e1 SECTION XV Pediatric Critical Care Board Review Questions e2 136 Board Review Questions Chapter 1 History of Pediatric Critical Care Medicine 1 Treatment for which of the following disease entities[.]
SECTION XV Pediatric Critical Care: Board Review Questions e1 136 Board Review Questions Chapter 1: History of Pediatric Critical Care Medicine Treatment for which of the following disease entities was not an important trigger in the early development of distinct, full-time, multidisciplinary pediatric intensive care units: A Measles B Poliomyelitis C Reye syndrome D Tetanus Preferred response: A Rationale In Europe, pediatric intensive care followed shortly after the poliomyelitis epidemic in Denmark in 1952 In 1955, Dr Goran Haglund, a pediatric anesthesiologist, established the first medical-surgical pediatric intensive care unit (PICU) for infants and children at the Children’s Hospital in Göteborg in Sweden In France, in 1963, a newborn presented with tetanus and was admitted to l’Hôpital des Enfants Malades of Paris Shortly afterward, Dr Gilbert Huault and J.B Joly, both neonatologists, opened the first multidisciplinary PICU in France at Saint Vincent de Paul Children’s Hospital This unit was the first pediatrician-directed PICU in Europe; it soon became a major influence on the development of PICUs In the mid-to-late 1970s, as pediatric cardiovascular surgery for more complex lesions in infants was developing, nurses provided postoperative care in designated units Children with Reye syndrome suddenly appeared, requiring complex multisystem care In addition, in the 1980s, emergency medical services (EMS) systems began transporting severely injured children to hospitals, where they required rapid assessment and intervention by nurses and physicians and initiation of cardiorespiratory and neurologic support Of the following, which most profoundly influenced the development of early distinct, geographically separate, multidisciplinary pediatric intensive care units? A Advanced forms of mechanical ventilation B Federal government finance programs C New therapeutic interventions for oncology patients D Nursing Preferred response: D e2 Rationale Pediatric critical care medicine (PCCM) developed initially through the efforts of pediatric anesthesiologists, as well as pediatric general and cardiac surgeons, and neonatologists In fact, most of the original PICUs were founded by pediatric anesthesiologists Before discrete, geographically separate, intensive care units evolved, critically ill children often received close monitoring, intensive nursing care, and pulmonary support in the postanesthetic recovery room Chapter 2: High-Reliability Pediatric Intensive Care Unit: Role of Intensivist and Team in Obtaining Optimal Outcomes The three dimensions of healthcare quality stated by Donabedian are: A Reliability, operations, resilience B Safety, efficiency, outcome C Structure, process, outcome D Structure, system, efficiency Preferred response: C Rationale Avedis Donabedian, an early “systems thinker” in healthcare, stated that healthcare quality should be based upon three dimensions: structure-process-outcomes Structure is the setting in which care is delivered Process refers specifically to how care is provided, including incorporation of high reliability principles into daily activities Outcomes refer to endpoints of care, including commonly used quality and safety measures, and other key outcomes such as length of stay, patient/family experience, and cost/value A care bundle is defined as: A A flow-chart to guide provider decision making for a disease process B A list of standardized, best practice interventions for a patient population or disease C A way of designing an intensive care unit to cohort patients according to their disease process D Collaboration between multiple hospitals to provide the best possible patient care Preferred response: B CHAPTER 136 Board Review Questions Rationale A care bundle is a relatively short list of standardized, generally evidence-based or best practice interventions for a patient population or disease that, when implemented consistently, leads to improved outcomes It is the combination of elements performed consistently and in aggregate that drive improvement A clinical pathway is a flow chart to guide provider decision making The PICU leadership team at your hospital is discussing the results of a recent analysis of a quality and safety benchmark report showing a drop in performance measures over the previous three quarters The PICU nursing director states that several PICUs have improved quality by learning from so-called high-reliability organizations Which of the following industries are commonly cited as high-reliability organizations? A Coal mining B Commercial aviation C Healthcare D High-speed passenger railroad Preferred response: B Rationale The most commonly cited examples of high-reliability organizations include U.S Navy aircraft carrier flight deck operations, commercial aviation, nuclear power, and wilderness/forest firefighting Whereas many healthcare organizations certainly aspire to become high-reliability organizations, there are few examples (if any) of high-reliability organizations in healthcare today High-reliability organizations are characterized by five core principles Which of the following is a core principle of all high-reliability organizations? A Commitment to resilience B Deference to hierarchy (“command and control”) C Lack of transparency D Preoccupation with success Preferred response: A Rationale The five core principles of high-reliability organizations include deference to expertise, reluctance to simplify, sensitivity to operations (which often means greater transparency), preoccupation with failure (and learning from failures), and commitment to resilience Chapter 3: Critical Communication in the Pediatric Intensive Care Unit Which is an important factor in the successful implementation of huddles? A Designating a leader B Encouraging the elective participation of team members C Holding the huddle in a remote location D Performing on an ad hoc basis Preferred response: A e3 Rationale All huddles should be led by a designated leader to keep the discussions brief and focused Mandatory participation of all team members is required for a successful huddle Huddles should be held in a central location to encourage all team members to attend Huddles should be incorporated in an