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[.]
50 S E C T I O N I Pediatirc Critical Care: The Discipline and 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 support (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 improvement that will inform design for the next PDSA cycle Realtime team debriefing around critical events (doing in context) represents a particularly effective interdisciplinary simulation teaching modality.49 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) Participation 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 Benefits of a Learning Healthcare Environment Key References 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 clinical research related to pediatric critical 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 Facilitates identification, delivery of high value patient and family care Fostering A Learning Healthcare Environment Ely EW The ABCDEF Bundle: Science and philosophy of how ICU liberation serves patients and families Crit Care Med 2017;45(2):321-330 Lane-Fall MB, Miano TA, Aysola J, Augoustides JGT Diversity in the emerging critical care workforce: analysis of demographic trends in critical care fellows from 2004 to 2014 Crit Care Med 2017; 45(5):822-827 Meade MO, Ely EW Protocols to improve the care of critically ill pediatric and adult patients JAMA 2002;288(20):2601-2603 Mendoza FS, Walker LR, Stoll BJ, et al Diversity and inclusion training in pediatric departments Pediatrics 2015;135(4):707-713 Rivara FP, Alexander D Randomized controlled trials and pediatric research Arch Pediatr Adolesc Med 2010;164(3):296-297 Rotenstein LS, Jena AB Lost Taussigs: the consequences of gender discrimination in medicine N Engl J Med 2018;378(24):2255-2257 Smith MD, et al., eds, for the Committee on the Learning Health Care System in America Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Washington DC: National Academy Press; 2013 Walrath JM, Muganlinskaya N, Shepherd M, et al Interdisciplinary medical, nursing, and administrator education in practice: the Johns Hopkins experience Acad Med 2006;81(8):744-748 Promotes wellness for the community ICU practitioners and patients • Fig 7.3 Fostering a learning healthcare environment The full reference list for this chapter is available at ExpertConsult.com e1 References Smith MD, et al, eds, for the Committee on the Learning Health Care System in America Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Washington DC: National Academy Press; 2013 Hernu R, Cour M, de la Salle S, Robert D, Argaud L, for the Costs in French ICUs Study Group Cost awareness of physicians in intensive care units: a multicentric national study Intensive Care Med 2015;41(8):1402-1410 Thornton KC, Schwarz JJ, Gross AK, et al Preventing Harm in the ICU-building a culture of safety and engaging patients and families Crit Care Med 2017;45(9):1531-1537 Leape LL, Berwick DM Five years after To Err Is Human: what have we learned? JAMA 2005;293(19):2384-2390 Piazza O, Cersosimo G Communication as a basic skill in critical care J Anaesthesiol Clin Pharmacol 2015;31(3):382-383 Lane-Fall MB, Miano TA, Aysola J, Augoustides JGT Diversity in the Emerging critical care workforce: analysis of demographic trends in critical care fellows from 2004 to 2014 Crit Care Med 2017;45(5):822-827 Xierali IM, Castillo-Page L, Zhang K, Gampfer KR, Nivet MA AM last page: the urgency of physician workforce diversity Acad Med 2014;89(8):1192 Alesina A, Devleeschauwer A, Easterly W, Kurlat S, Wacziarg R Fractionalization EconPapers Harvard Institute of Economic Research Working Papers 2002; Harvard Institute of Economic Research (1959) Vespa J, Armstrong DM, Medina L Demographic turning points for the United States: Population Projections for 2020 to 2060 https:// www.census.gov/content/dam/Census/newsroom/press-kits/2018/ jsm/jsm-presentation-pop-projections.pdf 10 Libby DL, Zhou Z, Kindig DA Will minority physician supply meet U.S needs? Health Aff (Millwood) 1997;16(4):205-214 11 Saha S, Komaromy M, Koepsell TD, Bindman AB Patientphysician racial concordance and the perceived quality and use of health care Arch Intern Med 1999;159(9):997-1004 12 Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR Patient-centered communication, ratings of care, and concordance of patient and physician race Ann Intern Med 2003;139(11):907-915 13 Laveist TA, Nuru-Jeter A Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav 2002;43(3):296-306 14 Shone LP, Dick AW, Brach C, et al The role of race and ethnicity in the State Children’s Health Insurance Program (SCHIP) in four states: are there baseline disparities, and what they mean for SCHIP? Pediatrics 2003;112(6 Pt 2):e521 15 Shone LP, Dick AW, Klein JD, Zwanziger J, Szilagyi PG Reduction in racial and ethnic disparities after enrollment in the State Children’s Health Insurance Program Pediatrics 2005;115(6):e697-705 16 Crawford D, Paranji S, Chandra S, Wright S, Kisuule F The effect of racial and gender concordance between physicians and patients on the assessment of hospitalist performance: a pilot study BMC Health Serv Res 2019;19(1):247 17 Valantine HA, Collins FS National Institutes of Health addresses the science of diversity Proc Natl Acad Sci U S A 2015;112(40): 12240-12242 18 Rotenstein LS, Jena AB Lost Taussigs - The Consequences of gender discrimination in medicine N Engl J Med 2018;378(24):2255-2257 19 Nivet MA, Castillo-Page, L Diversity in the Physician Workforce; Facts & Figures 2014 Washington DC: Association of American Medical Colleges; 2014 20 Committee on Pediatric Workforce Enhancing pediatric workforce diversity and providing culturally effective pediatric care: implications for practice, education, and policy making Pediatrics 2013;132(4):e1105-e1116 21 Cohen JJ, Gabriel BA, Terrell C The case for diversity in the health care workforce Health Aff (Millwood) 2002;21(5):90-102 22 Mendoza FS, Walker LR, Stoll BJ, et al Diversity and inclusion training