Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience

Abstract

Objective

To describe the characteristics of pediatric intensive care neurologists and their practice in the United States and Canada.

Methods

We performed a survey-based study of child neurologists who self-identify as ‘intensive care neurologists’. The survey included questions about demographics, training, pediatric neurocritical care service and job structure, teaching, academics, challenges, and views on the future of pediatric neurocritical care.

Results

We analyzed 55 surveys. Most respondents were 31-50 years of age with ≤10 years of practice experience. Fifty-four percent identified as female. Most completed subspecialty training after child neurology residency. The majority practice at highly resourced centers with >45 intensive care unit beds. Respondents cover a variety of inpatient (critical and noncritical care) services, at times simultaneously, for a median of 19.5 weeks/y and work >70 hours/wk when on service for pediatric neurocritical care. The top 3 challenges reported were competing demands for time, excess volume, and communication with critical care medicine. Top priorities for the “ideal pediatric neurocritical care service” were attendings with training in pediatric neurocritical care or a related field and joint rounding with critical care medicine.

Conclusion

We report a survey-based analysis of the demographics and scope of practice of pediatric critical care neurologists. We highlight challenges faced and provide a framework for the further development of this rapidly growing field.

Keywords

Pediatric Neurocritical Care Pediatric Stroke Pediatric Neurology Pediatric Neurohospitalist

Introduction

Children with acute neurologic illness account for a large proportion of pediatric intensive care unit (ICU) admissions,^1–6 as well as a high rate of pediatric ICU mortality.^7–9 Moreover, children with systemic illnesses often suffer neurologic complications of their primary disorder,⁴ and children with chronic neurologic disease are at risk for decompensation, necessitating admission to the pediatric ICU.¹⁰ This has contributed to a growing interest in pediatric neurocritical care (PNCC), with prior publications describing management of the pediatric neurocritical care patient,^11–13 programmatic structure,^1–3 education in critical care neurology,^2,14 and pediatric neurocritical care follow-up clinics.^15,16 Although there are no standards for the designation of a pediatric neurocritical care program or a neuroscience pediatric ICU, there are at least 45 self-reported pediatric neurocritical care services⁶ and 8 neuroscience pediatric ICUs¹⁷ in the United States (U.S).

With more than 80% of pediatric neurocritical care services functioning as consultation services, often in association with an acute stroke service,⁶ we hypothesize that child neurologists play important leadership roles and function as key clinical participants within these teams. However, there are limited data describing the demographics, training background, job structure, care team structure, or challenges faced by child neurologists practicing pediatric neurocritical care. Furthermore, the number of child neurologists whose practice focuses on pediatric neurocritical care is unknown.

What is known is that the number of pediatric ICU beds in the United States has steadily increased^17,18; in 2018, there were 5388 pediatric ICU beds,¹⁸ with almost half of pediatric ICU beds concentrated in 63 hospitals.¹⁷ The Virtual Pediatric Systems database, which collects data from 117 US pediatric ICUs, reported 136,483 admissions in 2019.¹⁹ According to the latest statistics by the American Board of Medical Specialties, there are 2752 physicians with an active specialty in child neurology accredited by the American Board of Psychiatry and Neurology.²⁰ This number, however, includes certificate holders who are retired, and we estimate only a fraction of those with an active practice have expertise/subspecialty training in pediatric neurocritical care.

Considering a modest 15% of critically ill children requiring neurologic consultation⁵ (∼20,472), these numbers demonstrate a mismatch between the growing need for expertise in pediatric neurocritical care and the number of child neurologists with the skill set necessary to care for critically ill children, making it important to describe the existing workforce and identify barriers for child neurologists within the practice of pediatric neurocritical care. We use a survey-based approach to investigate the characteristics of pediatric intensive care neurologists and gain insight into their practice within pediatric neurocritical care.

