for nuisance variables Standardization represents the foundation for iterative improvement, and without standardization, measurements of improvement are not possible Which of the following outcomes has been reported in a doseresponse fashion as a function of proportional compliance with the ICU Liberation ABCDEF bundle elements? A Decreased incidence of anemia requiring transfusion B Decreased ventilator-associated lung injury C Improved ICU and hospital survival D Increased proportion of rapid eye-movement sleep Preferred response: C Rationale Two independent cohort analyses demonstrated that proportional compliance with ABCDEF bundle elements resulted in significant and dose-related improvements in patient-centered, clinically meaningful outcomes such as survival, duration of mechanical ventilation, neurological organ dysfunction (i.e., delirium and coma), use of physical restraints, ICU readmission rates, and discharge disposition of ICU survivors Anemia, ventilator-associated lung injury, and sleep quality data have not been published Which aspect of simulation in an interdisciplinary teaching model is particularly effective? A Real time debriefing B Role playing C Systems thinking D Teamwork practicing Preferred response: A Rationale All activities related to simulation-based education are important, but real-time team debriefing around critical events (doing in context) represents a particularly effective interdisciplinary (simulation) teaching modality In addition to identification of best available evidence to support best practice, what is the other benefit of a learning healthcare environment? A Encouraging empiric treatment modalities B Facilitating craftsman care attitude C Promoting wellness and resiliency D Training basic researchers Preferred response: C CHAPTER 136 Board Review Questions Rationale The second, sometimes less obvious benefit of a learning healthcare environment is promoting wellness and resiliency among critical care providers Participation of the interdisciplinary team in shared education and research/quality improvement activities provides opportunities for critical care providers to debrief and reflect, to provide mutual support, and to reinvigorate a sense of purpose Chapter 8: Challenges of Pediatric Critical Care in Resource-Poor Settings Which of the following is the leading cause of childhood deaths under the age of years in low-middle income countries? A Diarrheal illnesses B Lower respiratory illnesses C Malaria D Neonatal problems E Road traffic injuries Preferred response: D Rationale The majority of childhood deaths under the age of years in lowand middle income countries are related to neonatal problems (34%), followed by lower respiratory (16%) and diarrheal illnesses (10%), as well as malaria (7%) Road traffic injuries play an important role in children to 14 years old You are the attending consultant in a tertiary care center in a low-middle income country The unit is equipped with facilities for mechanical ventilation (1 available ventilator), intermittent arterial blood gases, vasopressors, intermittent blood products You are on call, and there are two patient calls: The first call is from the casualty senior resident for an 11-yearold child with chronic liver disease with pneumonia of days duration with pediatric acute respiratory distress syndrome (PARDS) requiring mechanical ventilation and monitoring The second call is for a child admitted in the pediatric ward A colleague of yours is requesting shifting this 10-yearold child with a rare genetic disorder, who he followed since birth to the ICU with septic shock, PARDS, and multiorgan dysfunction The child is also being referred from the ministry of health Which of the following policies regarding admission to PICU are to be considered while deciding admissions in units in low resource settings? A Chronological order in which PICU requests are made not matter B Optimization of overall benefit that could result from use of PICU resources C Preference is to be given for requests made by the central and state health authorities or hospital administration D The trainee can decide “who to admit” or “who not to admit’” without discussion with the attending physician Preferred response: B Rationale In resource limited countries, many children not have access to ICUs With a growing demand for intensive care and availability of limited resources, having policies for ICU admission therefore is of significant importance in such settings Guidelines available for admission and discharge policies from high income countries e7 may not be applicable to low- and middle-income countries with high burden of mortality from acute illnesses However, the broad principles that could be adopted based on the patient population and resource availability have been discussed by Argent et al At Red Cross War Memorial Children’s in South Africa, for example, general principles for PICU admission are the following: • Children will be considered for admission in terms of the chronological order in which that request is made • Preference will not be given to children from the Red Cross War Memorial Children’s Hospital In fact, where possible, preference will be given to children who are referred from other areas (where they have very limited access to alternative intensive care) • No child will be refused admission to the PICU without a decision by the ICU attending on call at the time • No trainee will be asked to make a final decision about the appropriateness of PICU admission This MUST be a consultant decision Which of the following statements is false regarding performance of PCCM research in low resource settings (LRS)? A Investigators in LRS would benefit from participation in networks that include other investigators within LRS and collaborations with investigators outside of LRS B Research programs based on high-income countries should lead