50 SECTION I Pediatirc Critical Care The Discipline and respect; practicing complex communication; acknowledging patient, family, and other perspectives; sharing trust, value, and power; and thinking[.]
Trang 1and respect; practicing complex communication; acknowledging
patient, family, and other perspectives; sharing trust, value, and
power; and thinking about systems.48 For example, if a particular
PICU is interested in successfully transitioning patients receiving
active cardiopulmonary resuscitation onto extracorporeal life
sup-port (ECPR), the simulation must include surgeons, intensivists,
nurses, pump technicians, respiratory care personnel, and social
work providers Educational siloes related to ECPR cannot achieve
the desired outcome As noted previously, all of critical care is a
team activity, and team education around any clinical standard
work must be an essential component of continuous process
im-provement that will inform design for the next PDSA cycle
Real-time team debriefing around critical events (doing in context)
represents a particularly effective interdisciplinary simulation
teaching modality.49
Benefits of a Learning Healthcare
Environment
In a learning healthcare environment, the activities of patient
care, clinical research, and shared education are inexorably linked
to two common purposes ( Fig 7.3 ) The first obvious benefit is
generation or identification of best available evidence to support
best practice In addition to facilitating and participating in
clini-cal research related to pediatric criticlini-cal care, PICUs might also
consider implementation of E-SCOPE—evidence scanning for
clinical, operational, and practice efficiencies.49 E-SCOPE is a
systematic approach to identify and then rapidly implement
clinical practices that are supported by high-quality evidence It includes the following recurring steps: (1) conduct quarterly evidence searches, (2) decide which evidence-based practices to implement, (3) support implementation of selected practices, and (4) monitor progress.
The second, less obvious benefit is promoting wellness and resiliency among critical care providers Constant, significant stressors related to provision of pediatric intensive care represent real risk factors for burnout syndrome and a number of related adverse outcomes for PICU practitioners49 (see Chapter 22) Par-ticipation of the interdisciplinary team in shared education and research/quality improvement activities affords opportunities for critical care providers to unwind, debrief, and reflect, to provide mutual support, and to reinvigorate a sense of purpose for the important work of pediatric critical care.
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19 Nivet MA, Castillo-Page, L Diversity in the Physician Workforce;
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22 Mendoza FS, Walker LR, Stoll BJ, et al Diversity and inclusion
training in pediatric departments Pediatrics 2015;135(4):707-713.
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2018;378(3):209-211
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30 Lo Sasso AT, Richards MR, Chou CF, Gerber SE The $16,819 pay gap for newly trained physicians: the unexplained trend of men
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pediatric and adult patients JAMA 2002;288(20):2601-2603.
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case for quality improvement Pediatr Crit Care Med
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trends and compliance with bundle strategies Am J Infect Control
2015;43(5):489-493
45 Ely EW The ABCDEF bundle: science and philosophy of how ICU
liberation serves patients and families Crit Care Med 2017;
45(2):321-330
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6,064 patients Crit Care Med 2016.
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Trang 4Abstract: A learning healthcare system occurs when patient care,
interdisciplinary education, and clinical research are so integrated
and intercalated that they are basically inseparable Each element
synergistically benefits from and informs the other Benefits of a
learning healthcare system include generation or identification of
best available evidence to support best practice and promoting
wellness and resiliency among critical care providers.
Key Words: Learning healthcare system, diversity, inclusion, best-practice clinical care, clinical research, quality improvement, shared educational model, evidence-based medicine, burnout, wellness, resiliency
Trang 58
Challenges of Pediatric Critical Care
in Resource-Poor Settings
AMÉLIE VON SAINT ANDRÉ–VON ARNIM, JHUMA SANKAR, ANDREW ARGENT,
AND ERICKA FINK
• Global child mortality is declining due to decreasing poverty
and increasing basic medical care access and quality
• Given the large burden and high mortality of critical illness
and availability of low-cost therapies, there is ample
ratio-nale for expanding critical care services in least-developed
countries
• Pediatric critical care services do not have to be costly,
nor do they need to be overtly reliant on high-end
technology
PEARLS
• Publicly funded intensive care unit treatment remains limited
in low-income countries (LICs), and its introduction requires careful resource allocation
• Healthcare systems improvements for the critically ill should involve a graded approach of strengthening capacity to provide health maintenance, basic critical care, and publicly funded intensive care services as overall health indices improve
• Critical care research from LICs is sorely needed to guide effective and efficient care and advocate for resources
Life-threatening illnesses are a global phenomenon with
mark-edly disparate outcomes depending on available resources and
access to care Low- to middle-income countries (LMICs) are
economies defined by a gross national income per capita of $995
or less, and $996 to $3895 in 2017, respectively ( eFig 8.1 ).1 In
high-income countries (HICs), caring for critically ill patients
involves a coordinated system of (1) triage, (2) transport
net-works, (3) emergency and intensive care provided in well-
resourced units and by trained personnel with (4) access to
con-temporary laboratory services, (5) imaging, (6) transfusion, and
(7) surgical services This cohesive system is resource intensive
and, hence, less affordable for many LMICs, where care is
frag-mented The burden of critical illness remains inordinately high
in LMICs, despite an overall decrease in global childhood
mor-tality ( Fig 8.2 ).2 Thus, access to quality care for the critically ill
child with sudden and serious reversible disease, in addition to
trauma and postoperative critical care support, should be a
uni-versal shared goal Delivery of critical care in low-resource
set-tings (LRSs) is in need of a tiered approach to scaling toward a
gold standard that includes both strengthening capacity for
pub-lic health and critical care services.
For the purposes of this chapter, we define pediatric critical care
as the care of children who suffer an acutely life-threatening illness
or injury regardless of the location where care is provided For
ex-ample, irrespective of the setting—whether in a district health
center with minimal resources and personnel or a tertiary care
setting—treatment of severe lower respiratory infections, malaria,
or diarrhea with dehydration is critical care.5 In contrast, intensive
care is defined as care provided for the critically ill or injured or
those who have undergone major surgical procedures in an inten-sive care unit (ICU) with mechanical ventilators and equipment for close patient monitoring.
Child Mortality Rates Current Trends and Health Maintenance
Globally, child and adolescent deaths decreased 51.7%, from 13.77 million in 1990 to 6.64 million in 2017.6 However, ag-gregate disability increased 4.7% to a total of 145 million years lived with disability globally.6 Progress was uneven and inequity increased, with low- and low- to middle-income regions experi-encing 82.2% of deaths, up from 70.9% in 1990 The gains are partly attributable to attention by individual countries to the Mil-lennium Development Goals (MDGs), especially MDG 4, which was related to decreasing the under-5-years-old mortality rate by two-thirds by 2015 from 1990 baseline The overall improve-ments in other sectors—poverty, water, sanitation and hygiene, and socioeconomic indices—along with increasing vaccination rates, basic education, access to perinatal and other medical care and improving quality of care, have further helped to reduce mor-tality in infants and children globally.