A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit

Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department

OBJECTIVES

The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork.

METHODS

This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool.

RESULTS

We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007).

CONCLUSIONS

Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.

Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study

OBJECTIVES

Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU.

DESIGN

Multicenter retrospective cohort study using structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). Cases with potential errors were further reviewed by four pediatric intensivists who made final consensus determinations of diagnostic error occurrence. Demographic, clinical, clinician, and encounter data were also collected.

SETTING

Four academic tertiary-referral PICUs.

PATIENTS

Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 882 patient admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission. Infections (46%) and respiratory conditions (23%) were the most common missed diagnoses. One diagnostic error caused harm with a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history (69%) and failure to broaden diagnostic testing (69%). Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%, p = 0.011), neurologic chief complaints (46.2% vs 18.8%, p = 0.024), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%, p = 0.042), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 wk, p = 0.031), and diagnostic uncertainty on admission (77% vs 25.1%, p < 0.001). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58; 95% CI, 0.94-17.1) and diagnostic uncertainty on admission (OR 9.67; 95% CI, 2.86-44.0) were significantly associated with diagnostic error.

CONCLUSIONS

Among critically ill children, 1.5% had a diagnostic error up to 7 days after PICU admission. Diagnostic errors were associated with atypical presentations and diagnostic uncertainty on admission, suggesting possible targets for intervention.

Continuity Strategies for Long-Stay PICU Patients: Consensus Statements From the Lucile Packard Foundation PICU Continuity Panel

OBJECTIVES

To develop consensus statements on continuity strategies using primary intensivists, primary nurses, and recurring multidisciplinary team meetings for long-stay patients (LSPs) in PICUs.

PARTICIPANTS

The multidisciplinary Lucile Packard Foundation PICU Continuity Panel comprising parents of children who had prolonged PICU stays and experts in several specialties/professions that care for children with medical complexity in and out of PICUs.

DESIGN/METHODS

We used modified RAND Delphi methodology, with a comprehensive literature review, Delphi surveys, and a conference, to reach consensus. The literature review resulted in a synthesized bibliography, which was provided to panelists. We used an iterative process to generate draft statements following panelists' completion of four online surveys with open-ended questions on implementing and sustaining continuity strategies. Panelists were anonymous when they voted on revised draft statements. Agreement of 80% constituted consensus. At a 3-day virtual conference, we discussed, revised, and re-voted on statements not reaching or barely reaching consensus. We used Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence and rate the statements' strength. The Panel also generated outcome, process, and balancing metrics to evaluate continuity strategies.

RESULTS

The Panel endorsed 17 consensus statements in five focus areas of continuity strategies (Eligibility Criteria, Initiation, Standard Responsibilities, Resources Needed to Implement, Resources Needed to Sustain). The quality of evidence of the statements was low to very low, highlighting the limited evidence and the importance of panelists' experiences/expertise. The strength of the statements was conditional. An extensive list of potential evaluation metrics was generated.

CONCLUSIONS

These expert/parent-developed consensus statements provide PICUs with novel summaries on how to operationalize, implement, and sustain continuity strategies for LSP, a rapidly growing, vulnerable, resource-intensive population in PICUs.

Palliative care for NICU survivors with chronic critical illness

The sickest of NICU survivors develop chronic critical illness (CCI). Most infants with CCI will leave the NICU using chronic medical technology and will experience repeated rehospitalizations. The unique issues for these NICU graduates- escalating chronic medical technologies, fractured post-NICU healthcare, gaps in home health services, and family strain-are common and predictable. This means that raising family and NICU team awareness of these issues, and putting plans in place to address them, should occur for every NICU infant with CCI. Pediatric palliative care is one resource that can be engaged within the NICU to support the child and family through NICU discharge and beyond. This review examines what is known about the unique needs of infants who leave the NICU with CCI and the role that NICU-initiated palliative care involvement can play for these patients, families, clinicians, and the health care system.

Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs

OBJECTIVES

To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived.

DESIGN

A cross-sectional survey.

SETTING

U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships.

SUBJECTS

One senior physician and one senior nurse at each institution.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility.

CONCLUSIONS

Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.

A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity

Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.

Parent and Provider Perspectives on Primary Continuity Intensivists and Nurses for Long-Stay Pediatric Intensive Care Unit Patients

Rationale: Primary continuity intensivists and nurses for long-stay patients (LSPs) in pediatric intensive care units (PICUs) are understudied strategies used to mitigate the fragmented care of typical rotating care models. Objectives: To investigate the advantages and disadvantages of primary continuity intensivists and nurses for LSPs as perceived by their parents and PICU providers. Methods: We conducted a prospective cross-sectional mixed-methods study of the perspectives of parents whose children were admitted to a PICU for >10 days and had one or more complex chronic conditions regarding the care provided by their PICU intensivists and nurses. As part of a trial, patients had been randomized to care provided by a rotating on-service intensivist who changed weekly and by PICU nurses who changed every 12 hours (usual care group) or to care provided by the same on-service intensivist plus a primary continuity intensivist and primary nurses (primary group). In addition, PICU providers (intensivists, fellows, and nurses) were queried for their perspectives on primary intensivists and nurses. Novel questionnaires, assessed for content and face validity and for readability, were used. The parental questionnaire involved indicating their degree of agreement with 16 statements about their children's care. The provider questionnaire involved rating potential advantages of primary continuity intensivists and nurses and estimating the frequency of disadvantages. Descriptive statistics and divergent stack bar charts were used; parents' and providers' responses were compared, stratified by their children's group (usual care or primary) and provider role, respectively. Results: The parental response rate was 71% (120 completed questionnaires). For 10 of 16 statements, parents whose children had primary continuity intensivists and nurses indicated significantly more positive perceptions of care (e.g., communication, listening, decision making, problems due to changing providers). The provider response rate was 61% (117 completed questionnaires); more than 80% believed that primary intensivists and nurses were highly or very highly beneficial for LSPs. Providers perceived more benefits for patients/families (e.g., informational continuity, facilitating and expediting decision making) than for staff/institutions (e.g., staff satisfaction). Providers reported associated stress, expenditure of time and effort, and decreased staffing flexibility with primary practices. Conclusions: Perceived benefits of primary continuity intensivists and nurses by both parents and providers support more widespread adoption and study of these continuity strategies.