efforts to solve problems in LRS as they have better resources C Research led by investigators in LRS have informed important changes in clinical guidelines for fluid resuscitation for shock and for cost-effective delivery of noninvasive respiratory support D The research agenda for LRS should be informed by research priorities identified in LRS Preferred response: B Rationale Research priorities are ideally based on indicators such as the leading causes of child morbidity and mortality and thus vary by region Clinicians and researchers in low-resource regions should lead prioritization of the research agenda, even though there are less research resources available including training opportunities and funding Collaboration, research network, and training opportunities in concert with investigators and programs in highresourced regions may serve to benefit overall strengthening of research infrastructure in low-resourced regions Chapter 9: Public Health Emergencies and Emergency Mass Critical Care Your hospital receives news from the World Health Organization and the Centers for Disease Control that there is an emerging infectious disease rapidly spreading internationally Estimates indicate your area will start seeing cases within the week What actions should the ICU team take to prepare? A Activate crisis standards of care B Review the incident command system with ICU leaders C Teach staff to provide manual ventilation D Utilize personal protective equipment for all patients Preferred response: B Rationale Preparing for a potential pandemic should prompt each unit to review their own internal emergency plans and ensure all key staff e8 S E C T I O N XV Pediatric Critical Care: Board Review Questions are aware of how decisions will be made and communicated during the public health emergency (PHE) The primary way decisions are centralized and made with the best available information is the Incident Command System (ICS) ICU leaders will need to know what information they are expected to provide the incident command center and what decisions the incident commander will make versus what the local leaders will make As the current resources are adequate to provide for the patients there is not a need to utilize crisis standards of care yet; hopefully conservation and contingency strategies will help avoid the need to utilize crisis standards of care Personal protective equipment (PPE) should not be used for all patients as this will exhaust supplies of critical equipment Manual ventilation should only be used as part of emergency mass critical care (EMCC) and when mechanical ventilators are not available; as such, this technique should not be a high priority for education and instead educational efforts should focus on reviewing the hospital and unit disasters plan for infectious outbreaks The emergency department calls to alert the ICU that a local shopping center building has collapsed on a Saturday with many people inside, and they are expecting many casualties to arrive within minutes What is the correct order of steps to take? A Communicate with the incident commander, send a triage team to the ED, rapid transfer/discharge of any non-ICU level patients B Rapid assessment of surge capacity, communicate with the incident commander, send a triage team to the ED C Rapid transfer/discharge any non-ICU level patients, communicate with the ICS, assemble a triage team D Send a triage team to the ED, communicate with the incident commander, rapid assessment of surge capacity Preferred response: B Rationale In any potential surge knowing the available hospital surge capacity is a critical first step Upon notice of an incident each unit performs a rapid assessment of which patients can be safely transferred or discharged and communicates this information succinctly to the incident commander Units should not proactively transfer or discharge patients without word from the ICS as this could result in uncoordinated, unneeded, or inappropriate allocation of resources After alerting the incident commander, members of the ICU designated for the triage team should proceed to the ED to aid in helping with identifying patients appropriate for rapid transfer to the ICU A prolonged surge event due to severe influenza has caused the hospital to activate their incident command center (ICS) and utilize strategies to meet surge needs The incident commander sends word that the ICU should begin converting OR spaces to ICU spaces, that personal protective equipment goggles should be cleaned and reused whenever possible, and that ICU staff are being asked to work overtime What level of surge response is this? A Conventional B Contingency C Crisis D Emergency mass critical care Preferred response: B Rationale Converting reasonably equipped hospital spaces to ICU space, selective reuse of supplies, and extension of existing ICU staffing pool are all contingency strategies Conventional strategies lie in conserving resources, utilizing available staff without significantly extending staffing, substituting only where equivalent, and making use of supply caches Crisis strategies include converting poorly equipped or non-hospital areas to ICU spaces, using nonICU staff for ICU care, and reallocating (rationing) scarce resources EMC refers to the global category of needing to provide ICU care to a much larger than usual number of patients Another hospital in the area calls to request that some of their ICU level patients be moved to your hospital’s ICU They were the hospital closest to a school bus crash and received 15 critically ill pediatric victims from the crash Their usual ICU capacity is 16 patients, and they were at capacity before the event Your ICU’s usual capacity is 80 patients and it is usually 90% occupied What size of surge did the 15 victims create at the outside hospital and what size surge would your ICU have if you accepted all 15? A Major surge