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.
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
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
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
Provonost 2000
Provonost JAMA 2002
Overall RR 0.61 (0.5-0.75) in favour of ‘High Intensity’
High intensity = Intensivist-led care
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
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.....
NURSING
• 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
NURSE-STAFFING LEVELS AND THE QUALITY OF CARE IN
HOSPITALS
Needleman NEJM 2002
Data from 799 US hospitals
NEEDLEMAN 2006 Estimate projected all non-federal US Acute Care Hospitals
Amaravadi Intens care Med 2000
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
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)
Designing for safe 24/7 cover
231,000 admissions
myocardial infaction
New Jersey
1987 - 2002
Crit Care Med 2006
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.
Brown KL Int Care Med 2011 et al.
PCICU GOSH London
At night....
Fewer doctors
Sicker admissions
More ECMOMore ECMO
More CPR
Training the Cardiac Intensivist
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”
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’
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
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.....
NICOR – CCAD National data 2000 - 2010
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
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
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
www.pcics.org
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