OBJECTIVE -In a recent randomized controlled trial, lowering blood glucose levels to 80 -110 mg/dl improved clinical outcomes in critically ill patients. In that study, the insulin infusion protocol (IIP) used to normalize blood glucose levels provided valuable guidelines for adjusting insulin therapy. In our hands, however, ongoing expert supervision was required to effectively manage the insulin infusions. This work describes our early experience with a safe, effective, nurse-implemented IIP that provides detailed insulin dosing instructions and requires minimal physician input.RESEARCH DESIGN AND METHODS -We collected data from 52 medical intensive care unit (MICU) patients who were placed on the IIP. Blood glucose levels were the primary outcome measurement. Relevant clinical variables and insulin requirements were also recorded. MICU nurses were surveyed regarding their experience with the IIP.RESULTS -To date, our IIP has been employed 69 times in 52 patients admitted to an MICU. Using the IIP, the median time to reach target blood glucose levels (100 -139 mg/dl) was 9 h. Once blood glucose levels fell below 140 mg/dl, 52% of 5,808 subsequent hourly blood glucose values fell within our narrow target range; 66% within a "clinically desirable" range of 80 -139 mg/dl; and 93% within a "clinically acceptable" range of 80 -199 mg/dl. Only 20 (0.3%) blood glucose values were Ͻ60 mg/dl, none of which resulted in clinically significant adverse events. In general, the IIP was readily accepted by our MICU nursing staff, most of whom rated the protocol as both clinically effective and easy to use. CONCLUSIONS -Our nurse-implemented IIP is safe and effective in improving glycemic control in critically ill patients. Diabetes Care 27:461-467, 2004I n 2001, a large randomized controlled trial from Leuven, Belgium, demonstrated that normalization of blood glucose levels using an intensive insulin infusion protocol (IIP) improved clinical outcomes in patients admitted to a surgical intensive care unit (ICU) (1). In the Leuven study, intensive insulin therapy (to maintain blood glucose levels between 80 and 110 mg/dl) reduced ICU mortality by 42% and also reduced the incidence of bloodstream infections, the incidence of acute renal failure, the need for prolonged ventilatory support, and the duration of ICU stay. Strict glycemic control appears to be beneficial in other intensive care settings as well. In the DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) study (2,3), an intravenous insulin-glucose infusion (followed by an outpatient multidose subcutaneous insulin regimen) improved long-term prognosis in diabetic patients following acute myocardial infarction. In patients undergoing open heart surgery, the use of a perioperative IIP dramatically reduced the incidence of deep sternal wound infections (4).Based on this emerging clinical evidence, there are increasing efforts worldwide to maintain strict glycemic control in critically ill patients. However, achieving this goal requires exte...

Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and(3) developing and implementing quality improvement initiatives and CICUspecific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.The goal of pediatric palliative care (PPC) is to provide support and reduce suffering for children with serious illnesses and their families. 1 These objectives are accomplished through expert interdisciplinary assessment and management of physical and psychological symptoms, provision of high-quality communication to facilitate decision-making and advance care planning, attention to psychosocial and spiritual suffering, enhancement of quality of life, and provision of emotional, logistic, grief, and bereavement support. [2][3][4][5] The National Academy of Medicine has long advocated for the provision and evaluation of child-and family-centered

OBJECTIVES: With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD). METHODS: In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007–2009 (early) and 2015–2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence. RESULTS: Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]). CONCLUSIONS: Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.

Key Points Question In the absence quality metrics for end-of-life care in pediatric cardiac intensive care units (CICUs), how do interdisciplinary staff perceive quality of dying and death (QODD)? Findings In this cross-sectional survey study of 713 medical professionals involved in 60 deaths in the CICU, the pediatric intensive care unit (PICU)–QODD instrument was a reliable and valid measure of QODD in CICUs, with overall positive perceptions of QODD yet negative perceptions of the 7 days prior. Lower PICU-QODD scores were reported by nursing or allied health staff, by less experienced staff, for patients with cardiac-surgical admissions and comorbidities, and for deaths following treatment limitation or misaligned with family wishes. Meaning These data could guide strategies to improve staff well-being and end-of-life experiences.