Methods

Study Design and Survey Characteristics

A survey was developed by the authors of the manuscript. The conditional branching survey consisted of 8 sections: (1) Demographics; (2) Education and Training; (3) Intensive Care Neurology Service Structure; (4) Teaching Responsibilities; (5) Job Structure; (6) Academic Considerations; (7) Work-related Challenges; and (8) Views on the Future of Pediatric Neurocritical Care. (Supplementary File)

Survey Recipients

An advertisement addressed to child neurologists who consider themselves “intensive care neurologists” was sent through the Child Neurology Society and Pediatric Neurocritical Care Research Group (http://www.pncrg.org/) listservs and contained a link to the survey. No a priori definition of “intensive care neurologist” was provided in order to gain insight into who consider themselves to be a pediatric intensive care neurologist or neurointensivist and how that translates into clinical practice. Clicking the link to the survey was considered consent to participate. Survey settings were such that respondents could only fill out the survey once, and responses were anonymous. Respondents were permitted to skip questions they preferred not to answer. A reminder was sent through the above-mentioned listservs 2 weeks after the original advertisement. The survey was closed 2 weeks after the last survey response was received. Surveys devoid of responses, as well as those completed by nonneurologists, were excluded from analysis.

A subset of questions addressed the pediatric intensive care neurology service structure at respondents’ institutions. Because our survey did not query the specific location or institution at which respondents practice to ensure anonymity, the responses to these questions may include redundant data if more than 1 intensive care neurologist from a given institution responded to the survey. An estimation of the number of institutions represented was performed by cross-referencing the following questions: (1) region of pediatric neurocritical care service, (2) number of attendings in the pediatric neurocritical care coverage pool, (3) directorship of pediatric neurocritical care at the center, (4) presence of a pediatric neurocritical care fellowship, and (5) number of ICU beds. These questions were chosen for cross-referencing because of their unambiguity.

Survey Apparatus and Statistical Analysis

The survey was generated using Qualtrics software, version XM. Descriptive statistics were performed according to rate of response of respondents (not all respondents answered all questions). Normally distributed data were described with mean and standard deviation (SD). Skewed continuous measures were summarized using median and interquartile range (IQR). Group comparisons were made using the χ² test for categorical outcomes and the Wilcoxon rank-sum test for ordinal outcomes. Exact test methods were used because of the small sample size. Significance was determined at the 0.01 level. The analysis was performed using SAS, version 9.4 (SAS Institute, Cary, NC). Open-ended questions were analyzed using thematic analysis approach.²¹

Results

Sixty-one surveys were opened, 6 of which were excluded from further analysis because of being devoid of responses (n = 2) or being completed by a non–child neurologist (n = 4). Fifty-five surveys were analyzed. Not all respondents answered all questions in the survey, and thus analysis was performed accounting for the number of responses for each individual question. By cross-referencing, we estimate that at least 30 centers with pediatric critical care neurology services are represented. The entire survey is included as Supplementary File 1.

Demographics of Respondents

Table 1 shows the demographic characteristics of respondents and their institutions. The majority of respondents were between 31 and 50 years of age with ≤10 years of experience practicing neurocritical care, and 54% identified as female. Eighty-two percent (n = 40) pursued subspecialty training after completion of child neurology training; 27% (n = 13) pursued training in more than 1 subspecialty. Of those who pursued subspecialty training in pediatric neurocritical care, all but 2 reported practicing for ≤10 years, and the majority have been practicing for ≤5 years (64%, n = 7). Eighteen percent (n = 9) of respondents have no subspecialty training beyond child neurology residency, including 46% (n = 6) of the 13 neurologists with >10 years of experience practicing neurocritical care. Board certification in neurocritical care was rare, although 19% (n = 9) are planning to apply for neurocritical care board certification from the American Board of Psychiatry and Neurology.

Table 1.

Demographics by Respondent and Institution.

