Quantifying Pediatric Intensive Care Unit Staffing Levels at a Pediatric Academic Medical Center: A Mixed Methods Approach

Aim: Identify, simulate, and evaluate the formal and informal patient-level and unit-level factors that nurse managers use to determine the number of nurses for each shift. Background: Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last-minute adjustments or inappropriate staffing levels. Methods: Staffing schedules at a pediatric intensive care unit (PICU) were simulated based on nurse-to-patient assignment rules from interviews with nursing management. Multivariate regression modeled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels.Results: Nurse-to-patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift.Conclusion: Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand.Implications for Nursing Management: Data-driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last-minute adjustments.<br/

Population-level management of Type 1 diabetes via continuous glucose monitoring and algorithm-enabled patient prioritization: Precision health meets population health

OBJECTIVE: To develop and scale algorithm-enabled patient prioritization to improve population-level management of type 1 diabetes (T1D) in a pediatric clinic with fixed resources, using telemedicine and remote monitoring of patients via continuous glucose monitor (CGM) data review. RESEARCH DESIGN AND METHODS: We adapted consensus glucose targets for T1D patients using CGM to identify interpretable clinical criteria to prioritize patients for weekly provider review. The criteria were constructed to manage the number of patients reviewed weekly and identify patients who most needed provider contact. We developed an interactive dashboard to display CGM data relevant for the patients prioritized for review. RESULTS: The introduction of the new criteria and interactive dashboard was associated with a 60% reduction in the mean time spent by diabetes team members who remotely and asynchronously reviewed patient data and contacted patients, from 3.2 ± 0.20 to 1.3 ± 0.24 min per patient per week. Given fixed resources for review, this corresponded to an estimated 147% increase in weekly clinic capacity. Patients who qualified for and received remote review (n = 58) have associated 8.8 percentage points (pp) (95% CI = 0.6–16.9 pp) greater time-in-range (70–180 mg/dl) glucoses compared to 25 control patients who did not qualify at 12 months after T1D onset. CONCLUSIONS: An algorithm-enabled prioritization of T1D patients with CGM for asynchronous remote review reduced provider time spent per patient and was associated with improved time-in-range

Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard

Background Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers. Objectives This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data. Methods We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation. Results The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data. Conclusion A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.</p

Using Machine Learning Models to Identify Factors Associated With 30-Day Readmissions After Posterior Cervical Fusions: A Longitudinal Cohort Study

Objective Readmission rates after posterior cervical fusion (PCF) significantly impact patients and healthcare, with complication rates at 15%–25% and up to 12% 90-day readmission rates. In this study, we aim to test whether machine learning (ML) models that capture interfactorial interactions outperform traditional logistic regression (LR) in identifying readmission-associated factors. Methods The Optum Clinformatics Data Mart database was used to identify patients who underwent PCF between 2004–2017. To determine factors associated with 30-day readmissions, 5 ML models were generated and evaluated, including a multivariate LR (MLR) model. Then, the best-performing model, Gradient Boosting Machine (GBM), was compared to the LACE (Length patient stay in the hospital, Acuity of admission of patient in the hospital, Comorbidity, and Emergency visit) index regarding potential cost savings from algorithm implementation. Results This study included 4,130 patients, 874 of which were readmitted within 30 days. When analyzed and scaled, we found that patient discharge status, comorbidities, and number of procedure codes were factors that influenced MLR, while patient discharge status, billed admission charge, and length of stay influenced the GBM model. The GBM model significantly outperformed MLR in predicting unplanned readmissions (mean area under the receiver operating characteristic curve, 0.846 vs. 0.829; p < 0.001), while also projecting an average cost savings of 50% more than the LACE index. Conclusion Five models (GBM, XGBoost [extreme gradient boosting], RF [random forest], LASSO [least absolute shrinkage and selection operator], and MLR) were evaluated, among which, the GBM model exhibited superior predictive performance, robustness, and accuracy. Factors associated with readmissions impact LR and GBM models differently, suggesting that these models can be used complementarily. When analyzing PCF procedures, the GBM model resulted in greater predictive performance and was associated with higher theoretical cost savings for readmissions associated with PCF complications

Design Initiative for a 10 TeV pCM Wakefield Collider

This document outlines a community-driven Design Study for a 10 TeV pCM Wakefield Accelerator Collider. The 2020 ESPP Report emphasized the need for Advanced Accelerator R\&D, and the 2023 P5 Report calls for the ``delivery of an end-to-end design concept, including cost scales, with self-consistent parameters throughout." This Design Study leverages recent experimental and theoretical progress resulting from a global R\&D program in order to deliver a unified, 10 TeV Wakefield Collider concept. Wakefield Accelerators provide ultra-high accelerating gradients which enables an upgrade path that will extend the reach of Linear Colliders beyond the electroweak scale. Here, we describe the organization of the Design Study including timeline and deliverables, and we detail the requirements and challenges on the path to a 10 TeV Wakefield Collider

Design Initiative for a 10 TeV pCM Wakefield Collider

This document outlines a community-driven Design Study for a 10 TeV pCM Wakefield Accelerator Collider. The 2020 ESPP Report emphasized the need for Advanced Accelerator R\&amp;D, and the 2023 P5 Report calls for the ``delivery of an end-to-end design concept, including cost scales, with self-consistent parameters throughout." This Design Study leverages recent experimental and theoretical progress resulting from a global R\&amp;D program in order to deliver a unified, 10 TeV Wakefield Collider concept. Wakefield Accelerators provide ultra-high accelerating gradients which enables an upgrade path that will extend the reach of Linear Colliders beyond the electroweak scale. Here, we describe the organization of the Design Study including timeline and deliverables, and we detail the requirements and challenges on the path to a 10 TeV Wakefield Collider