The Child With Severe Chronic Illness in the ICU: A Concise Review

OBJECTIVES

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs.

DATA SOURCES

English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed.

STUDY SELECTION

Original articles, review articles, and commentaries were considered.

DATA EXTRACTION

Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review.

DATA SYNTHESIS

Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured.

CONCLUSIONS

The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

A Research Agenda for Diagnostic Excellence in Critical Care Medicine

Diagnosing critically ill patients in the intensive care unit is difficult. As a result, diagnostic errors in the intensive care unit are common and have been shown to cause harm. Research to improve diagnosis in critical care medicine has accelerated in past years. However, much work remains to fully elucidate the diagnostic process in critical care. To achieve diagnostic excellence, interdisciplinary research is needed, adopting a balanced strategy of continued biomedical discovery while addressing the complex care delivery systems underpinning the diagnosis of critical illness.

Understanding diagnostic processes in emergency departments: a mixed methods case study protocol

INTRODUCTION

Diagnostic processes in the emergency department (ED) involve multiple interactions among individuals who interface with information systems to access and record information. A better understanding of diagnostic processes is needed to mitigate errors. This paper describes a study protocol to map diagnostic processes in the ED as a foundation for developing future error mitigation strategies.

METHODS AND ANALYSIS

This study of an adult and a paediatric academic ED uses a prospective mixed methods case study design informed by an ED-specific diagnostic decision-making model (the modified ED-National Academies of Sciences, Engineering and Medicine (NASEM) model) and two cognitive theories (dual process theory and distributed cognition). Data sources include audio recordings of patient and care team interactions, electronic health record data, observer field notes and stakeholder interviews. Multiple qualitative analysis methods will be used to explore diagnostic processes in situ, including systems information flow, human-human and human-system interactions and contextual factors influencing cognition. The study has three parts. Part 1 involves prospective field observations of patients with undifferentiated symptoms at high risk for diagnostic error, where each patient is followed throughout the entire care delivery process. Part 2 involves observing individual care team providers over a 4-hour window to capture their diagnostic workflow, team coordination and communication across multiple patients. Part 3 uses interviews with key stakeholders to understand different perspectives on the diagnostic process, as well as perceived strengths and vulnerabilities, in order to enrich the ED-NASEM diagnostic model.

ETHICS AND DISSEMINATION

The University of Michigan Institutional Review Board approved this study, HUM00156261. This foundational work will help identify strengths and vulnerabilities in diagnostic processes. Further, it will inform the future development and testing of patient, provider and systems-level interventions for mitigating error and improving patient safety in these and other EDs. The work will be disseminated through journal publications and presentations at national and international meetings.

Ready to Go Home? Assessment of Shared Mental Models of the Patient and Discharging Team Regarding Readiness for Hospital Discharge

BACKGROUND

A critical task of the inpatient interprofessional team is readying patients for discharge. Assessment of shared mental model (SMM) convergence can determine how much team members agree about patient discharge readiness and how their mental models align with the patient's self-assessment.

OBJECTIVE

Determine the convergence of interprofessional team SMMs of hospital discharge readiness and identify factors associated with these assessments.

DESIGN

We surveyed interprofessional discharging teams and each team's patient at time of hospital discharge using validated tools to capture their SMMs.

PARTICIPANTS

Discharge events (N = 64) from a single hospital consisting of the patient and their team (nurse, coordinator, physician).

MEASURES

Clinician and patient versions of the validated Readiness for Hospital Discharge Scales/Short Form (RHDS/SF). We measured team convergence by comparing the individual clinicians' scores on the RHDS/SF, and we measured team-patient convergence as the absolute difference between the Patient-RHDS/SF score and the team average score on the Clinician-RHDS/SF.

RESULTS

Discharging teams assessed patients as having high readiness for hospital discharge (mean score, 8.5 out of 10; SD, 0.91). The majority of teams had convergent SMMs with high to very high interrater agreement on discharge readiness (mean r*wg(J), 0.90; SD, 0.10). However, team-patient SMM convergence was low: Teams overestimated the patient's self-assessment of readiness for discharge in 48.4% of events. We found that teams reporting higher-quality teamwork (P = .004) and bachelor's level-trained nurses (P < .001) had more convergent SMMs with the patient.

CONCLUSION

Measuring discharge teams' SMM of patient discharge readiness may represent an innovative assessment tool and potential lever to improve the quality of care transitions.

Standardized Work Rounds Enhance Teaming, Comprehensiveness, Shared Mental Model Development, and Achievement Rate of End-of-Shift Goals

OBJECTIVES

To determine the impact of standardized PICU work rounds on the frequency of ideal teaming behaviors, rounds comprehensiveness, shared mental model index development, and rate of completed end-of-shift goals.

DESIGN

A single-center, pre-post, prospective cohort study.

SETTING

A 259-bed, quaternary, pediatric referral center.

PATIENTS

Children 0-18 years old from November 2018 to January 2020.

