Fostering a learning healthcare environment in the pediatric intensive care unit

Pearls

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A learning healthcare system occurs when patient care, interdisciplinary education, and clinical research are so integrated and intercalated that they are basically inseparable. Each element informs and benefits from the other.
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Professionalism provides the foundation for a learning healthcare environment and encompasses the concepts of accountability, respect, and an inclusive, diverse team.
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Standardization, in the form of clinical standard work, represents the infrastructure for iterative improvement. Without standardization, measurements of improvement are not possible.
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Because pediatric critical care providers should ideally base practice on science and not empiricism, the pediatric intensive care unit must serve as the clinical laboratory for generation of evidence.
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Primary benefits of a learning healthcare environment include identification of best available evidence to support best practice and promotion of wellness and resiliency among critical care providers.

Incredibly important as it is, there is more to working in the pediatric intensive care unit (PICU) than providing care for critically ill children. When critical care providers converse about what they do, the discussion typically includes ensuring rapid and accurate diagnosis and treatment, providing support for dysfunctional/failed organ systems, and preventing complications of critical illness and its treatment. However, this chapter considers another activity that will enrich any PICU, including the physical space, the actual work, and the people who provide and receive treatment. This overlooked but key aspect of critical care may be described as fostering a learning healthcare environment.

Learning healthcare system

A learning healthcare system occurs when patient care, interdisciplinary education, and clinical research are so integrated and intercalated that they are basically inseparable ( Fig. 7.1 ). Each element synergistically benefits from and informs the other. Such continuous and reciprocal learning and knowledge translation ultimately facilitates enhanced performance and improved outcomes for both patients and providers.

Foundation predicated on professionalism

Professionalism provides the foundation for a learning healthcare environment and encompasses the concepts of accountability, respect, and teamwork. In the PICU, accountability means practicing value-based care that considers both the cost and the quality of care delivered plus demanding a culture of safety. Critical care practitioners work at the intersection of complex patients, complex therapies, and a complex environment that collectively provide the antecedents for a potential perfect storm for inadvertent adverse events. A culture of safety includes being personally accountable, practicing clinical standard work, engaging multidisciplinary teams, focusing on systems, and anticipating unintended consequences, all of which are linked with effective communication ( Fig. 7.2 ).

Respect within professionalism centers around inclusion and diversity. Unfortunately, research in workforce diversity and inclusion, including healthcare industry workforce as a whole and within different specialties and subspecialties, is sparse. However, numerous studies have concluded that race and ethnicity are social constructs with profound social, economic, legal, financial, and health implications for the global population, including the PICU workforce. A 2018 study concluded: “There is an urgent need for greater diversity, with respect to gender, race, ethnicity, and sexual orientation in the U.S. healthcare workforce. While society, in general, is becoming more diverse, the same cannot be said of American medicine.” ^,

Interestingly, at least by some measures, the most diverse countries are considered to be in sub-Saharan Africa, while the least diverse tend to be in Europe and Northeast Asia, with the United States in the middle, ranking slightly above Russia and slightly below Spain. Census data from 2017 demonstrated that the United States is becoming more diverse, with Asian and mixed-race populations leading the way.

American healthcare, including PICU staffing, has not kept pace with changing general population demographics. A 1997 study found that the supply of minority physicians will need to double for Hispanic and black physicians, triple for Native American physicians, and decrease by two-fifths for white physicians and two-thirds for Asian and Pacific Island physicians to meet US healthcare needs with racial and ethnic population parity, based on managed care–based recommendations of 218 physicians per 100,000 population.

In defining the scope of diversity, race, gender (including nonbinary identities), genetics, and socioeconomics must be considered and respected. At the lowest bar, institutional and individual healthcare providers can be disbarred from third-party private and governmental payers for treating patients differently based on diversity characteristics noted earlier. As healthcare moves into quality outcomes as a determinant for reimbursement, these issues take on even greater importance. Studies have shown that concordance between physician and patient demographics improves quality measures. In pediatric populations, studies have found that racial and ethnic minority children have disparities in their healthcare access and outcomes versus their white counterparts. Enrollment in the State Children’s Health Insurance Program decreases but does not eliminate these disparities, which vary by state. A recent British study found that concordance did not affect a patient’s assessment of hospitalist performance. This is good news for the PICU population in terms of quality measures.

Historically, clinical research, one of the pillars of a learning healthcare environment, was not necessarily designed and conducted to measure and analyze the different responses of racial/ethnic and gender minorities to a given treatment. There is evidence that research scholarship generated by diverse research teams yields research that is higher quality and more impactful. ^, The National Institutes of Health (NIH) has been encouraging diversity in research enrollment for years, and the Scientific Workforce Diversity Office leads the NIH’s effort to diversify the national scientific workforce (e.g., #GREATMINDSThinkDifferently [ https://diversity-nih-gov.easyaccess1.lib.cuhk.edu.hk/ ]). The Department of Health and Human Services recently offered funding opportunities to increase minority participation in multidisciplinary PICU conferences (R13, Pediatric Critical Care Conferences Initiative, RFA-HD-20-012). Nevertheless, African-American, LatinX, Native Alaskan, Native American, and Native Hawaiian populations remain underrepresented in medicine as compared with their proportion of the general population. For example, African Americans and LatinX constitute about 13% and 17% of the general population, respectively, but represent only about 4.2% and 4.6%, respectively, of physicians. Native American, Alaskan Native, Native Hawaiian, and Pacific Islander are represented even less. ^, ^, Providers from underrepresented minority groups are more likely to practice in an underserved area. ^, Even less is known about LGBT physician workforce numbers. A recent survey of Pediatric Department Chairs in the United States found that only 0.4% of faculty identified as LGBT.