institution’s standard work The duration of huddles should be 10 minutes or less, whenever possible What is the focus of team training programs? A Avoiding errors during training to prevent confusion B Developing communication strategies that promote hierarchy among team members C Emphasizing individual tasks, duties, and responsibilities D Facilitated debriefings Preferred response: D Rationale Team training programs focus on facilitated debriefings to transform experiences into retained knowledge Members are encouraged to learn all team tasks, duties, and responsibilities Incorporating errors during training allows for the creation of contingency plans The focus of communication strategies is to flatten hierarchy and encourage assertiveness Closed-loop communication maintains a shared mental model among all team members Chapter 4: Professionalism in Pediatric Critical Care Which of the following best describes the Charter on Medical Professionalism? A It depicts the good and virtuous doctor B It focuses on putting the patient first C It portrays professionalism as a social contract D It recognizes the patient’s right to access all medical resources Preferred response: C Rationale The charter sets forth a social contract by which professionals justify the privileges of their profession by performing as professionals It lays out principles that underlie 10 commitments of physicians to patients and society It is not a description of the good and virtuous doctor All recognize that doctor by his or her behaviors toward patients and others It views the social contract in the context of the “medical marketplace” and social and financial pressure Although it emphasizes altruism and putting the patient first, it goes well beyond that in defining broad commitments to society The charter recognizes the patient’s right to make informed choices among the available options, but it also lays out commitments under which the physician distributes finite resources equitably and informs patients honestly and as completely as possible so that they can choose wisely e4 S E C T I O N XV Pediatric Critical Care: Board Review Questions Which is true of the Physician Charter? A It describes professional responsibilities B It expresses ethical values C It mandates professional behaviors D It sets guidelines for regulatory agencies Preferred response: A Rationale The charter describes the responsibilities that fulfill the physician’s professional contract with society It does not have the force of law and has no power to mandate professional behavior It does not reduce physician responsibilities to guidelines for actions It is not so much a statement of ethical values as it is a commitment to 10 practical physician responsibilities Chapter 5: Leading and Managing Change in the Pediatric Intensive Care Unit The following questions are based on this vignette: You are the medical director of a “closed” PICU in which surgical patients are co-managed by the surgical and critical care services with all other medical admissions admitted to the critical care service, and consultant services not enter patient orders without express discussion with the critical care team One common exception to this delineation of medical team hierarchy involves the anesthesia pain service which has maintained direct management of all patient controlled anesthesia (PCA) infusions even in the PICU In the past months, (1) two new orthopedic surgeons joined the practice and have contributed to a doubling of the usual admission volume for postoperative spinal fusion admissions, (2) a new delivery system was deployed for all PCA pumps that requires a code to be entered to reprogram the PCA settings, (3) a new hospital policy now restricts prescription of additional opioid medications to only pain service physicians and nurse practitioners for all patients who have PCA orders, and (4) the pain service has lost personnel going from physicians and nurse practitioners providing 24/7 coverage to physician and nurse practitioner that provide daytime in-person coverage with nights and weekend coverage provided by the on-call anesthesia team At the same time, patient satisfaction scores have declined for these patients, anonymous family surveys report feeling like their child’s pain was ignored in the postoperative period, and multiple adverse event reports have been submitted detailing challenging conversations and delays in patient care Specifically, families have complained, and the bedside nursing team has reported that acute pain episodes not resolved with PCA parameters are left unaddressed for too long while the critical care team calls the pain service to adjust analgesia and add adjunctive therapies in response to breakthrough pain Also, the PICU bedside team reports frustration that the pain service does not take into account nursing pain assessments when making decisions You have been tasked with implementing a new care guideline that addresses the perception that there is a delay in responding immediately to patient reported pain symptoms As you consider how to address this patient care issue, the initial approach MOST LIKELY to achieve rapid and sustained improvement in management of postoperative pain in this patient population with the LEAST amount of disruption of established practice and work flow among involved parties is: A Meet with the medical director of anesthesia pain service and explain that for all other consulting services on PICU patients, the PICU has direct management of all patient care Therefore, the PICU will now assume primary responsibility of all pain management including PCA prescriptions The pain service would be consulted only if the patient’s pain is not adequately controlled by the PICU team’s approach and at time of transfer from the PICU, at which time the pain service will assume primary responsibility for pain management as currently occurs in all other surgical inpatient admissions B Request a comprehensive report from the hospital Process Improvement Committee of the past year’s posterior spinal fusion post-op PICU admissions that details patient data from the first 24 hours of PICU admission related to pain scores, total patient opioid exposure, frequency of prn doses of rescue medications for increased patient pain, and pain service documentation C Meet with the PICU RN leading Process Improvement initiatives in the PICU to discuss the situation and identify