Respondents	n (%)
Gender, female (N = 55)	30 (55)
Age (N = 55)
31-40	21 (38)
41-50	22 (40)
51-60	5 (9)
>60	7 (13)
Years of experience (n = 49)
≤5	20 (41)
6-10	16 (33)
11-15	3 (6)
16-20	5 (10)
>20	5 (10)
Subspecialty training after child neurology residency^a (n = 49)
Epilepsy/neurophysiology	17 (35)
PCCM	11 (22)
PNCC	11 (22)
None	9 (18)
Stroke (adult and/or pediatric)	5 (10)
Adult CCM and/or NCC	4 (8)
Other^b	10 (20)
Board certification in NCC (n = 48)	4 (8)
Institution
Region of hospital (n = 53)
Northeast	11 (21)
Midwest	14 (27)
West	12 (23)
South	15 (29)
Canada	1 (2)
Type of hospital^a (N = 55)
University-based	36 (66)
Freestanding pediatric hospital	30 (56)
Private/community	1 (2)
Government/county	1 (2)
Children's center within adult hospital	1 (2)
No. of beds in pediatric/cardiac ICU (n = 44)
<15	4 (9)
15-25	2 (5)
26-35	2 (5)
36-45	5 (11)
46-55	10 (23)
>55	21 (48)

Abbreviations: CCM, critical care medicine; ICU, intensive care unit; NCC, neurocritical care; PCCM, pediatric critical care medicine; PNCC, pediatric neurocritical care.

Respondents may choose multiple responses.

Anesthesia, brain injury medicine, developmental neuroscience, neonatal neurology, neuroimmunology, neurorehabilitation.

Institutional Characteristics and Critical Care Neurology Service Structure

Respondents most commonly practice at university-based and/or freestanding children’s hospitals with more than 45 pediatric ICU and cardiac ICU beds combined (Table 1). Figure 1 shows the resources available at respondents’ institutions. Respondents’ pediatric critical care neurology services are most often composed of 6 or fewer attendings (66%, n = 29), staffed solely by neurologists (80%, n = 36), and include advanced practice providers (56%, n = 24) (Table 2).

Table 2.

Service and Individual Practice Characteristics.

Critical care neurology service characteristics	n (%) or median (IQR)
PNCC service solely covers critically ill patients ^a (n = 44)	32 (73)
PICU + CICU + NICU	18 (57)
No. of members in coverage pool (n = 44)
1-3	13 (30)
4-6	16 (36)
7-9	7 (16)
>10	8 (18)
CCM in coverage pool for PNCC (n = 45)	9 (20)
APP coverage (n = 43)	24 (56)
ICU EEG interpretation (n = 37)
PNCC	11 (30)
CNP/epilepsy	26 (70)
Individual practice characteristics
No. of total inpatient weeks covered/year^b (n = 22), median (IQR)	19.5 (13.5-25.5)
No. of PNCC weeks covered/year^c (n = 19), median (IQR)	16 (7-18)
No. of CCM services covered when on PNCC service (n = 44), median (IQR)	4 (3-5)
Continuity of care at night^d (n = 38)	23 (60)
Continuity of care on weekend^d (n = 38)	21 (55)
Average no. of consults per week (n = 40)
≤5	2 (5)
6-10	11 (28)
11-15	16 (40)
16-20	5 (13)
>20	6 (15)
Total no. of nights per year on call^a (n = 35)
≤35	5 (14)
36-45	7 (20)
46-65	5 (14)
>65	18 (51)
Total no. of hours of work per week when on PNCC service (n = 35)
≤50	8 (23)
51-70	7 (20)
>70	20 (57)
wRVU goals per 1.0 FTE (n = 35)
No goals	16 (46)
2000-3000	2 (6)
3001-4000	6 (17)
4001-5000	8 (23)
>5000	3 (9)
Rounds jointly with CCM (n = 38)	31 (82)
% time dedicated to clinical work (n = 37), median (IQR)	70 (50-80)
% time dedicated to education (n = 37), median (IQR)	10 (5-10)
% time dedicated to research (n = 37), median (IQR)	10 (5-35)
% time dedicated to administration (n = 37), median (IQR)	10 (4-12.5)

Abbreviations: APP, advanced practice provider; CCM, critical care medicine; CICU, cardiac intensive care unit; CNP, clinical neurophysiology; EEG, electroencephalogram; FTE, full-time equivalent; IQR, interquartile range; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit; PNCC, pediatric neurocritical care; wRVU, work relative value units.

PICU/CICU/NICU/stroke + /−ICU EEG.