INTERVENTIONS

Standardized, bedside, nurse-led PICU work rounds, emphasizing ideal teaming behaviors using a collaboratively developed rounding script and quality/safety checklist.

MEASUREMENTS AND MAIN RESULTS

Study data were collected by direct observation and immediate postrounds participant questionnaire data. Primary outcomes were frequency of observed ideal teaming behaviors, rounds comprehensiveness, efficiency (rounds content divided by duration), shared mental model index (congruence among rounds participants regarding key healthcare data and planning), rounds face validity, and achievement rate of rounds-established, end-of-shift goals. During study, 154 encounters were observed (50 preintervention, 52 after Plan-Do-Study-Act cycle 1, and 52 after Plan-Do-Study-Act cycle 2). We observed improvements in overall shared mental model index (24-87%), rounds comprehensiveness (72-98%), and ideal teaming behaviors (including closed-loop communication: 82-100%; responsibility delegation: 74-100%; interdependence behaviors: 26-98%, all p < 0.01) by the end of study. Nursing presentations accounted for 3.6 ± 1.5 minutes of rounds and rounds duration was unchanged postintervention (11 ± 5 min preintervention and 11 ± 4 min after Plan-Do-Study-Act cycle 2, p > 0.99). Face validity, assessed using questionnaire data from 953 participants, revealed positive attitudes regarding efficiency, clarity, and participant self-value. Greatest enhancements in self-value were noted among advanced practice providers and respiratory therapists. On exploratory modeling, we noted associations between ideal teaming behaviors, rounds comprehensiveness, and shared mental model index. Similarly, we noted a positive association between the shared mental model index and the rate of achieved rounds-established, end-of-shift goals (odds ratio, 8.9; 95% CI, 1.7-46; p < 0.01).

CONCLUSIONS

Standardization of PICU work rounds may encourage ideal teaming behaviors, enhance rounds comprehensiveness, strengthen the congruence of participant shared mental model, and affect the rate of achieved goals established during rounds without compromising workplace efficiency.

Analysis of the cognitive demands of electronic health record use

The goal of this study was to elicit the cognitive demands facing clinicians when using an electronic health record (EHR) system and learn the cues and strategies expert clinicians rely on to manage those demands. This study differs from prior research by applying a joint cognitive systems perspective to examining the cognitive aspects of clinical work. We used a cognitive task analysis (CTA) method specifically tailored to elicit the cognitive demands of an EHR system from expert clinicians from different sites in a variety of inpatient and outpatient roles. The analysis of the interviews revealed 145 unique cognitive demands of using an EHR, which were organized into 22 distinct themes across seven broad categories. In addition to confirming previously published themes of cognitive demands, the main emergent themes of this study are: 1) The EHR does not help clinicians develop and maintain awareness of the big picture; 2) The EHR does not support clinicians' need to reason about patients' current and future states, including effects of potential treatments; and 3) The EHR limits agency of clinicians to work individually and collaboratively. Implications for theory and EHR design and evaluation are discussed.

Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography

PURPOSE

The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children.

MATERIALS AND METHODS

We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17 years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge.

RESULTS

Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication.

CONCLUSIONS

Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.

Bedside Rounds in Intensive Care Units during the COVID-19 Pandemic and Beyond

A survey-based pilot study was performed to examine the feasibility of videoconferencing to facilitate multidisciplinary rounds following the initiation of strict isolation and social distancing policies in a pediatric intensive care unit (PICU). The use of a mobile workstation was implemented as the central hub for rounding at the bedside by the attending physicians, while other members of the multidisciplinary and multispecialty team joined rounds from other locations with maintaining appropriate social distance. Fifty-eight staff members who participated in videoconferencing rounds completed the postimplementation survey. Eighty-eight per cent of staff agreed that the use of videoconferencing to facilitate rounds was an effective strategy to maintain social distancing between team members during the pandemic. Sixty-four percent of staff agreed that the use of videoconferencing improved participation of the PICU team and consultants by increasing access to rounds. Over 50% of staff agreed that the use of videoconferencing improved the efficiency of rounds and team productivity. Only 4% of staff responded that videoconferencing increased the duration of rounds and 37% responded that it decreased resident and team education. Fifty-five percent of staff agreed that videoconferencing was used to promote parental participation during this pandemic month. Videoconferencing was found to be a feasible solution to safely conduct multidisciplinary rounds while maintaining social distancing, and participants found it effective without interfering with normal workflow. Incorporating videoconferencing into traditional rounding practices may be advantageous following the pandemic to improve team and family access to rounds and workflow efficiency and rounding structure.

Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018

OBJECTIVES

To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings.

DATA SOURCES

Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018.

STUDY SELECTION

Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting.

DATA EXTRACTION

Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice.

DATA SYNTHESIS

Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes.

CONCLUSIONS

Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.

Basic life support training using shared mental models improves team performance of first responders on normal wards: A randomised controlled simulation trial

INTRODUCTION

Survival of in-hospital cardiac arrest (IHCA) depends on fast and effective action of the first responding team. Not only technical skills, but professional teamwork is required. Observational studies and theoretical models suggest that shared mental models of members improve teamwork. This study investigated if a training on shared mental models, improves team performance in simulated in-hospital cardiac arrest.

METHODS

On the background of an introduction of mandatory Basic Life Support (BLS) training for clinical staff a randomized controlled trial was performed to compare two training methods. Staff from clinical departments was randomised to receive either a conventional instructor led training (control group) or an interventional training (intervention group). The interventional training was based on self-directed learning of the group in order to develop shared mental models. Primary outcome were mean scores of the team assessment scale (TAS) and the hands-off time. Secondary outcome were mean scores for quality of BLS.