in pediatric departments Pediatrics 2015;135(4):707-713 23 Jagsi R Sexual harassment in medicine: #MeToo N Engl J Med 2018;378(3):209-211 24 Files JA, Mayer AP, Ko MG, et al Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias J Womens Health (Larchmt) 2017;26(5):413-419 25 Mehta S, Rose L, Cook D, Herridge M, Owais S, Metaxa V The speaker gender gap at critical care conferences Crit Care Med 2018;46(6):991-996 26 Maxwell AR, Riley CL, Stalets EL, Wheeler DS, Dewan M State of the unit: physician gender diversity in pediatric critical care medicine leadership Pediatr Crit Care Med 2019;20(7):e362-e365 27 Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM Sex differences in academic rank in US medical schools in 2014 JAMA 2015;314(11):1149-1158 28 Sege R, Nykiel-Bub L, Selk S Sex differences in institutional support for junior biomedical researchers JAMA 2015;314(11):1175-1177 29 Weaver AC, Wetterneck TB, Whelan CT, Hinami K A matter of priorities? Exploring the persistent gender pay gap in hospital medicine J Hosp Med 2015;10(8):486-490 30 Lo Sasso AT, Richards MR, Chou CF, Gerber SE The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women Health Aff (Millwood) 2011;30(2):193201 31 Darwin JR, Selvaraj PC The effects of work force diversity on employee performance in Singapore organisations Int J Bus Admin 2015;6(2) 32 Herring C Does diversity pay?: Race, gender, and the business case for diversity Sociol Rev 2009;74(2) 33 Tulshyan R Racially diverse companies outperform industry norms by 35% Forbes 2015 January 30 34 Donovan AL, Aldrich JM, Gross AK, et al Interprofessional Care and Teamwork in the ICU Crit Care Med 2018;46(6):980990 35 Zimmerman BA A piece of my mind Patient’s sister, seeking job JAMA 2013;309(19):2003-2004 36 Womack JP, Jones DT Lean Thinking 2nd ed New York: Simon & Schuster, Inc.; 2003:397 37 Ohno T Toyota Production System: Beyond Large-Scale Production Portland, OR: Productivity Press; 1988 38 Ma H, Sun H, Sun X Survival improvement by decade of patients aged 0-14 years with acute lymphoblastic leukemia: a SEER analysis Sci Rep 2014;4:4227 39 Meade MO, Ely EW Protocols to improve the care of critically ill pediatric and adult patients JAMA 2002;288(20):2601-2603 40 Bernard C Pensées: Notes Detachées Bailliere et Fils Paris; 1937 41 Goldstein JL On the origin and prevention of PAIDS (paralyzed academic investigator’s disease syndrome) J Clin Invest 1986;78(3): 848-854 42 Rivara FP, Alexander D Randomized controlled trials and pediatric research Arch Pediatr Adolesc Med 2010;164(3):296-297 43 Nowak JE, Brilli RJ, Lake MR, et al Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: Business case for quality improvement Pediatr Crit Care Med 2010;11(5):579587 44 Edwards JD, Herzig CT, Liu H, et al Central line-associated blood stream infections in pediatric intensive care units: longitudinal 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 46 Barnes-Daly MA, Phillips G, Ely EW Improving hospital survival and reducing brain dysfunction at seven california community e2 hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients Crit Care Med 2016 47 Pun BT, Balas MC, Barnes-Daly MA, et al Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults Crit Care Med 2019;47(1): 3-14 48 Walrath JM, Muganlinskaya N, Shepherd M, Awad M, Reuland C, Makary MA, et al Interdisciplinary medical, nursing, and administrator education in practice: the Johns Hopkins experience Acad Med 2006;81(8):744-748 49 Allen JA, Reiter-Palmon R, Crowe J, Scott C Debriefs: teams learning from doing in context Am Psychol 2018;73(4):504-516 e3 Abstract: 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, bestpractice clinical care, clinical research, quality improvement, shared educational model, evidence-based medicine, burnout, wellness, resiliency Challenges of Pediatric Critical Care in Resource-Poor Settings AMÉLIE VON SAINT ANDRÉ–VON ARNIM, JHUMA SANKAR, ANDREW ARGENT, AND ERICKA FINK • Life-threatening illnesses are a global phenomenon with markedly 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 networks, (3) emergency and intensive care provided in wellresourced units and by trained personnel with (4) access to contemporary 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 fragmented The burden of critical illness remains inordinately high in LMICs, despite an overall decrease in global childhood mortality (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 universal shared goal Delivery of critical care in low-resource settings (LRSs) is in need of a tiered approach to scaling toward a gold standard that includes both strengthening capacity for public 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 example, irrespective of the setting—whether in a district health center with minimal resources and personnel or a tertiary care • • • • 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 rationale for expanding critical care services in least-developed countries Pediatric critical care services not have to be costly, nor 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 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 intensive 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, aggregate 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 experiencing 82.2% of deaths, up from 70.9% in 1990 The gains are partly attributable to attention by individual countries to the Millennium 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 improvements 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 mortality in infants and children globally 51 ... of my mind Patient’s sister, seeking job JAMA 2013;309(19):2003-2004 36 Womack JP, Jones DT Lean Thinking 2nd ed New York: Simon & Schuster, Inc.; 2003:397 37 Ohno T Toyota Production System: Beyond... access to contemporary 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... includes both strengthening capacity for public 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