Indicates total number of inpatient weeks/nights covered (not exclusive to PNCC).

Indicates the total number of PNCC weeks covered (may include simultaneous coverage of non-ICU consult services).

Continuity of care denotes same attending being on call at night/weekend (may be in supervisory role).

Almost three-quarters (n = 32) of respondents’ services care only for critically ill patients, including stroke consults, with just over half of those (n = 18) providing coverage in the pediatric ICU, cardiac ICU, and neonatal ICU. Other less common arrangements include providing care only in the pediatric ICU, only in the pediatric ICU and cardiac ICU, or only in the cardiac and neonatal ICUs, with or without simultaneous stroke and/or ICU electroencephalogram (EEG) coverage. The remaining quarter (n = 12) of respondents’ services care simultaneously for both critically ill and non–critically ill children (eg, on the neurology ward or general pediatrics ward).

Seventy percent (n = 26) of respondents reported that the neurophysiology service performs formal interpretation of ICU EEG studies. Of these, 37% (n = 10) have a dedicated neurophysiology service that exclusively interprets ICU EEG studies, whereas the remainder are interpreted by the same service responsible for non-ICU EEG studies. Thirty percent (n = 11) of respondents stated ICU EEG studies are formally interpreted by the critical care neurology service, only if the attending is board certified/eligible in clinical neurophysiology or epilepsy in 73% (8/11), and regardless of board certification in the remainder. Respondents at institutions where critical care neurology provides formal interpretation of ICU EEG studies were more likely to have subspecialty training in epilepsy or clinical neurophysiology than respondents at institutions where a neurophysiology service provides formal interpretation of ICU EEGs (10/11 [91%] vs 4/26 [15%], P ≤ .001).

Structure of Respondents’ Individual Practice

Table 2 describes pediatric critical care neurologists’ individual practice characteristics. The median number of yearly weeks dedicated to covering a pediatric neurocritical care service was 16 (IQR 7-18). Survey respondents cover a median of 4 (IQR 3-5) separate services simultaneously when providing pediatric neurocritical care coverage (eg, pediatric ICU, cardiac ICU, neonatal ICU, or stroke), with the majority performing an average of 6-15 new consults and working over 70 hours per week. In addition to inpatient responsibilities, the majority (n = 31, 89%) of respondents spend at least 1 full day per month in clinic and almost half (n = 17, 49%) spend 5 or more full days in clinic per month, most frequently staffing general neurology clinics and/or resident clinics.

Respondents reported dedicating most of their time to clinical care, with less time spent on education, research, and administrative duties. wRVU (work relative value unit) goals reported were variable. Of those without wRVU goals, 69% (n = 11) had completed either a critical care medicine or pediatric neurocritical care fellowship. The 3 with wRVU goals >5000 had completed clinical neurophysiology or epilepsy fellowships. Starting base salary was queried only for attendings practicing for ≤5 years (n = 20), 13 of whom responded. The majority (n = 11) reported a starting base salary of $151-200K.

Most respondents use clinical care pathways (40/43, 93%) for a variety of disorders (ie, stroke, status epilepticus, anoxic brain injury, etc). They also contribute to multicenter registries (31/33, 94%), including the Cardiac Neurodevelopmental Outcome Collaborative, the Critical Care EEG Monitoring Research Consortium, the International Pediatric Stroke Study, and the Pediatric Status Epilepticus Research Group, among others. Forty percent (14/35) maintain a pediatric neurocritical care database, with the outcome data collected varying widely (Supplemental Figure 1).

