e2 50 Philibert I, Friedmann, P, Williams WT for the members of the AC GME Work Group on Resident Duty Hours New requirements for resident duty hours JAMA 2002;288 1112 1114 51 APRN Consensus Work Gro[.]
Trang 150 Philibert I, Friedmann, P, Williams WT for the members of the
AC-GME Work Group on Resident Duty Hours New requirements for
resident duty hours JAMA 2002;288:1112-1114.
51 APRN Consensus Work Group & National Council of State Boards
of Nursing APRN Advisory Committee The Consensus Model for
APRN Regulation: Licensure, Accreditation, Certification, Education
2008 https://www.ncsbn.org/Consensus_Model_for_APRN_
Regulation_July_2008.pdf.
52 Tume LN, Coetzee M, Dryden-Palmer K, et al Pediatric critical care
nursing research priorities—initiating international dialogue Pediatr
Crit Care Med 2015;16:e174-e182.
53 Hooper-Kyriakidis P, Stannard D Clinical Wisdom and Interventions
in Acute and Critical Care 2nd ed New York, NY: Springer; 2011.
54 Curley MAQ The essence of pediatric critical care nursing In: Curley
MAQ, Moloney-Harmon PA, eds Critical Care Nursing of Infants and
Children Philadelphia: WB Saunders; 2001.
55 McAlvin SS, Carew-Lyons A Family presence during resuscitation
and invasive procedures in pediatric critical care Am J Crit Care 2014;
23:477-485.
56 Curley MAQ, Meyer EC, Scoppettuolo LA, et al Parent presence during invasive procedures and resuscitation: evaluating a clinical
practice change Am J Respir Crit Care Med 2012;186:1133-1139.
57 O’Grady TP A new age for practice: creating the framework for
evi-dence In: Malloch K, O’Grady TP, eds Introduction to Evidence-Based Practice in Nursing and Healthcare 2nd ed Sudbury, MA: Jones and
Bartlett; 2009.
58 Donovan AL, Aldrich JM, Gross AK, et al Interprofessional care and
teamwork in the ICU Crit Care Med 2018:46;980-990.
Trang 2Abstract: As the critical care environment became increasingly
complex, nurses caring for critically ill children and their families
ensured that their practice evolved to best meet patient and family
needs Nurses spend the most time in direct contact with patients
and families and are essential members of the critical care team
Quality of care and morbidity and mortality outcomes of patients
are positively impacted by nursing care, nurses’ level of experience,
and certification Roles for nurses working in pediatric critical care have evolved with the specialty Nurses create an environ-ment to safely shepherd children and their families during the critical care experience
Key Words: Nursing science, quality of care, Nightingale metrics, synergy, professional development, pediatric critical care nursing
Trang 37
Fostering a Learning Healthcare
Environment in the Pediatric
Intensive Care Unit
MELVIN G PERRY JR AND JERRY J ZIMMERMAN
• A learning healthcare system occurs when patient care,
inter-disciplinary education, and clinical research are so integrated
and intercalated that they are basically inseparable Each
element informs and benefits from the other.
• Professionalism provides the foundation for a learning
healthcare environment and encompasses the concepts of
accountability, respect, and an inclusive, diverse team.
• Standardization, in the form of clinical standard work, represents
the infrastructure for iterative improvement Without
standard-ization, measurements of improvement are not possible.
PEARLS
• Because pediatric critical care providers should ideally base practice on science and not empiricism, the pediatric intensive care unit must serve as the clinical laboratory for generation of evidence.
• Primary benefits of a learning healthcare environment include identification of best available evidence to support best practice and promotion of wellness and resiliency among critical care providers.