RESULTS

Performance of 75 teams of the interventional and 66 of the control group was analysed. The hands-off time was significantly lower in the interventional group (5.42% vs. 8.85%, p = 0.029). Scores of the TAS and the overall BLS score were high and not significantly different between the groups. Hands-off time correlated significantly negative with all TAS items.

CONCLUSION

BLS training for clinical staff which creates shared mental models reduces hands-off time in a simulated cardiac arrest scenario. Training methods establishing shared mental models of team members can be considered for effective team trainings without adding additional training time.

Association of Data Integration Technologies With Intensive Care Clinician Performance: A Systematic Review and Meta-analysis

IMPORTANCE

Sources of data in the intensive care setting are increasing exponentially, but the benefits of displaying multiparametric, high-frequency data are unknown. Decision making may not benefit from this technology if clinicians remain cognitively overburdened by poorly designed data integration and visualization technologies (DIVTs).

OBJECTIVE

To systematically review and summarize the published evidence on the association of user-centered DIVTs with intensive care clinician performance.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and Web of Science were searched in May 2014 and January 2018.

STUDY SELECTION

Studies had 3 requirements: (1) the study tested a viable DIVT, (2) participants involved were intensive care clinicians, and (3) the study reported quantitative results associated with decision making in an intensive care setting.

DATA EXTRACTION AND SYNTHESIS

Of 252 records screened, 20 studies, published from 2004 to 2016, were included. The human factors framework to assess health technologies was applied to measure study completeness, and the Quality Assessment Instrument was used to assess the quality of the studies. PRISMA guidelines were adapted to conduct the systematic review and meta-analysis.

MAIN OUTCOMES AND MEASURES

Study completeness and quality; clinician performance; physical, mental, and temporal demand; effort; frustration; time to decision; and decision accuracy.

RESULTS

Of the 20 included studies, 16 were experimental studies with 410 intensive care clinician participants and 4 were survey-based studies with 1511 respondents. Scores for study completeness ranged from 27 to 43, with a maximum score of 47, and scores for study quality ranged from 46 to 79, with a maximum score of 90. Of 20 studies, DIVTs were evaluated in clinical settings in 2 studies (10%); time to decision was measured in 14 studies (70%); and decision accuracy was measured in 11 studies (55%). Measures of cognitive workload pooled in the meta-analysis suggested that any DIVT was an improvement over paper-based data in terms of self-reported performance, mental and temporal demand, and effort. With a maximum score of 22, median (IQR) mental demand scores for electronic display were 10 (7-13), tabular display scores were 8 (6.0-11.5), and novel visualization scores were 8 (6-12), compared with 17 (14-19) for paper. The median (IQR) temporal demand scores were also lower for all electronic visualizations compared with paper, with scores of 8 (6-11) for electronic display, 7 (6-11) for tabular and bar displays, 7 (5-11) for novel visualizations, and 16 (14.3-19.0) for paper. The median (IQR) performance scores improved for all electronic visualizations compared with paper (lower score indicates better self-reported performance), with scores of 6 (3-11) for electronic displays, 6 (4-11) for tabular and bar displays, 6 (4-11) for novel visualizations, and 14 (11-16) for paper. Frustration and physical demand domains of cognitive workload did not change, and differences between electronic displays were not significant.

CONCLUSIONS AND RELEVANCE

This review suggests that DIVTs are associated with increased integration and consistency of data. Much work remains to identify which visualizations effectively reduce cognitive workload to enhance decision making based on intensive care data. Standardizing human factors testing by developing a repository of open access benchmarked test protocols, using a set of outcome measures, scenarios, and data sets, may accelerate the design and selection of the most appropriate DIVT.

An Opportunity for Cognitive Task Analysis in Neonatal Resuscitation

Approximately 10% of newborn infants require resuscitative intervention at birth. Ideally, this care is provided by a team of expert healthcare professionals who possess exceptional cognitive, psychomotor, and communication skills. Human errors and deviations from resuscitation protocol are common and may be attributable to excessive cognitive demand experienced by the resuscitation team. Cognitive Task Analysis (CTA) is a group of methods used to assess knowledge, judgments, goals, and decision-making of expert healthcare professionals. These methods may be used during neonatal resuscitation to gain an improved understanding of the approaches used by healthcare professionals. CTA methods have been applied in many medical disciplines including neonatology. CTA has been used to identify information previously confined to the intuition of experts. This information has been used to assess, develop, and improve medical technology, clinical decision support tools (DSTs), communication structure, and training methods. Knowledge attained through CTA might be applied similarly to neonatal resuscitation, which may in turn decrease human errors, and improve patient safety.

Pediatric continuity care intensivist: A randomized controlled trial

INTRODUCTION

Long-stay critically ill patients in the Pediatric Intensive Care Unit (PICU) may be at risk for inconsistencies in treatment plan, delay in plan progression, and patient/family dissatisfaction with communication. This article describes the development and evaluation of an intervention designed to improve continuity and communication delivered by continuity PICU attendings.

METHODS AND ANALYSIS

A randomized controlled trial of an intervention in one PICU that was randomized at the patient level. Eligible patients and their parents included those admitted to the PICU for longer than one week and were anticipated to remain for an additional 7 days. The intervention, a Continuity Care Intensivist (CCI), included early assignment of a continuity attending (separate from a regularly scheduled service attending), standardization of the continuity role to ensure consistent team and family contact and facilitate timely decision making, and enhancement of CCI communication skills. The outcomes evaluated were 1) patient PICU length of stay, ventilator-dependent days, and hospital acquired infections, 2) parental mood and satisfaction with PICU communication, and 3) intensivist perception of acceptability of intervention. Intention to treat analysis will be completed using multivariable linear regression to determine the impact of the intervention on outcomes. Lessons have been learned about the appropriate enrollment criteria for patients to allow for impact of continuity attending, frequent prognostic uncertainty in determining which patients will become longer stay in the PICU, and the difficulty of achieving timely initial contact of continuity attending with patients given the CCI's other commitments.