Challenges and the Future of Pediatric Neurocritical Care

The top 3 challenges reported by respondents were competing demands for time and focus, excessive volume, and communication with the critical care medicine team (Figure 2). Respondents were asked to describe how they would construct a pediatric neurocritical care service if they had no time or budgetary constraints. Top priorities identified by respondents included services comprised of attendings with subspecialty training in pediatric neurocritical care, attendings with subspecialty training in a field related to pediatric neurocritical care (eg, epilepsy/clinical neurophysiology, stroke, etc), and joint rounding with the critical care medicine team (Figure 3). When asked about the ideal training pathway for a child neurology resident interested in pediatric intensive care neurology, the top 3 choices recommended by respondents, not taking into account rank order, were a pediatric neurocritical care fellowship (n = 29, 83%), a pediatric neurocritical care and epilepsy/clinical neurophysiology fellowship (n = 20, 57%), or a pediatric stroke fellowship (n = 12, 34%) with different weights given to rank (of note, pediatric neurocritical care and pediatric neurocritical care + epilepsy/clinical neurophysiology were commonly selected as number 1 whereas pediatric stroke was never chosen as number 1). Only 7 respondents answered the open-ended question on their opinion of the future of pediatric neurocritical care. Four respondents shared the sole common theme, which emphasized also focusing on the importance of nonacute aspects of care, for example, family meetings and palliative care considerations.

Discussion

We report a survey-based study of child neurologists whose clinical practice focuses on the care of critically ill children. The pediatric neurologists who responded to our survey are generally early in their career, have diverse subspecialty training, and tend to work at large, resource-rich centers capable of multimodal neuromonitoring. The pediatric neurocritical care services described by this cohort are staffed primarily by child neurologists and provide consultative services for various intensive care subspecialties. Survey respondents endorsed similar challenges in their daily practice, and their views on the future of pediatric neurocritical care suggest commonalities from which to continue to build this field.

In 2014, Riviello and Chang described the practice of pediatric neurocritical care by the child neurologist.²² At that time, they recommended that to further the field, we

1) continue the development of pediatric NCC [neurocritical care] services and units, 2) continue the development of the various levels of training needed to practice pediatric NCC in its varied settings, 3) develop treatment guidelines and protocols, 4) improve the multimodality monitoring for pediatric NCC, 5) perform the clinical and basic science research needed to improve care, and 6) perform the outcomes research needed to demonstrate improvement in patient outcomes.

Seven years later, using a survey-based approach, we assess interval progress in the development of this field and identify continued areas for growth.

Based on the results of our survey, the development of pediatric neurocritical care services appears to have evolved around a consultative model, and this is in keeping with prior reports.^1–3,6 However, within the consultative model, we found considerable heterogeneity; for example, the complement of intensive care units covered by respondents’ critical care neurology services varies widely, as does the call structure, ICU EEG interpretation practices, and incorporation of advanced practice providers. There remain gaps in our understanding of what constitutes the ideal pediatric neurocritical care service, and it is likely that the variability observed in this cohort, at least in part, reflects diverse institution-specific child neurology practice structures and resources.

An important factor to consider when assessing the development of pediatric neurocritical care is the expertise and training background of the physicians staffing these services. There has been growth over the last 7 years in pediatric neurocritical care training opportunities. Sixty-four percent of survey respondents who have been practicing for ≤5 years and 22% of the overall cohort pursued training in pediatric neurocritical care. The remainder of respondents had a diverse training background, with many having subspecialty training in fields highly relevant to pediatric neurocritical care (eg clinical neurophysiology/epilepsy and stroke). Pediatric neurocritical care training was most commonly chosen as a top 3 ideal pathway for fellowship training as well as the ideal background of the attending on the pediatric neurocritical care service, and this is in keeping with prior reports.^3,14,22,23 Pediatric neurocritical care fellowship is an attractive training option for child neurologists who want to focus their practice on pediatric neurocritical care. It is shorter than a critical care medicine fellowship yet allows for a deep understanding of cerebral physiology during critical illness in a field where evidence-based approaches are lacking and management decisions are made on the basis of an understanding of cellular mechanisms of disease in critically ill children.³ Opportunities for growth exist within pediatric neurocritical care education. Although there are proposed essential competencies for training in pediatric neurocritical care,¹⁴ there is no ACGME-accredited fellowship, there exists variability between training programs, and there is no regulatory board or pediatric neurocritical care certification process.

