Adding a dose of empathy to healthcare: What can healthcare systems do?

RATIONALE, AIMS AND OBJECTIVES: Healthcare practitioners often note system-level barriers to empathy between patients and practitioners. These include burnout-inducing administrative workloads, unfriendly meeting times, burdensome protocols, lack of wellbeing spaces, and undervaluing empathy as a core part of an institution's mission. The need for empathy in healthcare has been magnified with the current SARS-COV-2 outbreak which has limited the expression of interpersonal empathy due to rigid isolation protocols and the use of personal protective equipment. METHOD: This study-the first of its kind that we are aware of-outlines the details of a facilitated workshop run with the leadership of a tertiary level pediatric center in Canada. The workshop used a modified nominal group technique to discuss and prioritize actions to enhance empathy into the hospital system. RESULTS: Inter-professional and inter-disciplinary group of healthcare leader participants agreed on several immediately actionable steps, including embedding patient satisfaction with care measures as standard, and streamlining booking appointments. A roadmap was created to implement the other priorities. CONCLUSION: A systematic approach to infusing empathy into the structure of our healthcare system is much needed. Furthermore, inter-professional and inter-disciplinary educational workshops was well-received as a way to facilitate discussion and drive change.

Hydrocephalus-induced neurogenic stunned myocardium and cardiac arrest in a child: completely reversed with CSF diversion.

Neurogenic stunned myocardium (NSM) is a potentially fatal cause of sudden cardiogenic dysfunction due to an acute neurological event, most commonly aneurysmal subarachnoid hemorrhage in adults. Only two pediatric cases of hydrocephalus-induced NSM have been reported. Here the authors report a third case in a 14-year-old boy who presented with severe headache, decreased level of consciousness, and shock in the context of acute hydrocephalus secondary to fourth ventricular outlet obstruction 3 years after standard-risk medulloblastoma treatment. He was initially stabilized with the insertion of an external ventricular drain and vasopressor treatment. He had a profoundly reduced cardiac contractility and became asystolic for 1 minute, requiring cardiopulmonary resuscitation when vasopressors were inadvertently discontinued. Over 1 week, his ventricles decreased in size and his cardiac function returned to normal. All other causes of heart failure were ruled out, and his impressive response to CSF diversion clarified the diagnosis of NSM secondary to hydrocephalus. He was unable to be weaned from his drain during his time in the hospital, so he underwent an endoscopic third ventriculostomy and has remained well with normal cardiac function at more than 6 months' follow-up. This case highlights the importance of prompt CSF diversion and cardiac support for acute hydrocephalus presenting with heart failure in the pediatric population.

The impact of a quality improvement project to standardize pain, agitation, and withdrawal assessments on the use of morphine and midazolam in the Pediatric Intensive Care Unit.

BACKGROUND: This study aims to assess the impact of a quality improvement initiative to increase assessments of pain, agitation, and iatrogenic withdrawal syndrome, on the use of sedative and analgesic medication in a pediatric intensive care unit. METHODS: This is a retrospective pre and post, observational, quality improvement study conducted in an 18-bed medical-surgical-cardiac, tertiary intensive care unit. We included patients consecutively admitted from October 1 to March 31 (pre-period 2015-2016, post-period 2016-2017) who were mechanically ventilated beyond 48 hours. A multidisciplinary team, including a family advisor, implemented the following interventions using rapid "Plan-Do-Study-Act cycles:" (a) standardized pain and sedation assessments, (b) standardized sedation goal setting, and (c) non-pharmacological strategies to manage pain and agitation. We did not implement any specific sedation protocol. We used audit and feedback to reinforce change. RESULTS: The post-intervention phase started once sedation scores were documented q12h for >60% of patients. The groups (n = 45 per group) were similar regarding demographics, severity of illness, and mechanical ventilation duration, but different in length of intensive care stay. The cumulative dose of midazolam equivalent was significantly lower in the post-intervention period (3.71 vs 2.65 mg/kg/mechanical ventilation day, P = 0.009, 95% CI: -1.12 (-1.89, -0.31)). Morphine equivalent usage went from 3.51 to 2.57 mg/kg/mechanical ventilation day (P = 0.066, 95% CI: -0.67 [-1.44, 0.05]). There were no significant pre-post-differences in the use of other sedative agents, rates of iatrogenic withdrawal syndrome or severe pain, nor medication cost. CONCLUSION: Implementation of a multifaceted QI project was successful at increasing standardized assessments of pain and agitation, and was associated with a significant reduction in midazolam use. We also observed a decrease in morphine use without increasing rates of severe pain. Incidence of iatrogenic withdrawal syndrome and cost were unchanged.

A Stewardship Program to Optimize the Use of Inhaled Nitric Oxide in Pediatric Critical Care.

PURPOSE: Inhaled nitric oxide (iNO) is a pulmonary vasodilator that is approved for use in term and near-term neonates with hypoxic respiratory failure associated with evidence of pulmonary hypertension. However, it is commonly used in infants and children to treat a variety of other cardiopulmonary diseases associated with pulmonary hypertension and hypoxic respiratory failure. In critically ill children, iNO therapy may be continued for a prolonged period, and this increases the risk for adverse consequences including toxicity and unnecessary costs. We implemented an iNO Stewardship Program with the aim of improving adherence to guidelines and reducing unnecessary iNO utilization. METHODS: Between April 1, 2011, and March 31, 2015, a before and after cohort study was conducted at The Hospital for Sick Children. Prospective iNO usage and outcome variables in the poststewardship period were examined. RESULTS: Patient characteristics and outcomes were similar before and after stewardship implementation. The number of iNO therapy courses were also similar in the before and after period. Inhaled nitric oxide utilization in the pediatric intensive care unit and the cardiac critical care unit decreased from 15 765 hours in the prestewardship period (April 2011 to March 2013) to 10 342 hours in the poststewardship period (April 2013 to March 2015), with significant improvement in adherence to the iNO guideline and a small decrease in expenditure (3%). CONCLUSION: Implementation of the iNO Stewardship was successful at reducing overall iNO utilization. This quality improvement initiative helped us optimize practice and subsequently expand the methodology to inform the clinical indication for iNO.

