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Mercurio MR, Peterec SM. "On duty, not on call: time to rethink Neonatal Intensive Care Unit attending hours". J Perinatol 2023; 43:1453-1454. [PMID: 37714893 DOI: 10.1038/s41372-023-01776-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/17/2023]
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Machut KZ, Gilbart C, Murthy K, Michelson KN. A Qualitative Study of Nurses' Perspectives on Neonatologist Continuity of Care. Adv Neonatal Care 2023; 23:467-477. [PMID: 37499687 PMCID: PMC10544817 DOI: 10.1097/anc.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND Families and staff in neonatal intensive care units (NICUs) value continuity of care (COC), though definitions, delivery, and impacts of COC are incompletely described. Previously, we used parental perspectives to define and build a conceptual model of COC provided by neonatologists. Nursing perspectives about COC remain unclear. PURPOSE To describe nursing perspectives on neonatologist COC and revise our conceptual model with neonatal nurse input. METHODS This was a qualitative study interviewing NICU nurses. The investigators analyzed transcripts with directed content analysis guided by an existing framework of neonatologist COC. Codes were categorized according to previously described COC components, impact on infants and families, and improvements for neonatologist COC. New codes were identified, including impact on nurses, and codes were classified into themes. RESULTS From 15 nurses, 5 themes emerged: (1) nurses validated parental definitions and benefits of COC; (2) communication is nurses' most valued component of COC; (3) neonatologist COC impact on nurses; (4) factors that modulate the delivery of and need for COC; (5) conflict between the need for COC and the need for change. Suggested improvement strategies included optimizing staffing and transition processes, utilizing clinical guidelines, and enhancing communication at all levels. Our adapted conceptual model describes variables associated with COC. IMPLICATIONS FOR PRACTICE AND RESEARCH Interdisciplinary NICU teams need to develop systematic strategies tailored to their unit's and patients' needs that promote COC, focused to improve parent-clinician communication and among clinicians. Our conceptual model can help future investigators develop targeted interventions to improve COC.
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Affiliation(s)
- Kerri Z. Machut
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University (Chicago, IL)
- Ann & Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL)
| | | | - Karna Murthy
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University (Chicago, IL)
- Ann & Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL)
| | - Kelly N. Michelson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University (Chicago, IL)
- Ann & Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL)
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Cuevas Guaman M, Miller ER, Dammann CEL, Bishop CE, Machut KZ. Neonatologist staffing models: urgent change is needed. J Perinatol 2022; 42:1556-1557. [PMID: 36207513 PMCID: PMC9540071 DOI: 10.1038/s41372-022-01527-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Milenka Cuevas Guaman
- Department of Pediatrics, Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Emily R Miller
- Cincinnati Children's Hospital Medical Center, Division of Neonatology, Perinatal Institute, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Christine E Bishop
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kerri Z Machut
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Parental Perspectives on Neonatologist Continuity of Care. Adv Neonatal Care 2021; 21:E162-E170. [PMID: 34138794 DOI: 10.1097/anc.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuity of care (COC) is highly regarded; however, data about benefits are mixed. Little is known about components, parental views, or the value COC may provide to neonatal intensive care unit (NICU) infants and families. PURPOSE To describe parents' perspectives on definitions, reasons they value, and suggested improvements regarding COC provided by neonatologists. METHODS We performed a qualitative study of in-person, semistructured interviews with parents of NICU infants hospitalized for 28 days or more. We analyzed interview transcripts using content analysis, identifying codes of parental experiences, expressed value, and improvement ideas related to neonatologist COC, and categorizing emerging themes. RESULTS Fifteen families (15 mothers and 2 fathers) described 4 themes about COC: (1) longitudinal neonatologists: gaining experience with infants and building relationships with parents over time; (2) background knowledge: knowing infants' clinical history and current condition; (3) care plans: establishing patient-centered goals and management plans; and (4) communication: demonstrating consistent communication and messaging. Parents described benefits of COC as decreasing knowledge gaps, advancing clinical progress, and decreasing parental stress. Suggested improvement strategies included optimizing staffing and sign-out/transition processes, utilizing clinical guidelines, and enhancing communication. Using parent input and existing literature, we developed a definition and conceptual framework of COC. IMPLICATIONS FOR PRACTICE NICUs should promote practices that enhance COC. Parental suggestions can help direct improvement efforts. IMPLICATIONS FOR RESEARCH Our COC definition and conceptual framework can guide development of research and quality improvement projects. Future studies should investigate nursing perspectives on NICU COC and the impact of COC on infant and family outcomes.