Incredibly important as it is, there is more to working in the
pediatric intensive care unit (PICU) than providing care for
critically ill children When critical care providers converse
about what they do, the discussion typically includes ensuring
rapid and accurate diagnosis and treatment, providing support
for dysfunctional/failed organ systems, and preventing
compli-cations of critical illness and its treatment However, this
chapter considers another activity that will enrich any PICU,
including the physical space, the actual work, and the people
who provide and receive treatment This overlooked but key
aspect of critical care may be described as fostering a learning
healthcare environment
Learning Healthcare System
A learning healthcare system occurs when patient care,
interdisci-plinary education, and clinical research are so integrated and
inter-calated that they are basically inseparable (Fig 7.1) Each element
synergistically benefits from and informs the other.1 Such
continu-ous and reciprocal learning and knowledge translation ultimately
facilitates enhanced performance and improved outcomes for both
patients and providers
Foundation Predicated on Professionalism
Professionalism provides the foundation for a learning healthcare environment and encompasses the concepts of accountability, respect, and teamwork In the PICU, accountability means prac-ticing value-based care that considers both the cost and the qual-ity of care delivered2 plus demanding a culture of safety.3 Critical care practitioners work at the intersection of complex patients, complex therapies, and a complex environment that collectively provide the antecedents for a potential perfect storm for inadver-tent adverse events A culture of safety includes being personally accountable, practicing clinical standard work, engaging multi-disciplinary teams, focusing on systems, and anticipating unintended consequences,4 all of which are linked with effective communication (Fig 7.2).5
Respect within professionalism centers around inclusion and diversity Unfortunately, research in workforce diversity and in-clusion, including healthcare industry workforce as a whole and within different specialties and subspecialties, is sparse However, numerous studies have concluded that race and ethnicity are so-cial constructs with profound soso-cial, economic, legal, finanso-cial, and health implications for the global population, including the
Trang 448 SECTION I Pediatirc Critical Care: The Discipline
PICU workforce A 2018 study concluded: “There is an urgent
need for greater diversity, with respect to gender, race, ethnicity,
and sexual orientation in the U.S healthcare workforce While
society, in general, is becoming more diverse, the same cannot be
said of American medicine.”6 , 7
Interestingly, at least by some measures, the most diverse
coun-tries are considered to be in sub-Saharan Africa, while the least
diverse tend to be in Europe and Northeast Asia, with the United
States in the middle, ranking slightly above Russia and slightly
below Spain.8 Census data from 2017 demonstrated that the
United States is becoming more diverse, with Asian and
mixed-race populations leading the way.9
American healthcare, including PICU staffing, has not kept
pace with changing general population demographics A 1997
study found that the supply of minority physicians will need to
double for Hispanic and black physicians, triple for Native
American physicians, and decrease by two-fifths for white
physi-cians and two-thirds for Asian and Pacific Island physiphysi-cians to
meet US healthcare needs with racial and ethnic population
par-ity, based on managed care–based recommendations of 218
physi-cians per 100,000 population.10
In defining the scope of diversity, race, gender (including
nonbinary identities), genetics, and socioeconomics must be
considered and respected At the lowest bar, institutional and
individual healthcare providers can be disbarred from third-party
private and governmental payers for treating patients differently
based on diversity characteristics noted earlier As healthcare moves into quality outcomes as a determinant for reimburse-ment, these issues take on even greater importance Studies have shown that concordance between physician and patient demo-graphics improves quality measures.11-13 In pediatric populations, studies have found that racial and ethnic minority children have disparities in their healthcare access and outcomes versus their white counterparts.14 Enrollment in the State Children’s Health Insurance Program decreases but does not eliminate these dis-parities, which vary by state.15 A recent British study found that concordance did not affect a patient’s assessment of hospitalist performance.16 This is good news for the PICU population in terms of quality measures