Despite the current variability in pediatric neurocritical care service structure and the heterogeneous training background of the neurologists integrating these teams, the use of multidisciplinary institutional pathways and multimodal monitoring appears to be common. The standardization of care via multidisciplinary institutional pathways facilitates collaboration between specialties and, importantly, allows for research, including comparative effectiveness and other studies that aim to determine care strategies that improve patient outcomes. Many respondents staff ICU follow-up clinics, collect outcome data, and participate in multicenter registries, all of which suggest an ideal milieu to quantify the impact of pediatric neurocritical clinical care on patient outcomes, another important mission cited by Riviello and Chang and echoed by others.^3,6,22 This comes with the caveat, however, that the outcome data collected is heterogeneous. This represents an area where collaboration and coordinated efforts among centers to develop and utilize common outcome measures could contribute significantly to the development of this field. Academic societies and interest groups (eg, Child Neurology Society, Neurocritical Care Society, and Pediatric Neurocritical Care Research Group, among others) have played an important role in unifying this small group. Leveraging the broad participation within these societies with the availability of virtual collaborative platforms and promoting the gathering of common data, including outcome measures, is an obvious way to further enhance the field of pediatric neurocritical care.

In addition to furthering our understanding of the development of pediatric neurocritical care, our survey adds to our understanding of the demographic characteristics of the neurologists who practice pediatric neurocritical care. Our cohort had near equal representation of females and males, most of whom were early in their career and had subspecialty training. We hypothesize that the fewer years of independent practice reflects the relative novelty of the field and scarce, albeit increasing, pediatric neurocritical care training opportunities.²⁴ Their work is mostly dedicated to clinical duties, and they tend to practice at large, university-based pediatric centers. The latter may be related to regionalization and subspecialization trends in larger pediatric ICUs, where level 1 Children’s Surgical/Trauma Center designation or availability of extracorporeal membrane oxygenation may drive a subsequent demand for subspecialized neurologic care. Further work is necessary to determine child neurology resource allocation, as well as appropriate triage and transport strategies to ensure every child with an acute neurologic condition gets prompt neurocritical care, regardless of their geographic location. This, however, may prove difficult because of the overwhelming shortage of neurologists, including child neurologists.^25,26 For this reason, we queried survey respondents’ views on the future of pediatric neurocritical care. They recommended commonalities from which to continue to build this field and barriers that may need to be overcome to do so. For example, we asked survey respondents to describe the challenges encountered in their daily practice. The most commonly reported challenge was competing demands for time and focus. This is likely a consequence of the practice characteristics described by respondents, specifically providing simultaneous consultative services for a large number of critical care medicine subspecialties (pediatric ICU, cardiac ICU, neonatal ICU) as well as non–critical care medicine services (neurology ward, emergency department, and other non-ICU consults, etc), the coverage of other services when not attending on a pediatric neurocritical care service (clinic, epilepsy monitoring unit, neurology ward, etc), the burden of yearly inpatient weeks, including overnight call and weekly hours worked, and the time dedicated to nonclinical activities.

The reason for this dispersion in clinical activities was not queried. Although survey respondents may desire to cover nonpediatric neurocritical care services, it is also possible that the diversity of their clinical duties may be a consequence of needing to meet clinical productivity/financial metrics in centers that are unable to financially sustain a dedicated pediatric critical care neurology service. Many child neurology practices rely heavily on wRVUs to determine base compensation and to assess productivity,²⁵ and indeed, more than 50% of our sample were assigned yearly wRVU goals. Child neurologists care for complex patients and non–wRVU generating activities such as nighttime home call duties, charting, and reviewing ancillary studies and records are ubiquitous. Pediatric critical care neurologists are further affected by an unpredictable workflow in which they need to be readily available to respond to emergencies and to attend family and multidisciplinary care team meetings, yet are unable to accurately predict their patient volume, and thus their wRVUs. We echo Zupanc and colleagues in the statement that productivity metrics and goals should consider downstream revenue generation, and that individual wRVUs should not be used as a sole measure of productivity or compensation.²⁵