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Sahni M, Mowes A. Effect of 24/7 attending coverage in the neonatal intensive care unit on fellow education. BMC MEDICAL EDUCATION 2020; 20:444. [PMID: 33208139 PMCID: PMC7672982 DOI: 10.1186/s12909-020-02372-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/10/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND There is a current change in type of attending coverage in the Neonatal Intensive Care Unit (NICU) from home calls to 24/7 in house coverage. Effects of this increased attending physician presence on education of NICU fellows has not been studied. The objective of this study is to evaluate the fellows' perception of in house attending coverage on their education and evaluate its effect on their perceived autonomy. METHODS A secure, anonymous, web-based survey was designed using RedCap. The web-based survey was sent via the section of Neonatal Perinatal Medicine of the American Academy of Pediatrics, to all members of Training & Early Career Neonatologists. Questions were focused on perception of IH attending coverage on fellows' educational experience including the respondent's perceived ability to make independent decisions (autonomy). Chi-square tests were used to compare responses between groups, with Fisher Exact tests used when the expected cell frequencies were small. RESULTS One hundred and twenty-three surveys were analyzed, that included responses from 82 fellows & 41 early career neonatologists. 52% reported having 24/7 attending in-house (IH) coverage. Thirty of the 123 respondents experienced a change in model of attending coverage during their training. Among these 30, only 26.6% preferred the model of attending IH coverage. The respondents currently working in IH models, when compared to those in non-IH coverage models felt IH attending coverage was beneficial for fellow education (p < 0.05) but was less likely to give fellows autonomy for decision making (p = 0.02). CONCLUSION In our survey respondents with in house attending, had a more favorable view of its benefit on fellow education. Institutions practicing or considering IH attending coverage should consider use of adequate measures to balance fellow supervision and education.
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Affiliation(s)
- Mitali Sahni
- Neonatal Intensive Care Unit, Pediatrix Medical Group, Sunrise Children's Hospital, 3186 S Maryland Pkwy, Las Vegas, NV, 89109, USA.
- University of Nevada, Las Vegas, NV, USA.
- Division of Neonatology, St. Christopher's Hospital for Children, Philadelphia, PA, USA.
| | - Anja Mowes
- Division of Neonatology, St. Christopher's Hospital for Children, Philadelphia, PA, USA
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Affiliation(s)
- Paria M Wilson
- Division of Emergency Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Maneesh Batra
- Department of Pediatrics, Division of Neonatology, Seattle Children's Hospital and the University of Washington, Seattle, WA
| | | | - John D Mahan
- The Ohio State University, Columbus, OH.,Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Betty B Staples
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Janet R Serwint
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Association of Neonatologist Continuity of Care and Short-Term Patient Outcomes. J Pediatr 2019; 212:131-136.e1. [PMID: 31201026 DOI: 10.1016/j.jpeds.2019.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/10/2019] [Accepted: 05/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To describe neonatologist continuity of care and estimate the association between these transitions and selected patient outcomes. STUDY DESIGN We linked Children's Hospitals Neonatal Database records with masked neonatologist daily schedules at 4 centers, which use 2- and 3-week and 1-month "on service" blocks to provide care. After describing the neonatologist transitions, we estimated associations between these transitions and selected short-term patient outcomes using multivariable Poisson, logistic, and linear regression analyses, independent of length of stay (LOS) and case-mix. We also completed analyses after stratifying the cohort by LOS, birthweight, age at admission categories, and selected diagnoses. RESULTS Stratified by LOS, patient transitions varied between centers in both unadjusted (P < .001) and multivariable analyses (adjusted incidence rate ratio; 95% CI for center B = 3.98 (3.81-4.15), center C = 4.92 (4.71-5.13), center D = 4.2 (4.0-4.4), P < .001), independent of LOS, gestational age, birthweight, surgical intervention, ventilator duration, and mortality. Only central venous line duration (adjusted incidence rate ratio 1.015, 95% CI 1.01-1.02) was minimally and independently associated with the number of transitions. No differences were observed in ventilator duration, oxygen use at neonatal intensive care unit discharge, bloodstream infections, or urinary tract infections. Surviving infants with meconium aspiration, hypoxic ischemic encephalopathy, cerebral infarction, bronchopulmonary dysplasia, and diaphragmatic hernia demonstrated similar findings. CONCLUSIONS Transitions in neonatologists are frequent in regional neonatal intensive care units but appear unrelated to short-term patient outcomes. Future work to define continuity of care and develop effective strategies that promote longitudinal inpatient management is needed.