Pediatrics appears to be doing better than other medical specialties and subspecialties regarding physician diversity, particularly from a gender standpoint. A 2017 workforce study found that 73% of residents, 64% of fellows, and 54% of faculty were female. American Board of Pediatrics data from 2017 showed that 40% of all certified PICU physicians were women and 60% of first-year fellows were female. Most African-American and LatinX physicians are first-generation doctors, unlike their white counterparts. Moreover, the majority of the underrepresented minorities enter primary care, not medical or surgical subspecialties. For critical care physicians, the most recent preliminary data of the Society of Critical Care Medicine’s Diversity and Inclusion Committee suggests that 1% to 2% of intensivist members are African American and about 10% are LatinX.

Despite the demonstrable benefits of a diverse physician workforce, disparities and outright discrimination remain evident. The literature surrounding this issue has primarily focused on women, but there is no reason to believe that the discriminatory behaviors toward women remain, while those toward ethnic and racial minorities would have ceased, since women represent a greater percentage of physicians, at 37%, than all racial minorities combined. A third of female physicians have experienced sexual harassment ; women are less likely to be introduced as “doctor” ; women are less likely to be first authors in top-tier journals ; women are less likely to be included on expert guideline consensus panels ; there are fewer women in leadership, including editorial board positions, even in pediatrics ^, ^, ; there are fewer women full professors ^, ; women receive less research startup funding ^, ; and a significant gender pay gap persists in medicine. ^,

Studies in other industries have demonstrated that management teams with higher gender diversity outperformed those with less diversity, and greater gender diversity increased overall business performance, including number of customers, revenue, and profits. Similarly, companies with a racially and ethnically diverse workforce financially outperform their competitors by 35%. Yet 97% of US companies have an executive/senior leadership that fails to reflect the country’s ethnic and racial diversity. Healthcare also fails in this regard—including pediatrics—and therefore likely also pediatric critical care. The case for a diverse healthcare workforce includes advancing culture competency, increasing access to high-quality healthcare services, strengthening the medical research agenda, and ensuring optimal management of the healthcare system.

The third aspect of professionalism is teamwork—and nowhere is this more important than in the PICU. Consider, for example, early mobilization and the cast of providers required to make it successful: physical therapy, nursing, respiratory therapy, nutrition services, pharmacy, physicians, and the patient and family. Effective teamwork in the PICU must acknowledge patients and families first, celebrate the interdisciplinary care team, include clinical research personnel, and promote wellness and resiliency. Such teamwork facilitates well-being; this, in turn, supports improved patient-clinician relationships, a high-functioning care team, and an engaged and effective workforce ( https://nam.edu/initiatives/clinician-resilience-and-well-being/ ).

Pillars of a learning healthcare environment

Best-practice clinical care

Characteristics of clinical standard work include being consciously developed and documented; evidence based whenever possible, consensus derived when evidence is absent, followed by everyone performing the work, “owned” by someone, describes a clinical pathway/patient trajectory, is measurable, and represents the basis for improvement. Standardization facilitates identifying and eliminating waste, communicating between providers, establishing a baseline for continuous improvement, and minimizing noise/controlling for nuisance variables. Standardization represents the infrastructure for iterative improvement. Without standardization, measurements of improvement are not possible. Clinical standard work benefits from continuous process improvement longitudinal plan-do-study-act (PDSA) cycles embedded in clinical research or quality improvement. Probably the best illustration of this concept, iterative research protocols implemented into clinical practice, is the amazing history of acute lymphocytic leukemia (ALL). In the 1950s, ALL was a death sentence for a child within a few months; today, almost all children with ALL experience long-term survival. Advantages of protocolized critical care have been summarized and include avoiding errors of omission, improving PICU efficiency, decreasing cost and improving value, and maintaining and improving the standard of care.

Clinical research, including quality improvement

Currently, of the three determinants that affect clinical decision-making by critical care practitioners—education, experience, and evidence—the latter is least abundant. However, Claude Bernard astutely noted that while most people regard medicine as the art of healing, it is more appropriate to regard medicine as the science of healing because providers should ideally arrive at a cure scientifically and not empirically. For a fundamental discovery to transpire, appropriate clinical stimuli must interact with scientific training —what better place than the PICU? But for this to happen, a real collaboration must exist among the principal investigator, patient and family, and the entire bedside care team. Primary clinical faculty must work alongside physician-scientists to ensure success of clinical research in the PICU.

One example of the power of critical care research is the story of central line–associated bloodstream infections (CLABSIs) among critically ill children. Previously, such infections were viewed as almost inevitable among critically ill children but are known to be associated with increased duration of stay, prolonged antibiotic therapy, ongoing need for venous access, increased morbidity and mortality, and increased healthcare costs. National quality improvement research focused on insertion and maintenance bundles for central venous catheters (CVCs) resulted in a decrease in PICU CLABSI from 5.8 to 1.4 infections per 1000 CVC days over a 5-year intervention interval. Today, a CLABSI typically evokes root cause analysis, reviewed as a serious adverse PICU event. In a similar fashion, investigators have critically examined the utility of the Society of Critical Care Medicine’s ICU Liberation bundle of clinical standard work elements as infrastructure for usual care provided to critically ill adults. ABCDEF Bundle elements are summarized in Table 7.1 .

TABLE 7.1

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