A Longitudinal and Sustainability Assessment of Pediatric Interfacility Transport Handover Standardization

Introduction:

Standardization of interfacility transport handover is associated with improved shared mental model development, efficiency, and teaming. We sought to build upon previously published data by evaluating 1-year follow-up data, assessing face-validity, and describing sustainability.

Methods:

We performed a pre-post, retrospective cohort study in a stand-alone, tertiary, pediatric referral center for children 0–18 years of age transported to our pediatric intensive care unit, neonatal intensive care unit, or emergency department from October 2016 to November 2017. Handover was standardized using multidisciplinary checklists, didactics, and simulation. Data were collected for three 8-week periods (preintervention, postintervention, and 1-year follow-up). Outcomes included shared mental model index (shared mental model congruence expressed as an index, percent congruence regarding healthcare data), teaming data (efficiency, attendance, interruptions, interdependence), and face validity (5-point, Likert scale questionnaires). Statistics included 1-way analysis of variance, Kruskal-Wallis, chi-square, and descriptive statistics.

Results:

One hundred forty-eight handovers (50 preintervention, 50 postintervention, and 48 at 1-year) were observed in the emergency department (41%), pediatric intensive care unit (45%), and neonatal intensive care unit (14%). No differences were noted in demographics, diagnoses, PIM-3-ROM, length of stay, mortality, ventilation, or vasoactive use. Sustained improvements were observed in shared mental model congruence expressed as an index (38% to 82%), physician attendance (76% to 92%), punctuality (91.5% to 97.5%), interruptions (40% to 10%), provision of anticipatory guidance (42% to 85%), and handover summarization (42% to 85%, all P < 0.01). Efficiency was maintained throughout (mean duration 4.5 ± 2.1 minutes). Face validity data revealed handover satisfaction, effective communication, and perceived professionalism.

Conclusions:

Enhancements in teaming, shared mental model development, and face validity were achieved and sustained 1-year following handover standardization with only minimal reeducation during the study period.

Art as Sanctuary: A Four-Year Mixed-Methods Evaluation of a Visual Art Course Addressing Uncertainty Through Reflection

PURPOSE

Engagement with visual art is a promising modality for addressing issues of uncertainty via reflective practice, one that is being increasingly used in health science education. An elective museum-based course for first-year medical students was created by two medical schools and led by an art educator experienced in medical education. The course, Observation and Uncertainty in Art and Medicine, sought to help students explore experiences of uncertainty and to develop reflective capacity through engagement with visual art.

METHOD

The course was run and evaluated from 2014 to 2017, with 47 students participating over the 4 years, with 12 students enrolled per year. Before and after the course, students were given the Groningen Reflection Ability Scale (GRAS) for reflective ability, the Tolerance for Ambiguity scale for ambiguity, and Best Intentions Questionnaire for personal bias awareness, and 35 students (74%) completed all of the scales. Focus group interviews and narrative postcourse evaluations were conducted, coded, and thematically analyzed.

RESULTS

Statistically significant improvement was found in GRAS scores. Qualitative themes included student enhancement of observational skills, awareness of the subjectivity and uncertainty of perception, exploration of multiple points of view, and recognition of the course as a place for restoration and connection to classmates.

CONCLUSIONS

Incorporating visual art into medical education is an effective pedagogical method for addressing competencies central to training, including observation, reflection, and self-care.

Variability in the time to initiation of CPR in continuously monitored pediatric ICUs

AIM

To study the influence of patient characteristics and unit ergonomics and human factors on the time to initiation of CPR.

METHODS

A single center study of children, 0 to 21 years old, admitted to an ICU who experienced cardiopulmonary arrest (CPA) requiring >1 min of chest compressions. Time of CPA was determined by analysis of continuous ECG, plethysmography, arterial blood pressure, and end-tidal CO₂ (EtCO₂) waveforms. Initiation of CPR was identified by the onset of cyclic artifact in the ECG waveform. Patient characteristics and unit ergonomics and human factors were examined including CPA cause, identification on the High-Risk Checklist (HRC), existing monitoring, ICU type, time of day, nursing shift change, and outcome.

RESULTS

The median time from CPA to initiation of CPR was 50.5 s (IQR 26.5 to 127.5) in 36 CPAs. Forty-seven percent of patients experienced time from CPA to initiation of CPR of >1 min. There was no difference in CPA cause, ICU type, time of day, or nursing shift change.

CONCLUSION

Nearly half of pediatric patients who experienced CPA in an ICU setting did not meet AHA guidelines for early initiation of CPR. This is an opportunity to study the recognition phase of CPA using continuous monitoring data with the aim of improving the understanding of and factors contributing to delays in initiation of CPR.

Standardization of Pediatric Interfacility Transport Handover: Measuring the Development of a Shared Mental Model

OBJECTIVES

To determine if standardization of pediatric interfacility transport handover is associated with the development of a prototypical shared mental model between healthcare providers.

DESIGN

A single center, prepost, retrospective cohort study.

SETTINGS

A 259-bed, tertiary care, pediatric referral center.

PATIENTS

Children 0 to 18 years old transferred to our critical care units or emergency center from October 2016 to February 2017.

