Ideal Staffing for Perioperative Care in Neonatal Cardiac Surgery
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1 Ideal Staffing for Perioperative Care in Neonatal Cardiac Surgery Duncan Macrae Consultant Paediatric Intensivist Royal Brompton Hospital London, U.K.
2 Paediatric Intensive Care Roots of PIC 1950/60 s Adult respiratory intensive care Neonatology /neonatal intensive care Pediatric general surgery Pediatric cardiac surgery Pediatric anesthesiology Grew out of need for increasingly complex post-operative management Development of sophisticated life support technology
3 Early models of Peditric Cardiac Care Care delivered by surgery / anesthesia/cardiology Often no identified leader of the intensive care Potential challenges Between different streams of care Difficulties in delivery of care Time-constraints on availability of surgeon/anesthesiologist Limited knowledge base
4 Brief history of Pediatric Intensive care s First specialised children s ICU s Philadelphia, Was198hington DC, Australia,(Melbourne, Adelaide) NZ Sweden(Gothenberg), UK (Liverpool, London) 1981 PediatricSection SCCM (US) 1984 American Academy Pediatrics Section on CCM» First certifying examination, 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
5 Provonost 2000 Provonost JAMA 2002 Overall RR 0.61 ( ) in favour of High Intensity High intensity = Intensivist-led care
6 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-ordinatedelivery of supportive care during cardio-respiratory and/or other organ-system failures In close collaboration with Cardiac surgeons / Cardologists/ Anesthesiologists/Other s
7 Fetal Cardiology PEDIATRIC CARDIOLOGY Catheter/ Non-invasive Invas EP Generalist Intervention Imaging Pediatric Cardiac Intensive Care Pediatric PCIC Physiotherapy Intensivist Nursing Pharmacy etc... PEDIATRIC CARDIAC SURGICAL TEAM Invas SURGEON ANESTHESIOLOGY PERFUSION NURSING ±CARDIOLOGY : TEE / EP / INTERVENTION
8 NURSING
9 Reduced intensivist coverage Reduced access to imaging / diagnostics 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
10 NURSE-STAFFING LEVELS AND THE QUALITY OF CARE IN HOSPITALS Needleman NEJM 2002 Data from 799 US hospitals
11 NEEDLEMAN 2006 Estimate projected all non-federal US Acute Care Hospitals
12 Amaravadi Intens care Med 2000
13 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
14 Nurse staffing and unplanned extubation in the pediatricintensive care unit Marcinet al. PedCritCare Med 2005 Case-control study, single PICU, Fifty-five of 1,004 intubatedpatients (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)
15 Designing for safe 24/7 cover
16 231,000 admissions myocardial infaction New Jersey
17 CritCare Med 2006
18 Out-of hours admission to PICU LuytCE, CritCare Med 2005 Retrospective cohort study 23 ICUs located in the Paris metropolitan region ~ 51,000 admissions No increase in mortality in out-of-hours admissions Arabi CritCare 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.
19 Brown KL IntCare Med 2011 et al. PCICU GOSH London At night... Fewer doctors Sicker admissions More ECMO More CPR
20 Training the Cardiac Intensivist
21 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 Pediatrics : ACC/AHA/AAP recomemndations insufficient to train independent cardiac intensivists
22 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 NO Paediatric Cardiac intensive Care certification in UK Most intensivists undertake additional year(s) of training in unofficial fellowship or temporary junior faculty posts
23 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 Better focus of cardiac care Better team learning Must continue to have ability to deliver non-cardiac care
24 Fetal Cardiology PEDIATRIC CARDIOLOGY Catheter/ Non-invasive Invas EP Generalist Intervention Imaging Pediatric Cardiac Intensive Care Pediatric PCIC Physiotherapy Intensivist Nursing Pharmacy etc... PEDIATRIC CARDIAC SURGICAL TEAM Invas SURGEON ANESTHESIOLOGY PERFUSION NURSING ±CARDIOLOGY : TEE / EP / INTERVENTION
25 NICOR CCAD National data
26 A Personal Reflection PediatricCardiac Intensivists Must speak the same language as Pediatriccardiac surgeons / cardiologists Likely to be judged (by surgeons etc.) on their cardiac knowledge and management Unlikleyto be judged on the excellence (or otherwise) of their non-cardiac management BIAS in favour of cardiac intensivists with core cardiology training
27 The Ideal Training for a Pediatric Cardiac Intensivist Core training in Anaesthesia / Paediatrics /Pediatric Cardiology + Training in general paediatric intensive care Training in pediatric cardiac intensive care (1 year) (1-2 years) Additional experience as required to meet core competencies: Pediatriccardiology (including basic ECHO and arrhythmia) Airway / vascular access Neonatology
28 Ideal staffing for perioperativecare in neonatal pediatriccardiac 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 Nursing 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 patients Very large units need team/ man-power plans to guard against over-sizing?parallel teams
29
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All new applicants must meet the following requirements as approved by the UNMH Board of Trustees, effective November 17, 2016: INSTRUCTIONS: Applicant: Check off the requested box for each privilege requested.