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Who Is Responsible for Mitigating Work Fatigue of Critical Care Clinicians-the Individual or the System? Ann Am Thorac Soc 2018; 13:1453-5. [PMID: 27627474 DOI: 10.1513/annalsats.201606-517ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Simulation of a Novel Schedule for Intensivist Staffing to Improve Continuity of Patient Care and Reduce Physician Burnout. Crit Care Med 2017; 45:1138-1144. [PMID: 28362643 DOI: 10.1097/ccm.0000000000002319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite widespread adoption of in-house call for ICU attendings, there is a paucity of research on optimal scheduling of intensivists to provide continuous on-site coverage. Overnight call duties have traditionally been added onto 7 days of continuous daytime clinical service. We designed an alternative ICU staffing model to increase continuity of attending physician care for patients while also decreasing interruptions to attendings' nonclinical weeks. DESIGN Computer-based simulation of a 1-year schedule. SETTING A simulated ICU divided into two daytime teams each covered by a different attending and both covered by one overnight on-call attending. SUBJECTS Simulated patients were randomly admitted on different service days to assess continuity of care. INTERVENTIONS A "shared service schedule" was compared to a standard "7 days on schedule." For the 7 days on schedule, an attending covered a team for 7 consecutive days and off-service attendings cross-covered each night. For the shared schedule, four attendings shared the majority of daytime and nighttime service for two teams over 2 weeks, with recovery periods built into the scheduled service time. MEASUREMENTS AND MAIN RESULTS Continuity of care as measured by the Continuity of Attending Physician Index increased by 9% with the shared schedule. Annually, the shared service schedule was predicted to increase free weekends by 3.4 full weekends and 1.3 weekends with either Saturday or Sunday off. Full weeks without clinical obligations increased by 4 weeks. Mean time between clinical obligations increased by 5.8 days. CONCLUSIONS A shared service schedule is predicted to improve continuity of care while increasing free weekends and continuity of uninterrupted nonclinical weeks for attendings. Computer-based simulation allows assessment of benefits and tradeoffs of the alternative schedule without disturbing existing clinical systems.
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"You're not Superman you know..." (1). Pediatr Crit Care Med 2012; 13:602-3. [PMID: 22955463 DOI: 10.1097/pcc.0b013e31824557da] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Impact of resident duty hour limits on safety in the intensive care unit: a national survey of pediatric and neonatal intensivists. Pediatr Crit Care Med 2012; 13:578-82. [PMID: 22614570 PMCID: PMC3427401 DOI: 10.1097/pcc.0b013e318241785c] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Resident duty-hour regulations potentially shift the workload from resident to attending physicians. We sought to understand how current or future regulatory changes might impact safety in academic pediatric and neonatal intensive care units. DESIGN Web-based survey. SETTING U.S. academic pediatric and neonatal intensive care units. SUBJECTS Attending pediatric and neonatal intensivists. INTERVENTIONS We evaluated perceptions on four intensive care unit safety-related risk measures potentially affected by current duty-hour regulations: 1) attending physician and resident fatigue; 2) attending physician workload; 3) errors (self-reported rates by attending physicians or perceived resident error rates); and 4) safety culture. We also evaluated perceptions of how these risks would change with further duty-hour restrictions. MEASUREMENTS AND MAIN RESULTS We administered our survey between February and April 2010 to 688 eligible physicians, of whom 360 (52.3%) responded. Most believed that resident error rates were unchanged or worse (91.9%) and safety culture was unchanged or worse (84.4%) with current duty-hour regulations. Of respondents, 61.9% believed their own work-hours providing direct patient care increased and 55.8% believed they were more fatigued while providing direct patient care. Most (85.3%) perceived no increase in their own error rates currently, but in the scenario of further reduction in resident duty-hours, over half (53.3%) believed that safety culture would worsen and a significant proportion (40.3%) believed that their own error rates would increase. CONCLUSIONS Pediatric intensivists do not perceive improved patient safety from current resident duty-hour restrictions. Policies to further restrict resident duty-hours should consider unintended consequences of worsening certain aspects of intensive care unit safety.
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Jobe AH, Martin RJ. 24/7 neonatal intensive care unit attending physician coverage: a clash of missions. Am J Respir Crit Care Med 2010; 182:729-31. [PMID: 20833828 DOI: 10.1164/rccm.201006-0884ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Sanders MR, Estrada E, Leopold H, Makari J, Murray N, Schoem S, Wiley CC, Bhandari A. Flexing to aging: a children's hospital responds to a maturing workforce. J Pediatr 2010; 157:177-178.e1. [PMID: 20633719 DOI: 10.1016/j.jpeds.2010.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Marilyn R Sanders
- Department of Pediatrics, The Connecticut Children's Medical Center, Hartford, CT 06106, USA.
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