Pediatric Chronic Critical Illness: Gaps in Inpatient Intrateam Communication*

Abstract

Objectives: The number of children with medical complexity and prolonged hospitalizations is rising. Strategies to adapt acute care approaches for this population are falling behind clinical demand. This study aimed to identify how inpatient team communication practices match the needs of teams caring for these patients and families, and to identify priority areas for improvement. Design: Cross-sectional mixed methods survey. Setting: Academic children’s hospital. Subjects: Interdisciplinary healthcare professionals: physicians, nurse practitioners, nurses, resident and fellow trainees, respiratory therapists, clinical pharmacists, occupational therapists, physical therapists, social workers, and child life specialists. Interventions: None. Measurements and Main Results: Four-hundred eight interdisciplinary healthcare professionals participated (33% response rate). Half (53%) worked in ICUs and 37% had greater than 10 years clinical experience. Three overarching themes emerged regarding communication during care of children with prolonged hospitalizations are as follows: 1) Dysfunctional team collaboration: the many involved healthcare providers for these children have inconsistent team meetings and few platforms for reaching clinical consensus; 2) Continuity gaps: time-limited clinician rotations and no designated longitudinal clinical leaders undermine relationships with families and key elements of shared decision-making; and 3) Inadequate communication skills and tools: healthcare professionals have inadequate training to address complex conversations and big picture concerns, and often default to daily management conversations. Nearly half (40%) perceived intra-team conflict to occur more commonly during care of these children compared with those with short hospitalizations, and many feel unskilled to address these conflicts. Healthcare providers working in ICUs were more likely than other healthcare providers to find care of children with chronic critical illness stressful “most of the time” (ICU 46%; 60/131 vs non-ICU 25%; 21/84; p = 0.02). Conclusions: Acute care inpatient communication practices require modification to meet the needs of healthcare professionals who provide longitudinal care to children with repeated and prolonged hospitalizations. Improvement strategies should prioritize building collaboration, continuity, and communication skills among healthcare professionals.

Slow and Steady: Optimizing Intensive Care Unit Treatment Weans for Children with Chronic Critical Illness

“…14 30 31 Team communication has often been identified as a gap in critical care training, especially the longitudinal communication that promotes collaboration and continuity in PCCI care. 32 33 34 The current study suggests that the number of ICU setbacks a child with PCCI has increased as the number of covering attendings goes up. Ongoing work is needed to examine how strategies like continuity attendings might improve that.…”

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

“…Shared decision-making and anticipatory guidance can be subpar, put off, and not include older patients to the extent appropriate to their neurodevelopmental abilities. Along with frustration and apprehension among families (1, 2, 77, 86), rapport, trust, and confidence with providers can be weakened (85, 88). A conceptual model of the downstream effects of narrowly focused, fragmented care is available in Supplemental Figure 1 (http://links.lww.com/CCM/H81).…”

Chronic Illness in Pediatric Critical Care

“…With increased chronicity and accompanying medical complexity, CYSHCN have large multi-disciplinary teams that can change frequently over the course of a PICU stay, creating challenges in collaboration, continuity, handoffs, medication reconciliation, ownership for medical decision making, and forming consensus (37,38). Longer PICU stays may result as treatment plans are formulated and chronic medication regimens are manipulated (39,40).…”