Other subspecialties within child neurology that have been presented with similar opportunities and challenges and that antedate pediatric critical care neurology include pediatric stroke neurology and neonatal neurology. Pediatric stroke neurology emerged as a distinct subspecialty in the early 2000s. Similar to pediatric critical care neurology, there is no ACGME-approved training pathway or accreditation board for pediatric stroke, and subspecialists typically supplement their clinical time as a stroke neurologist with other clinical duties and/or funded research.²⁷ The field of neonatal neurology can be traced back to the 1980s and, at that time, was dominated by neonatologists.²⁸ Like critical care neurologists, neonatal neurologists function as consultants in neonatal intensive care units, have aimed to standardize care using protocols and pathways, and serve as key participants in multidisciplinary teams.²⁹ As demonstrated by Mulkey and colleagues, the presence of a neonatal neurology service may improve video EEG resource utilization, as well as increase consultation and follow-up encounters.²⁹ Though these subspecialties are distinct from pediatric critical care neurology, there is overlap in the conditions encountered and cross coverage may be common, as demonstrated by our cohort.

We acknowledge several limitations of our study. First, the total number of child neurologists who practice pediatric neurocritical care is unknown, hindering our ability to make generalizable conclusions based on our sample size. Second, this is a survey-based study and is therefore subject to reporting bias. There may be pediatric critical care neurologists who did not receive the survey or chose not to complete it or who perform substantial clinical duties in the intensive care unit but do not self-identify as critical care neurologists or neurointensivists, for example, stroke neurologists or neonatal neurologists who also provide pediatric neurocritical care coverage. Third, not all respondents answered all questions, further limiting our ability to gain comprehensive insight into their practice characteristics. Fourth, the answers collected reflect the individual respondents’ characteristics and not necessarily those of the institutions at which they practice. Therefore, responses to questions addressing “centers” or “PNCC services” likely provide redundant information as several respondents may belong to the same institution; however, to preserve anonymity, we chose not to query the institutions at which survey respondents practice. Lastly, we did not include pediatric intensivists and other subspecialties who may be practicing pediatric neurocritical care, and thus their scope of practice is not included in this study. Similarly lacking from analysis is a description of service time dedicated to nonneurology specialties (ie, pediatric critical care medicine) for those child neurologists with specialty training outside of neurology.

Conclusions

We present the results of a survey-based analysis of the characteristics and practice of a cohort of pediatric critical care neurologists. We have gained insight into the demographics, training background, and practice structure of physicians who continue to shape this growing field. We report their views on the future of pediatric neurocritical care and potential barriers to growth of this field. This publication serves as a framework that could be utilized to perform subsequent studies of pediatric neurocritical care and the physicians who lead these teams. Future research directed at pediatric critical care neurology practice variabilities, regionalization of care to centers with pediatric neurocritical care for specific neurocritical care conditions, as well as the linkage of pediatric neurocritical care to outcomes utilizing standardized measures are pathways to enhance the field of pediatric neurocritical care.

Supplemental Material

sj-pdf-1-jcn-10.1177_08830738211070099 - Supplemental material for Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience

Supplemental material, sj-pdf-1-jcn-10.1177_08830738211070099 for Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience by Raquel Farias-Moeller, Anuj Jayakar, Rejean M. Guerriero, Jessica L. Carpenter, Mark S. Wainwright and Dana B. Harrar in Journal of Child Neurology

Footnotes

Acknowledgments

We thank Rebecca Rehborg and Rupa Nallamothu for assistance with coordination of study; Daniel Eastwood, MS, for assistance with statistical analyses; and the Medical College of Wisconsin, Milwaukee, WI, USA.

Conflict of Interest

Declaration of Conflicting Interests

The author(s) declare the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MSW is a member of the Clinical Advisory Board, Sage Therapeutics. DBH reports royalties from Demos Medical, Springer Publishing. RFM, AJ, RMG, and JLC report no disclosures relevant to this manuscript.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Ethical Approval

The study was approved by the Institutional Review Board of the Medical College of Wisconsin (Pro00036749) and certified exempt by the Institutional Review Board of Children’s National Hospital (Pro00014008).

ORCID iDs

Raquel Farias-Moeller

Mark S. Wainwright

Dana B. Harrar

Supplemental Material

Supplemental material for this article is available online.

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