Ideal Staffing for Perioperative Care in Neonatal Cardiac...
Transcript of Ideal Staffing for Perioperative Care in Neonatal Cardiac...
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Ideal Staffing for Perioperative
Care in Neonatal Cardiac Surgery
Duncan Macrae
Consultant Paediatric IntensivistConsultant Paediatric Intensivist
Royal Brompton Hospital
London, U.K.
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Paediatric Intensive Care
Roots of PIC 1950/60’s
– Adult respiratory intensive care
– Neonatology /neonatal intensive care
– Pediatric general surgery
– Pediatric cardiac surgery– Pediatric cardiac surgery
– Pediatric anesthesiology
– Grew out of need for increasingly complex post-operative
management
– Development of sophisticated life support technology
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Early models of Peditric Cardiac Care
• Care delivered by surgery / anesthesia /cardiology
• Often no identified leader of the “intensive care”
• Potential challenges• Potential challenges
– Between different streams of care
– Difficulties in delivery of care
• Time-constraints on availability of surgeon/anesthesiologist
• Limited knowledge base
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Brief history of Pediatric Intensive care
1960 -70s First specialised children’s ICU’s
Philadelphia, Was198hington DC,
Australia,(Melbourne, Adelaide) NZ
Sweden(Gothenberg), UK (Liverpool, London)
1981 Pediatric Section SCCM (US) 1981 Pediatric Section SCCM (US)
1984 American Academy Pediatrics – Section on CCM
» First certifying examination, 1987
1987 First comprehensive textbook of PIC
1988 Paediatric Intensive Care Society (UK)
1990 First full-time paediatric intensivist UK
2000 Peditric Critical Care Medicine journal established
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Provonost 2000
Provonost JAMA 2002
Overall RR 0.61 (0.5-0.75) in favour of ‘High Intensity’
High intensity = Intensivist-led care
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What is the role of the pediatric intensivist?
• To lead a team
– Intensivists, Nurses, RTs, Physiotherapy, Dieticians, Pharmacists,
Social workers, Clergy, Psychologists, etc...
• To co-ordinate delivery of supportive care • To co-ordinate delivery of supportive care
during cardio-respiratory and/or other organ-system failures
– In close collaboration with
• Cardiac surgeons / Cardologists / Anesthesiologists /Other s
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InvasCatheter/ Non-invasive EP Generalist
Intervention Imaging
Fetal
Cardiology
Pediatric Cardiac Intensive Care
“PEDIATRIC CARDIOLOGY”
InvasPEDIATRIC CARDIAC SURGICAL TEAM
SURGEON ANESTHESIOLOGY PERFUSION NURSING
± CARDIOLOGY : TEE / EP / INTERVENTION
Pediatric Cardiac Intensive Care
Pediatric PCIC Physiotherapy
Intensivist Nursing Pharmacy etc.....
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NURSING
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• Reduced intensivist coverage
• Reduced access to imaging / diagnostics
• Reduced access to “support teams” • Reduced access to “support teams” (RT, Physio, Dietetics, Pharmacy)
• Change in nursing skill mix
• Reduced support to nursing team from managers / nurse specialists
DEGENHARDT N 2011
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NURSE-STAFFING LEVELS AND THE QUALITY OF CARE IN
HOSPITALS
Needleman NEJM 2002
Data from 799 US hospitals
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NEEDLEMAN 2006 Estimate projected all non-federal US Acute Care Hospitals
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Amaravadi Intens care Med 2000
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No relationship between :
•Nursing skill mix or
•Nursing worked hours and mortality
BUT
• Retrospective ‘trawl’ of administrative data ?? Coding or other systematic errors
• Mortality is LOW and is a poor surrogate for QUALITY of OUTCOME
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Nurse staffing and unplanned extubation in the pediatric intensive
care unitMarcin et al. Ped Crit Care Med 2005
• Case-control study, single PICU, 1999-2002
• Fifty-five of 1,004 intubated patients (5.5%) experienced an
unplanned extubation
• Factors associated with unplanned extubations included
– A nurse-to-patient ratio of 1:2 relative to a nurse-to-patient ratio
of 1:1
– (odds ratio, 4.24; 95% confidence interval, 1.00, 19.10)
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Designing for safe 24/7 cover
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231,000 admissions
myocardial infaction
New Jersey
1987 - 2002
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Crit Care Med 2006
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Out-of hours admission to PICU
Luyt CE, Crit Care Med 2005
• Retrospective cohort study
• 23 ICUs located in the Paris metropolitan region
• ~ 51,000 admissions 2000-03
• No increase in mortality in “out-of-hours” admissions
Arabi Crit Care Med 2006Arabi Crit Care Med 2006
• Single centre
• 24/7 on-site staff intensivist
• No significant difference in hospital mortality rates related to time of admission
Ensminger SA, CHEST 2004
• No increase in hospital mortality of patients admitted to the (adult) ICU on weekends.