Historically, clinical research, one of the pillars of a learning healthcare environment, was not necessarily designed and con-ducted to measure and analyze the different responses of racial/ ethnic and gender minorities to a given treatment There is evi-dence that research scholarship generated by diverse research teams yields research that is higher quality and more impact-ful.17 , 18 The National Institutes of Health (NIH) has been encour-aging diversity in research enrollment for years, and the Scientific Workforce Diversity Office leads the NIH’s effort to diversify the national scientific workforce (e.g., #GREATMINDSThinkDiffer-ently [https://diversity.nih.gov/]) The Department of Health and Human Services recently offered funding opportunities to in-crease minority participation in multidisciplinary PICU confer-ences (R13, Pediatric Critical Care Conferconfer-ences Initiative, RFA-HD-20-012) Nevertheless, African-American, LatinX, Na-tive Alaskan, NaNa-tive American, and NaNa-tive Hawaiian populations remain underrepresented in medicine as compared with their proportion of the general population For example, African Americans and LatinX constitute about 13% and 17% of the general population, respectively, but represent only about 4.2% and 4.6%, respectively, of physicians.19 Native American, Alaskan Native, Native Hawaiian, and Pacific Islander are represented even less.6 , 7 , 19 Providers from underrepresented minority groups are more likely to practice in an underserved area.20 , 21 Even less is known about LGBT physician workforce numbers A recent sur-vey of Pediatric Department Chairs in the United States found that only 0.4% of faculty identified as LGBT.20
Pediatrics appears to be doing better than other medical spe-cialties and subspespe-cialties regarding physician diversity, particu-larly from a gender standpoint A 2017 workforce study found that 73% of residents, 64% of fellows, and 54% of faculty were female.22 American Board of Pediatrics data from 2017 showed that 40% of all certified PICU physicians were women and 60%
of first-year fellows were female.12 Most African-American and LatinX physicians are first-generation doctors, unlike their white counterparts Moreover, the majority of the underrepresented minorities enter primary care, not medical or surgical subspecial-ties For critical care physicians, the most recent preliminary data
of the Society of Critical Care Medicine’s Diversity and Inclusion Committee suggests that 1% to 2% of intensivist members are African American and about 10% are LatinX
Despite the demonstrable benefits of a diverse physician work-force, disparities and outright discrimination remain evident The literature surrounding this issue has primarily focused on women, but there is no reason to believe that the discriminatory behaviors toward women remain, while those toward ethnic and racial minorities would have ceased, since women represent a greater percentage of physicians, at 37%, than all racial minorities combined.19 A third of female physicians have experienced sexual
PICU Learning healthcare environment
Professionalism
Best practice clinical care Clinical research
Complex
patients therapiesComplex
Complex environment
• Fig. 7.2 Intensivecarecomplexity.
Trang 5CHAPTER 7 Fostering a Learning Healthcare Environment in the Pediatric Intensive Care Unit
harassment23; women are less likely to be introduced as “doctor”24;
women are less likely to be first authors in top-tier journals18;
women are less likely to be included on expert guideline
consen-sus panels25; there are fewer women in leadership, including
editorial board positions, even in pediatrics6 , 22 , 26; there are fewer
women full professors6 , 27; women receive less research startup
funding18 , 28; and a significant gender pay gap persists in
medicine.29 , 30
Studies in other industries have demonstrated that
manage-ment teams with higher gender diversity outperformed those with
less diversity,31 and greater gender diversity increased overall
busi-ness performance, including number of customers, revenue, and
profits.32 Similarly, companies with a racially and ethnically
di-verse workforce financially outperform their competitors by 35%
Yet 97% of US companies have an executive/senior leadership
that fails to reflect the country’s ethnic and racial diversity.33
Healthcare also fails in this regard—including pediatrics—and
therefore likely also pediatric critical care The case for a diverse
healthcare workforce includes advancing culture competency,
in-creasing access to high-quality healthcare services, strengthening
the medical research agenda, and ensuring optimal management
of the healthcare system.21
The third aspect of professionalism is teamwork—and
nowhere is this more important than in the PICU.34 Consider, for
example, early mobilization and the cast of providers required to
make it successful: physical therapy, nursing, respiratory therapy,
nutrition services, pharmacy, physicians, and the patient and
fam-ily Effective teamwork in the PICU must acknowledge patients