at outside hospital, minor surge for your ICU B Minor surge for outside hospital, usual volume for your ICU C Moderate surge for both D Moderate surge for outside hospital, minor surge for your ICU Preferred response: D Rationale For a 16 bed ICU an additional 15 patients is a 94% increase, which meets the range of a moderate surge (20–100% increase from usual capacity) For an 80 bed ICU, an additional 15 patients is an 18% increase which is a minor surge (up to 20% above usual capacity) This scenario would not constitute a major surge (.100%) for either unit Chapter 10: Lifelong Learning in Pediatric Critical Care You are preparing to teach a group of intensive care fellows about how to conduct an effective family meeting Interpersonal and communication skills are an example of which of the following: A Competency domain B Easily testable skill C Entrustable professional activity D Milestone E Stage of skill acquisition Preferred response: A Rationale The six core competency domains established by the ACGME are: • Practice-Based Learning and Improvement • Patient Care and Procedural Skills • Systems-Based Practice • Medical Knowledge • Interpersonal and Communication Skills • Professionalism These six domains should be used to guide and coordinate evaluation of all residents or fellows in their development CHAPTER 136 Board Review Questions A critical care fellow is preparing a simulation scenario to practice communication skills during cardiopulmonary resuscitation with the bedside team This type of simulation is an example of which of the following? A Crew Resource Management B Procedural Training C Resuscitation Manikin Teaching D Standardized Role Play E Task Training Preferred response: A Rationale Crew resource management was initiated in the aviation industry to improve safety in critical environments by focusing on interpersonal communication, leadership, and decision making You are preparing a curriculum to teach residents about pediatric acute respiratory distress syndrome Which of the following is an example of a method you might use that embraces adult learning principles? A Behavior management strategy B Didactic lecture using PowerPoint C See one, one, teach one D Small group learning E Videotaped lecture with question and answer period Preferred response: D Rationale Adults are self-directed and autonomous They learn best when they are active participants in the learning process and are allowed to practice newly acquired skills and concepts As a consequence, education is typically most effective when programs facilitate selflearning with specific goals of acquiring practical information Efforts to be inclusive of curricular methods that support adult learning principles are occurring in undergraduate, graduate, and continuing medical education Problem-based and small group learning, flipped classrooms, and simulation exercises allow many venues for reaching learners in different ways You are preparing to take the American Board of Pediatrics Critical Care Subspecialty examination Which of the following is not required to take the examination? A A job as a pediatric intensivist B Evidence of meaningful scholarly project during pediatric critical care fellowship C Initial certification in General Pediatrics D Successful completion of a Critical Care Medicine fellowship program E Valid unrestricted license to practice Preferred response: A Rationale To qualify for the ABP subspecialty examination, applicants are required to have a valid unrestricted allopathic and/or osteopathic license to practice, initial certification in general pediatrics, and e9 successful completion of critical care medicine training in a program accredited by the ACGME The applicant must also provide evidence of meaningful scholarship during training which can include research, an educational project, or a quality project You are planning to teach a group of critical care fellows how to manage a patient with acute respiratory distress syndrome Which of the following instructional techniques takes best advantage of the qualities of the adult learner? A Attending a webinar about ventilation strategies followed by a short quiz B Engaging in a detailed review of real patient cases followed by discussion of ventilation strategies C Attending a lecture with a PowerPoint presentation followed by a quiz D Reading a research article on ARDS and then discussing the merits of the study Preferred response: B Rationale Adult learners thrive with active, engaged learning environments Although all options have the potential for active, engaged learning, response B, review of real patient cases followed by discussion of care strategy, is an example of problem-based learning and requires active engagement by the learners It is also clearly related to their experience Which of the following is an example of an entrustable professional activity (EPA)? A Identifies subtle or unusual physical exam findings B Recognizes a patient requiring urgent or emergent care and initiates evaluation and management C Routinely provides vital signs and other laboratory data on rounds D Shows self-awareness of one’s own knowledge, skill, and emotional limitations that leads to appropriate help- seeking behaviors Preferred response: B Rationale Domains of competence refer to the six groups of physician subcompetencies defined by ACGME, including medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systemsbased practice Milestones are the developmental levels of knowledge, skills, and attitudes for each subcompetency and describe the progression of a physician’s ability Entrustable professional activities (EPAs) are tasks or responsibilities that trainees are entrusted to perform unsupervised once they have attained sufficient competency EPAs have been developed with patient safety in mind, but they also provide a framework for curricular development and lifelong progression