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Brown KL Int Care Med 2011 et al.
PCICU GOSH London
At night....
Fewer doctors
Sicker admissions
More ECMOMore ECMO
More CPR
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Training the Cardiac Intensivist
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Training the Pediatric Cardiac Intensivist
ACC/AHA/AAP
Recommendations for Training in Pediatric cardiology
Task Force 5 “Requirements for Pediatric Cardiac Critical Care”
Kulik T. Et al. JACC 2005
• Core Training goals (Pediatric cardiology) 3 years
• Advanced training goals (Pediatric cardiac critical care) 9 clinical months
“versus”
Pediatric critical care medicine
3 years / 18 months clinical
Baden et al. 2006 Pediatrics :
“ACC/AHA/AAP recomemndations insufficient to train independent cardiac intensivists”
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UK PIC training
• Joint board
• Accreditation in paediatric intensive care medicine open to
anesthesiologists, surgeons or paediatricians
• Core training in base specialty
• 2 years PIC training which must include some cardiac experience• 2 years PIC training which must include some cardiac experience
• NO Paediatric Cardiac intensive Care certification in UK
• Most intensivists undertake additional year(s) of training in
unofficial ‘fellowship’ or ‘temporary junior faculty posts’
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General ‘pediatric’ or pediatric ‘specialist’ intensive
care units?
• Cardiac cases ~ 40% of PIC admissions
• Complexity of cardiac cases is high
• Argues strongly for separate pediatric cardiac ICU or ‘stream’• Argues strongly for separate pediatric cardiac ICU or ‘stream’
– Better focus of cardiac care
– Better team learning
– Must continue to have ability to deliver ‘non-cardiac’ care
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InvasCatheter/ Non-invasive EP Generalist
Intervention Imaging
Fetal
Cardiology
Pediatric Cardiac Intensive Care
“PEDIATRIC CARDIOLOGY”
InvasPEDIATRIC CARDIAC SURGICAL TEAM
SURGEON ANESTHESIOLOGY PERFUSION NURSING
± CARDIOLOGY : TEE / EP / INTERVENTION
Pediatric Cardiac Intensive Care
Pediatric PCIC Physiotherapy
Intensivist Nursing Pharmacy etc.....
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NICOR – CCAD National data 2000 - 2010
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A Personal Reflection
Pediatric Cardiac Intensivists
– Must speak the same language as Pediatric cardiac surgeons /
cardiologists
– Likely to be judged (by surgeons etc.) on their cardiac knowledge
and managementand management
– Unlikley to be judged on the excellence (or otherwise) of their
non-cardiac management
– BIAS in favour of cardiac intensivists with core cardiology
training
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The Ideal Training for a
Pediatric Cardiac Intensivist
• Core training in Anaesthesia / Paediatrics /Pediatric Cardiology
+
• Training in general paediatric intensive care (1 year)
• Training in pediatric cardiac intensive care (1-2 years)
Additional experience as required to meet core competencies:
• Pediatric cardiology (including basic ECHO and arrhythmia)
• Airway / vascular access
• Neonatology
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Ideal staffing for perioperative care in
neonatal pediatric cardiac surgery
Intensivists
• PICU Director
• 24 / 7 Staff intensivist cover (probably in-house )
• All staff intensivists to have cardiac and general ICU training
• 24 / 7 Fellow / Senior trainee cover
NursingNursing
• Usually 1:1 nurse : patient ratio
• Competency-based allocation of nurse to patient
• Sufficient capacity within nurse team to support / respond
Unit size
Difficult for one staff intensivist + team to care for more than 12-15 patients
‘Very large’ units need team/ man-power plans to guard against ’over-sizing’
?Parallel teams
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www.pcics.org