and families first,35 celebrate the interdisciplinary care team,
include clinical research personnel, and promote wellness and
re-siliency Such teamwork facilitates well-being; this, in turn,
sup-ports improved patient-clinician relationships, a high-functioning
care team, and an engaged and effective workforce (https://nam
edu/initiatives/clinician-resilience-and-well-being/)
Pillars of a Learning Healthcare Environment
Best-Practice Clinical Care
Characteristics of clinical standard work include being
con-sciously developed and documented; evidence based whenever
possible, consensus derived when evidence is absent, followed by
everyone performing the work, “owned” by someone, describes a
clinical pathway/patient trajectory, is measurable, and represents
the basis for improvement.36 Standardization facilitates
identify-ing and eliminatidentify-ing waste, communicatidentify-ing between providers,
establishing a baseline for continuous improvement, and
mini-mizing noise/controlling for nuisance variables Standardization
represents the infrastructure for iterative improvement Without
standardization, measurements of improvement are not possible.37
Clinical standard work benefits from continuous process
im-provement longitudinal plan-do-study-act (PDSA) cycles
embed-ded in clinical research or quality improvement Probably the best
illustration of this concept, iterative research protocols
imple-mented into clinical practice, is the amazing history of acute
lymphocytic leukemia (ALL) In the 1950s, ALL was a death
sentence for a child within a few months; today, almost all
chil-dren with ALL experience long-term survival.38 Advantages of
protocolized critical care have been summarized and include
avoiding errors of omission, improving PICU efficiency,
decreas-ing cost and improvdecreas-ing value, and maintaindecreas-ing and improvdecreas-ing the
standard of care.39
Clinical Research, Including Quality Improvement
Currently, of the three determinants that affect clinical decision-making by critical care practitioners—education, experience, and evidence—the latter is least abundant However, Claude Bernard astutely noted that while most people regard medicine as the art
of healing, it is more appropriate to regard medicine as the science
of healing because providers should ideally arrive at a cure scien-tifically and not empirically.40 For a fundamental discovery to transpire, appropriate clinical stimuli must interact with scientific training41—what better place than the PICU? But for this to hap-pen, a real collaboration must exist among the principal investiga-tor, patient and family, and the entire bedside care team Primary clinical faculty must work alongside physician-scientists to ensure success of clinical research in the PICU.42
One example of the power of critical care research is the story
of central line–associated bloodstream infections (CLABSIs) among critically ill children Previously, such infections were viewed as almost inevitable among critically ill children but are known to be associated with increased duration of stay, prolonged antibiotic therapy, ongoing need for venous access, increased mor-bidity and mortality, and increased healthcare costs.43 National quality improvement research focused on insertion and mainte-nance bundles for central venous catheters (CVCs) resulted in a decrease in PICU CLABSI from 5.8 to 1.4 infections per 1000 CVC days over a 5-year intervention interval.44 Today, a CLABSI typically evokes root cause analysis, reviewed as a serious adverse PICU event In a similar fashion, investigators have critically ex-amined the utility of the Society of Critical Care Medicine’s ICU Liberation bundle of clinical standard work elements as infra-structure for usual care provided to critically ill adults.45 ABCDEF Bundle elements are summarized in Table 7.1
Cohort analyses from two independent investigations demon-strated that proportional compliance with ABCDEF bundle elements resulted in significant and dose-related improvements in outcomes—specifically survival, duration of mechanical ventila-tion, neurologic organ dysfunction (i.e., delirium and coma), physical restraint use, ICU readmission rates, and discharge dis-position of ICU survivors.46 , 47 These positive intervention effect sizes were not subtle
Interdisciplinary Educational Model
In a learning healthcare environment, everyone is a teacher and everyone is a student Benefits of an interdisciplinary model for teaching/education have been summarized and include developing teamwork; engaging in realistic simulations; expanding tolerance
TABLE
7.1 Elements of Society of Critical Care Medicine’s ICU Liberation Bundle
A Always prioritize assessment, prevention, and management of pain
B Both spontaneous awakening and breathing trials at least daily
C Cognizant choice of analgesics and sedatives
D Delirium: assess, prevent, and manage
E Early mobilization and exercise
F Family engagement and empowerment in the care plan