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