multi-disciplinary and multi-professional representatives to investigate the scope of the concerns, to understand the current work flow and impacted team members, to list key drivers impacting this aspect of care, and to identify current “best practice.” D Develop a comprehensive re-education process targeting new PICU RNs on the physiologic and psychologic aspects of pediatric pain and nonpharmacologic interventions that have been proven to reduce or eliminate need for pharmacologic intervention E Empower bedside PICU RNs to advocate for their patient and re-emphasize the role of the PICU charge RN to support and guide individual RNs through difficult situations Preferred response: C CHAPTER 136 Board Review Questions Rationale While all five answers are reasonable components of developing a new patient care guideline, only answer C describes an initial planning process that maps out a plan for gaining understanding of the scope of the challenge and for identifying needed participants in the development and implementation of the new guideline Depending on this preliminary planning work, any of the other four approaches could be needed components of the overall strategy However, beginning with any of the other four answers could create significant resistance to change (answer A), create significant time-intensive data collection that does not answer targeted questions (answer B), repeat training that does not address the necessary gaps in knowledge (answer D), or fail to recognize the role of other PICU team members in addressing the situation (answer E) You and your team have developed a new patient care guideline for post-op pain management for these patients The MOST EFFECTIVE and MOST RESPONSIVE means of evaluating the initial impact of these new guidelines is to: A Develop data collection tools that populate quarterly reports for review B Track monthly patient satisfaction scores and surveys and review the results with PICU staff C Perform rapid, real-time data collection for each patient impacted by the new analgesia and solicit verbal feedback on whether or not the patient’s pain has been adequately managed D Perform rapid, real-time data collection of pre-determined objective and subjective data elements and solicit input from bedside PICU team members for ways to improve the new guideline that can be immediately incorporated and evaluated after ad hoc review by a core team of identified project leaders E Hold monthly meetings during which the current bedside team caring for any patients undergoing posterior spinal fusions can provide their input on how the guidelines are working Preferred response: D Rationale Rapid Plan-Do-Study-Act (PDSA) cycles allow immediate assessment of the impact of change as well as timely and responsive adjustments to new initiatives that address unanticipated consequences of the new guidelines PDSA cycles evaluate predetermined outcomes and promote transparency about the effort for all involved PICU team members In order to avoid premature changes based on single instances, a core leadership team should evaluate proposed changes and adjust planned performance metrics accordingly e5 Since deployment months ago, these postoperative analgesia management guidelines have been very successful and are being used as a model for interprofessional pain management and team communication among other surgical specialty patients A senior anesthesiologist who started the pain service and was away on extended sabbatical over the past year returns to clinical service When first informed, he was skeptical about the guidelines, citing 30 years of personal experience in postoperative pain management as being superior to the approach used in the guidelines He has cancelled two previously informally scheduled meetings with you to review the new guidelines and discuss his specific concerns In the past weeks, he has become more vocal in his objections and has voiced his disagreement in front of families in the middle of morning rounds, leading to multiple complaints by PICU team member and family members You have firsthand experience working with this physician on other successfully implemented patient care initiatives and have always found his brusque comments and opinions to be insightful and well-meaning You believe that you have a productive, honest, and friendly relationship with him based on your prior shared successes The BEST initial method for addressing this physician’s disruptive behavior is: A Meet with the hospital Chief Medical Officer and the department chair of anesthesiology to discuss this individual’s behavior and request that he be removed from participation in clinical care for these patients until he has been counseled and completed education and training on these guidelines B Meet him in his office with two cups of coffee to begin an impromptu conversation to better understand the basis of his disagreements with the guidelines C Hold an intervention meeting with the anesthesiologist, yourself, and one or two members of your core guideline development leadership team to acknowledge that the anesthesiologists recent behavior has been disruptive and counterproductive to your shared goals for delivering optimal patient care, to describe the ways in which the guidelines have improved patient care, acknowledge the instances in which the guidelines could still be optimized, and to ask for specific thoughts on how the guidelines can be modified to address his specific concerns and misgivings D Collect statements from witnesses of his disruptive behavior to share with him and his department chair as examples of the negative impact of his actions, demand that he apologize to the PICU team, and set the expectation that he comply with the analgesia guidelines E Refer the situation to the hospital professional standards committee Preferred response: C ... you consider how to address this patient care issue, the initial approach MOST LIKELY to achieve rapid and sustained improvement in management of postoperative pain in this patient population with... initial method for addressing this physician’s disruptive behavior is: A Meet with the hospital Chief Medical Officer and the department chair of anesthesiology to discuss this individual’s behavior... is true of the Physician Charter? A It describes professional responsibilities B It expresses ethical values C It mandates professional behaviors D It sets guidelines for regulatory agencies