INTERVENTIONS

Standardization of interfacility handover using a multidisciplinary checklist, didactic teaching, and simulation conducted midway through the study period.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a shared mental model index defined as percent congruence among handover participants regarding key patient healthcare data including patient identification, diagnoses, transport interventions, immediate postadmission care plans, and anticipatory guidance for ongoing care. Secondary outcomes were handover comprehensiveness and teaming metrics such as efficiency, attendance, interruption frequency, and team member inclusion. During the study period, 100 transport handovers were observed of which 50 were preintervention and 50 post. A majority of handovers represented transfers to the emergency center (41%) or PICU (45%). There were no observable differences between prepost intervention cohorts by general characteristics, admission diagnoses, or severity of illness metrics including Pediatric Index of Mortality-3-Risk of Mortality, length of stay, mortality, frequency of invasive and noninvasive ventilation, and vasoactive use. The shared mental model index increased from 38% to 78% following standardization of handover. Attendance (76% vs 94%), punctuality (91.5% vs 98%), attention (82% vs 92%), summarization (42% vs 72%), and provision of anticipatory guidance (42% vs 58%) also improved. Efficiency was unchanged with a mean handover duration of 4 minutes in both cohorts.

CONCLUSIONS

Considerable enhancements in handover quality, team participation, and the development of a shared mental model after standardization of interfacility transport handover were noted. These findings were achieved without compromising handover efficiency.

Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units

OBJECTIVE

To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict.

DESIGN

Self-administered online survey.

SETTING

U.S. neonatal ICUs and PICUs.

SUBJECTS

Neonatologists and pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team.

CONCLUSIONS

ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.

Impact of an electronic handoff documentation tool on team shared mental models in pediatric critical care

OBJECTIVE

To examine the impact of the implementation of an electronic handoff tool (the Handoff Tool) on shared mental models (SMM) within patient care teams as measured by content overlap and discrepancies in verbal handoff presentations given by different clinicians caring for the same patient.

MATERIALS AND METHODS

Researchers observed, recorded, and transcribed verbal handoffs given by different members of patient care teams in a pediatric intensive care unit. The transcripts were qualitatively coded and analyzed for content overlap scores and the number of discrepancies in handoffs of different team members before and after the implementation of the tool.

RESULTS

Content overlap scores did not change post-implementation. The average number of discrepancies nearly doubled following the implementation (from 0.76 discrepancies per handoff group pre-implementation to 1.17 discrepancies per handoff group post-implementation); however, this change was not statistically significant (p=0.37). Discrepancies classified as related to dosage of treatment or procedure and to patients' symptoms increased in frequency post-implementation.

DISCUSSION

The results suggest that the Handoff Tool did not have the desired positive impact on SMM within patient care teams. Future electronic tools for facilitating team handoff may need longer implementation times, complementary changes to handoff process and structure, and improved designs that integrate a common core of shared information with discipline-specific records.

CONCLUSION

While electronic handoff tools provide great opportunities to improve communication and facilitate the formation of shared mental models within patient care teams, further work is necessary to realize their full potential.

Difficulties with assessment and management of an infant's distress in the postoperative period: Optimising opportunities for interdisciplinary information-sharing

OBJECTIVES

The importance of accurate paediatric patient assessment is well established but under-utilised in managing postoperative medication regimens.

METHODS

Data for this case report were collected through observations of clinical practice, conduct of interviews, and retrieval of information from the medical record. This case report involving a hospitalised 1-year-old boy demonstrates the difficulties associated with assessing and managing postoperative distress, including pain and other clinical conditions related to the surgical procedure.

RESULTS

Postoperatively, there were difficulties in managing pain and an episode of over-sedation, occasioning opiate reversal with naloxone. In addition, he had decreasing oxygen saturation and increased work of breathing. X-ray showed changes consistent with either atelectasis or aspiration, and he was commenced on antibiotics. The patient experienced respiratory distress and required intervention from the medical emergency team.

CONCLUSION

This case demonstrated the importance of comprehensive assessment and careful consideration of alternative causes of an infant's distress using the results of assessment tools to aid decision-making. Communication moderates effective patient care, and more favourable outcomes could be achieved by optimising interdisciplinary information-sharing.

Big-Data Based Decision-Support Systems to Improve Clinicians' Cognition

Complex clinical decision-making could be facilitated by using population health data to inform clinicians. In two previous studies, we interviewed 16 infectious disease experts to understand complex clinical reasoning. For this study, we focused on answers from the experts on how clinical reasoning can be supported by population-based Big-Data. We found cognitive strategies such as trajectory tracking, perspective taking, and metacognition has the potential to improve clinicians' cognition to deal with complex problems. These cognitive strategies could be supported by population health data, and all have important implications for the design of Big-Data based decision-support tools that could be embedded in electronic health records. Our findings provide directions for task allocation and design of decision-support applications for health care industry development of Big data based decision-support systems.

Facilitating Teamwork in Adolescent and Young Adult Oncology

A case of a young adult patient in the days immediately after a cancer diagnosis illustrates the critical importance of three interrelated core coordinating mechanisms-closed-loop communication, shared mental models, and mutual trust-of teamwork in an adolescent and young adult multidisciplinary oncology team. The case illustrates both the opportunities to increase team member coordination and the problems that can occur when coordination breaks down. A model for teamwork is presented, which highlights the relationships among these coordinating mechanisms and demonstrates how balance among them works to optimize team function and patient care. Implications for clinical practice and research suggested by the case are presented.