It Takes a Village to Move a Hospital: Simulation Improves Intensive Care Team Preparedness for a Move to a New Site.

OBJECTIVES: To evaluate in-situ simulation to prepare a PICU to move to a new, redesigned unit. METHODS: The study setting is an academic PICU. This is a cross-sectional study using in-situ simulations of common PICU admissions. Postsimulation, participants completed a survey comparing the perception of preparedness pre- and postsimulation (via a 10-point Likert scale). Participants were resurveyed 6 months postmove to assess whether effects persisted. Qualitative data were obtained via thematic review of the survey comment section and from postsimulation debriefing. RESULTS: Response rates were initially 100% and 67% at the 6-month follow-up. In the initial phase, all questions had statistically significant improvements in post- versus presimulation scores. Participants felt better prepared (presimulation: 6.20, postsimulation: 7.90, P < .001) and more confident about caring for real patients (presimulation: 5.49, postsimulation: 7.41, P < .001). They felt more comfortable working in the new unit (presimulation: 5.65, postsimulation: 7.50, P < .001) and better able to deliver safe care (presimulation: 5.85, postsimulation: 7.60, P < .001). Six months postmove, participants still believed that simulation was helpful (7.43, SD: 2.20) and still reported improved team confidence (7.36, SD: 2.11). Only 1 of 28 participants preferred less simulation. Exercises were described as helpful in identifying process and latent patient safety issues. CONCLUSIONS: Our pediatric intensive care team found simulations to be beneficial in preparation for providing care to critically ill children in a complex new setting. Simulations uncovered latent process, personnel, and patient-safety issues that were addressed before actual patient care.

The Academic Half-Day redesigned: Improving generalism, promoting CanMEDS and developing self-directed learners.

BACKGROUND: The Montreal Children's Hospital Pediatric Residency Program redesigned its Academic Half-Day based on program concerns consistent with the published literature. These concerns included inadequate preparation for general paediatric practice, gaps in CanMEDS education and exclusive use of didactic lectures. Novel instructional methods included monthly simulation sessions to learn CanMEDS competencies, increased use of general paediatricians as instructors, implementation of a 'systems-based' curriculum and development of self-directed learning skills through activities such as 'Residents as Teachers'. METHOD: A postimplementation online survey was sent to all 18 residents who had been exposed to both curricula. The survey was designed to determine the impact of the new curriculum on their perceived ability to retain information and acquire the competencies of a general paediatrician, and to assess the effect on their self-directed learning. Responses were recorded on a five-point Likert scale ranging from 'strongly disagree' to 'strongly agree'. RESULTS: Fourteen of 18 (78%) residents completed the survey. All residents preferred the 'systems-based' educational program. Seventy-nine percent of all residents agreed that the simulation sessions were an effective method of learning the CanMEDS competencies. Importantly, 64% of residents voluntarily read more about the topics presented and 71% agreed that they retained the content better. Moreover, 79% believed that changes made to the teaching curriculum better prepared them for a general paediatric practice and 64% of residents believed that it better 'supplements' learning in the clinical setting. CONCLUSION: The authors propose that the new curriculum is comprehensive, while developing the skills required for life-long learning as a general paediatrician.

HISTORIQUE: Le programme de résidence en pédiatrie de L'Hôpital pour enfants de Montréal a revu ses demi-journées d'enseignement en tenant compte de préoccupations également soulignées dans les publications scientifiques. Ces préoccupations incluaient la préparation insuffisante en pédiatrie générale, les lacunes dans la formation CanMEDS et l'utilisation exclusive des exposés magistraux. Parmi les nouveaux modes d'enseignement, soulignons les séances de simulation mensuelles pour acquérir les compétences CanMEDS, un recours accru aux pédiatres généraux comme formateurs, l'adoption d'un cursus fondé sur les systèmes et le perfectionnement des aptitudes d'apprentissage autodirigé par des activités comme les « résidents enseignants ¼. MÉTHODOLOGIE: Dix-huit résidents exposés aux deux cursus ont reçu un sondage virtuel. Ce sondage visait à déterminer les répercussions du nouveau cursus sur leur capacité perçue à retenir l'information et à acquérir les compétences d'un pédiatre général, ainsi qu'à en évaluer l'effet sur leur apprentissage autodirigé. Les chercheurs ont colligé les réponses sur une échelle Likert en cinq points oscillant entre « en total désaccord ¼ et « tout à fait d'accord. ¼ RÉSULTATS: Quatorze des 18 résidents (78 %) ont rempli le sondage. Tous préféraient le programme de formation fondé sur les systèmes. Soixante-dix-neuf pour cent de tous les résidents trouvaient les séances de simulation efficaces pour assimiler les compétences CanMEDS. Fait important, 64 % des résidents lisaient volontairement davantage sur les sujets présentés et 71 % convenaient qu'ils retenaient mieux la matière. De plus, 79 % étaient d'avis que les changements apportés au cursus d'enseignement les préparaient mieux à une pratique en pédiatrie générale, tandis que 64 % pensaient que ces changements complétaient mieux l'apprentissage en milieu clinique. CONCLUSION: D'après les auteurs, le nouveau cursus est complet et permet de perfectionner les aptitudes nécessaires à l'apprentissage continu d'un pédiatre général.