ObjectivesThe use of peripherally inserted central catheters (PICCs) are an integral part of caring for hospitalised children. We sought to estimate the incidence of and identify the risk factors for complications associated with PICCs in an advanced registered nurse practitioners (ARNP)-driven programme.DesignRetrospective cohort study.SettingSingle-centre, large quaternary children's hospital.ParticipantsHospitalised children who had PICC inserted from 1 January 2010 to 31 December 2016.InterventionsNone.Measurement and main resultsA total of 2558 PICCs were placed during the study period. Mean age at PICC insertion was 8.7 years, mean dwell time was 17.7 days. The majority of PICCs (97.8%) were placed by ARNP. Most were placed in a single attempt (79.6%). Mean PICC residual external length outside was 2.1±2.7 cm. The rate of central line-associated bloodstream infection (CLABSI), thrombosis and significant bleeding were 1.9%, 1% and 0.2%, respectively. The CLABSI rate in infants and early childhood was higher than those aged ≥5 years (2.8%, 3.1%, respectively vs 1.3%). In a multivariate analysis after adjustment of confounding effects of race and gender, infants (OR= 2.24, CI=1.14 to 4.39, p=0.02) and early childhood cohort (OR=2.37, CI=1.12 to 5.01, p=0.02) were associated with significantly higher odds of developing CLABSI compared with ≥5 years old. In the early childhood cohort, PICCs with longer residual external catheter length (OR=1.30, 95% CI=1.07 to 1.57, p=0.008) and those placed in the operating room (OR=5.49, 95% CI=1.03 to 29.19, p=0.04), were associated with significantly greater risk of developing CLABSI.ConclusionsThe majority of PICCs were successfully placed by ARNPs on the first attempt and had a low incidence of complications. Infants required more attempts for successful PICC placement than older children. The presence of residual external catheter length and placement in the operating room were independent predictors of CLABSI in younger children.

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Children's National INTRODUCTION/HYPOTHESIS: Discussion of prognosis is a vital component of communication during pediatric intensive care unit (PICU) family conferences when medical decision-making is anticipated. Prior studies demonstrate that sharing clear, meaningful prognostic information positively impacts parental hope, satisfaction, and medical decision-making. For effective communication, the prognosis statement must contain a message, defined as a forecasting of the probable course of a disease, and a meaning, which delineates the impact of the disease on the patient and/ or family. The current practice of how the healthcare team communicates prognosis to parents of critically ill children in the PICU is unknown. We evaluated the frequency and characteristics of prognostic statements made by the healthcare team during PICU decision-making family conferences. METHODS:We conducted a retrospective, qualitative study analyzing transcripts of audio-recorded PICU family conferences where critical decision-making was anticipated. Descriptive, thematic content analysis was applied to the transcripts to identify 1) the presence of prognostic statements and 2) the message and meaning of the prognostic statements. RESULTS:Seventy-two transcripts were analyzed, of which 53 (74%) included at least one prognostic statement. Clinicians made a total of 112 prognostic statements, of which 66 (59%) included both a message and a meaning, such as "your child's lungs are worsening (message) and extubation will be unsuccessful (meaning). " Conversely, 46/112 (41%) statements included a message only, such as "your child's lungs are worsening. " Messages fell into 4 themes: Time (fast vs. slow recovery), Disability (need for medical technology), Cure (reversibility of disease), and Additional disease (brain injury will lead to respiratory problems). CONCLUSIONS:Prognosis was discussed in the majority of family conferences of critical decision-making in the PICU, yet clinicians didn't discuss prognosis 26% of the time. When prognosis was discussed, 41% of the time clinicians struggled to provide meaning to families regarding how this life-altering news may impact the patient and family. Providing context to the prognosis is essential for families to understand the prognosis and plan for the future.

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