Chronic Critical Illness in Infants and Children: A Speculative Synthesis on Adapting ICU Care to Meet the Needs of Long-Stay Patients

OBJECTIVES

In this review, we examine features of ICU systems and ICU clinician training that can undermine continuity of communication and longitudinal guidance for decision making for chronically critically ill infants and children. Drawing upon a conceptual model of the dynamic interactions between patients, families, clinicians, and ICU systems, we propose strategies to promote longitudinal decision making and improve communication for infants and children with prolonged ICU stays.

DATA SOURCES

We searched MEDLINE and PubMed from inception to September 2015 for English-language articles relevant to chronic critical illness, particularly of pediatric patients. We also reviewed bibliographies of relevant studies to broaden our search.

STUDY SELECTION

Two authors (physicians with experience in pediatric neonatology, critical care, and palliative care) made the final selections.

DATA EXTRACTION

We critically reviewed the existing data and models of care to identify strategies for improving ICU care of chronically critically ill children.

DATA SYNTHESIS

Utilizing the available data and personal experience, we addressed concerns related to family perspectives, ICU processes, and issues with ICU training that shape longitudinal decision making.

CONCLUSIONS

As the number of chronically critically ill infants and children increases, specific communication and decision-making models targeted at this population could improve the feedback between acute, daily ICU decisions and the patient's overall goals of care. Adaptations to ICU systems of care and ICU clinician training will be essential components of this progress.

Handover and transport of critically ill children: An integrative review

BACKGROUND

The handover and transport of critically ill pediatric patients requires communication amongst multiple disciplines. Poor communication is a leading cause of sentinel events and human factors affect handover and transport.

OBJECTIVES

To synthesize published data on pediatric handover and transport and identify gaps to provide direction for future investigation.

METHODS

Integrative literature review.

RESULTS

Forty research studies were reviewed and revealed the following themes: risk for patient complications, standardized communication, and specialized teams and teamwork were associated with improved outcomes. No articles were identified regarding transportation of critically ill pediatric patients from the emergency room to the intensive care unit. There was a knowledge gap in best practices in handover and transport within the unique subsets of the pediatric population including neonate, toddler, school-aged, and adolescents.

CONCLUSIONS

Research supported a combined approach of specialized teams using standardized communication in the handover and transport of the pediatric patient to improve outcomes. Further study is warranted on interprofessional (team to team) handover practices, select subsets of the pediatric population, and the handover and transport of critically ill patients from the emergency room to the intensive care unit.

What can acute medicine learn from qualitative methods?

PURPOSE OF REVIEW

The contribution of qualitative methods to evidence-based medicine is growing, with qualitative studies increasingly used to examine patient experience and unsafe organizational cultures. The present review considers qualitative research recently conducted on teamwork and organizational culture in the ICU and also other acute domains.

RECENT FINDINGS

Qualitative studies have highlighted the importance of interpersonal and social aspects of healthcare on managing and responding to patient care needs. Clear/consistent communication, compassion, and trust underpin successful patient-physician interactions, with improved patient experiences linked to patient safety and clinical effectiveness across a wide range of measures and outcomes. Across multidisciplinary teams, good communication facilitates shared understanding, decision-making and coordinated action, reducing patient risk in the process.

SUMMARY

Qualitative methods highlight the complex nature of risk management in hospital wards, which is highly contextualized to the demands and resources available, and influenced by multilayered social contexts. In addition to augmenting quantitative research, qualitative investigations enable the investigation of questions on social behaviour that are beyond the scope of quantitative assessment alone. To develop improved patient-centred care, health professionals should therefore consider integrating qualitative procedures into their existing assessments of patient/staff satisfaction.

Revealing structures in narratives: A mixed-methods approach to studying interdisciplinary handoff in critical care

OBJECTIVE

To examine a novel mixed-methods approach for studying patterns of clinical communication that could inform future informatics solutions, with a specific focus on handoff within interdisciplinary teams.

MATERIALS AND METHODS

Researchers observed, recorded, and transcribed verbal handoff discussions of different members of critical care teams. The transcripts were coded qualitatively, and then analyzed quantitatively for emerging structural patterns using categorical cluster analysis, and for degree of shared mental models (SMM) using the modified Pyramid method.

RESULTS

An empirical study using the proposed mixed-methods approach suggested emerging patterns of communication among clinicians. For example, the temporal focus of handoff was often determined by the role of the clinician giving the handoff; the clinical content of handoff was consistent between clinicians, but varied between patients. The SMM index ranged from 0.065 (with the maximum possible overlap score of 1) to 0.007 with a median of 0.026; the overlap was higher in statements concerned with patient presentation (23.6% of these had overlap) and referring to the past (24% overlapped). This calculated SMM index was correlated with the assessment of coherence within the participating teams by independent physicians (r=0.63, p=0.038).

CONCLUSIONS

The proposed novel mixed-methods approach helped to reveal emerging patterns in content and structure of handoff communication and highlight differences due to the clinical context, and to the different priorities of clinicians on interdisciplinary patient care teams. The approach for calculating SMM is more ecologically sensitive as it relies on naturally occurring discourse and less intrusive than traditional ways of assessing SMM, and takes initial steps toward establishing empirical foundation for the design of electronic tools to support handoff in interdisciplinary teams.

Communication at pediatric rapid response events: a survey of health care providers

OBJECTIVES

The objective of this study was to explore perceptions of communication quality at pediatric rapid response events and to determine whether these perceptions differed between rapid response team (RRT) members (RRTm) and floor providers (FP).

METHODS

This survey study was conducted of clinical providers involved in RRT events at a tertiary care children's hospital. Perceptions of RRT communication were assessed by using a 5-point Likert scale, and qualitative comments were collected. Responses were compared between RRTm (responder nurses and intensive care fellows) and FP (floor nurses and resident physicians).