of learning Response B, “recognizes a patient requiring urgent or emergent care and initiates evaluation and management,” is a discrete, concrete skill that can be observed and entrusted e10 S E C T I O N XV Pediatric Critical Care: Board Review Questions Chapter 11: Essential Concepts in Clinical Trial Design and Statistical Analysis In a randomized controlled trial to evaluate the effects of prone positioning compared to supine positioning in pediatric acute respiratory distress syndrome (PARDS), bedside nurses and treating physicians are asked to complete daily questionnaires classifying whether the patient has had clinical improvement, stability, or deterioration This study is at risk of what kind of bias? A Ascertainment bias B Bias due to loss of data C Lead time bias D Selection bias Preferred response: A Rationale Ascertainment bias exists when those responsible for determining outcomes are aware of treatment group assignment In this study, it would not be possible to blind bedside nurses and treating physicians to study group assignment, and knowledge of the treatment group assignment might influence their responses regarding illness trajectory Bias due to loss of data occurs when substantial patient outcome data is missing, or when data is missing related to treatment arm assignment Lead time bias is a risk in screening intervention studies, where time to an outcome may increase only because an illness was identified earlier than it would have naturally presented, but the screening intervention did not actually impact the occurrence of the outcome Finally, selection bias occurs when certain patients are preferentially enrolled in the treatment or control arm of a study, creating imbalance between the study arms A randomized controlled trial of a biologic immunomodulating drug in patients with severe sepsis decreased mortality to 7% among patients receiving treatment, compared to 21% among patients in the control arm Among patients with similar baseline risk of mortality, what is the number needed to treat (NNT) with this medication to save one life? A B 3.5 C D 14 E Not enough information to answer Preferred response: C Rationale NNT is the inverse of the absolute risk reduction (ARR) 100, or 1/(riskuntreated – risktreated) 100 In this case, ARR 21% 7% 14%, and 100/14 ,7 The NNT can be adjusted for baseline risk; among septic patients with twice the baseline risk of mortality (,42%), the NNT would be halved, at 3.5 An interventional study for patients with traumatic brain injury randomizes half to receive an early physical therapy and mobilization bundle, compared to standard of care What is the most appropriate statistical test to compare the hospital length of stay between the two groups? A ANOVA B Chi square test C T-test D Wilcoxon rank-sum test Preferred response: D Rationale Hospital length of stay is a good example of a continuous variable with a skewed distribution, as most patients have short lengths of stay, but a handful of patients have very long lengths of stay A nonparametric test, like the Wilcoxon rank-sum test, is most appropriate for comparing the median of this kind of outcome measure between two groups A t-test is appropriate for comparing the mean of a normally distributed outcome measure between two groups (e.g., low-density lipoprotein cholesterol.) ANOVA is used to compare means of a normally distributed outcome measure between multiple groups Finally, a chi square test is used to compare frequencies in a table, typically used for binary outcomes An investigator wishes to conduct a randomized trial examining continuous renal replacement therapy (CRRT) for fluid overload in patients with severe acute respiratory distress syndrome (ARDS) Which of the following is true for this study? A If the study results demonstrate a relative risk of mortality of 0.8 in the treatment group, with a 95% CI of 0.55-1.05 and a p value of 0.12, then we can conclude that CRRT is not effective in improving outcomes for patients with severe ARDS B Patients who are randomized to CRRT but not receive it because their hemodialysis catheter malfunctioned should be analyzed along with patients who are in the control group C The outcomes should be compared based on original treatment group assignment, regardless of what therapy the patient actually received D The outcomes should be compared based on what therapy the patient actually received, regardless of original treatment group E This study cannot be conducted because it is impossible to blind patients and providers to the treatment group assignment Preferred response: C Rationale Intention to treat analysis preserves the benefits of randomization, and patients who are randomized to a treatment group should be analyzed along with that group It is legitimate to conduct studies in which blinding is not possible; however, study staff who ascertain subjective outcomes should be blinded to treatment group assignment These study results suggest that there may be a treatment effect—the majority of the 95% confidence interval lies below 1.0—but, there is a reasonable probability (12%) that this estimate of effect was found by chance It may be that there is no effect, but it may also be that this study was underpowered to identify this 20% decrease in mortality ... reasonable probability (12%) that this estimate of effect was found by chance It may be that there is no effect, but it may also be that this study was underpowered to identify this 20% decrease in mortality... ABP subspecialty examination, applicants are required to have a valid unrestricted allopathic and/or osteopathic license to practice, initial certification in general pediatrics, and e9 successful... discharged and communicates this information succinctly to the incident commander Units should not proactively transfer or discharge patients without word from the ICS as this could result in uncoordinated,