RESULTS

Survey response was 64% (18 of 28) for RRTm and 70% (194 of 278) for FP. RRTm gave lower ratings than FP for communication of: (1) the purpose of the call; (2) airway and breathing; (3) circulation; (4) background information; and (5) possible diagnosis and treatment. RRTm were more likely than FP to indicate that description of background information delayed communication of critical management problems ("often": RRTm, 7 of 17 [41%]; FP, 23 of 175 [13%]; "always": RRTm, 2 of 18 [12%]; FP, 19 of 175 [11%]; P=.001 for overall comparison). A structured approach for communication was generally supported, although less strongly among floor nurses. Themes from qualitative responses included role confusion, fractured room entry, and a dismissive attitude by RRTm.

CONCLUSIONS

A disconnect in perceived quality of communication was observed between RRTm and FP at pediatric rapid response events. A structured approach with well-defined roles may improve communication quality.

Pediatric Critical Care Nursing Research Priorities-Initiating International Dialogue

OBJECTIVE

To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice.

DESIGN

One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process.

SETTING

Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey.

PARTICIPANTS

Pediatric critical care nurses and nurse scientists attending the open consensus meeting.

INTERVENTIONS

Systematic review, gap analysis, and interactive multivoting.

MEASUREMENTS AND MAIN RESULTS

The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children.

CONCLUSIONS

The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.

Diagnostic Errors in a PICU: Insights From the Morbidity and Mortality Conference

OBJECTIVES

To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process.

DESIGN

Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports.

SETTING

Single tertiary referral PICU in Baltimore, MD.

PATIENTS

Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events.

CONCLUSIONS

Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive- and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

PURPOSE

Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research.

METHODS

A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion.

RESULTS

Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies.

CONCLUSIONS

Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.

Using team cognitive work analysis to reveal healthcare team interactions in a birthing unit

Cognitive work analysis (CWA) as an analytical approach for examining complex sociotechnical systems has shown success in modelling the work of single operators. The CWA approach incorporates social and team interactions, but a more explicit analysis of team aspects can reveal more information for systems design. In this paper, Team CWA is explored to understand teamwork within a birthing unit at a hospital. Team CWA models are derived from theories and models of teamwork and leverage the existing CWA approaches to analyse team interactions. Team CWA is explained and contrasted with prior approaches to CWA. Team CWA does not replace CWA, but supplements traditional CWA to more easily reveal team information. As a result, Team CWA may be a useful approach to enhance CWA in complex environments where effective teamwork is required.

PRACTITIONER SUMMARY

This paper looks at ways of analysing cognitive work in healthcare teams. Team Cognitive Work Analysis, when used to supplement traditional Cognitive Work Analysis, revealed more team information than traditional Cognitive Work Analysis. Team Cognitive Work Analysis should be considered when studying teams.

The concept of shared mental models in healthcare collaboration

AIM

To report an analysis of the concept of shared mental models in health care.

BACKGROUND

Shared mental models have been described as facilitators of effective teamwork. The complexity and criticality of the current healthcare system requires shared mental models to enhance safe and effective patient/client care. Yet, the current concept definition in the healthcare literature is vague and, therefore, difficult to apply consistently in research and practice.

DESIGN

Concept analysis.

DATA SOURCES

Literature for this concept analysis was retrieved from several databases, including CINAHL, PubMed and MEDLINE (EBSCO Interface), for the years 1997-2013.

METHODS

Walker and Avant's approach to concept analysis was employed and, following Paley's guidance, embedded in extant theory from the team literature.

RESULTS

Although teamwork and collaboration are discussed frequently in healthcare literature, the concept of shared mental models in that context is not as commonly found but is increasing in appearance. Our concept analysis defines shared mental models as individually held knowledge structures that help team members function collaboratively in their environments and are comprised of the attributes of content, similarity, accuracy and dynamics.

CONCLUSION

This theoretically grounded concept analysis provides a foundation for a middle-range descriptive theory of shared mental models in nursing and health care. Further research concerning the impact of shared mental models in the healthcare setting can result in development and refinement of shared mental models to support effective teamwork and collaboration.

'Safety by DEFAULT': introduction and impact of a paediatric ward round checklist

Introduction

Poor communication is a source of risk. This can be particularly significant in areas of high clinical acuity such as intensive care. Ward rounds are points where large amounts of information must be communicated in a time-limited environment with many competing interests. This has the potential to reduce effective communication and risk patient safety. Checklists have been used in many industries to improve communication and mitigate risk. We describe the introduction of a ward round safety checklist ‘DEFAULT’ on a paediatric intensive care unit.

Methods

A non-blinded, pre- and post-intervention observational study was undertaken in a 12-bedded Level 3 tertiary PICU between July 2009 and December 2011.

Results

Ward round stakeholders subjectively liked the checklist and felt it improved communication. Introduction of the ward round checklist was associated with an increase in median days between accidental extubations from 14 (range 2 to 86) to 150 (56 to 365) (Mann–Whitney P <0.0001). The ward round checklist was also associated with an increase in the proportion of invasively ventilated patients with target tidal volumes of <8 ml/kg, which increased from 35 of 71 patients at 08.00 representing a proportion of 0.49 (95% CI 0.38 to 0.60) to 23 of 38 (0.61, 0.45 to 0.74). This represented a trend towards an increased proportion of cases in the target range (z = 1.68, P = 0.09).

Conclusions

The introduction of a ward round safety checklist was associated with improved communication and patient safety.