Nurse Physician Partnership In Management of Critically Ill Children Ndidiamaka L Musa MD FCCM Associate Prof, Department of Pediatrics, University of Washington. Pediatric Cardiac Intensivist, Seattle Children’s Hospital. John Adabie Appiah Head, PICU KATH Medical Knowledge FIESTA 2016 Accra, Ghana

Objectives Current State of affairs Nurse training Physician attitudes toward nurses The patient is the focus Team based approach

Crossing the quality chasm in resource limited settings A young school-age boy with severe respiratory distress presented to the remote hospital. Previously, the boy had been seen by untrained private clinicians in the community three times over four days. At presentation to the hospital, the child was evaluated by a mid-level practitioner who provided an initial course of antibiotics. Despite the child's ill appearance, supportive treatment including intravenous fluids and supplemental oxygen were not provided until discussion with the Medical Director three hours later. Later that evening, the electric nebulizer and oxygen concentrator became unusable after the hospital lost power owing to a blackout of the public electric grid and malfunctioning of the hospital’s backup generator. The regulator for the backup oxygen canister could not be found. At this juncture, without the ability to provide oxygen, the medical team recommended transfer. The family did not agree to transfer due to the high costs of other regional health facilities (the facility provides free services). That evening, after not being examined for over two hours by on-call staff, the child was found unresponsive with a thready pulse. For over 10 minutes the midwife managing the ward did not know the procedure and the bag valve mask was not at the bedside. Following 15 minutes of unsuccessful resuscitation, the child was declared dead.

Highly complex environment Healthy Work Environments, Nurse-Physician Communication and Patient Outcomes By Milisa Manojlovich, RN, PhD, CCRN, and Barry DeCicco, MS (Statistics), MS (Industrial Engineering) IOM estimated that as many as 98000 hospitalized patients die each year from medical errors. Errors in the ICU occur at a reported rate as high as 1.7per patient per day. Highly complex environment Conclusion nurse physician communication reduced medication errors Am J Crit Care November 2007 vol. 16 no. 6 536-543

WHO Report 2008 In 2008 report recognized a patient can be harmed as a result of a variety of factors and that understanding these and devising solutions to eliminate or minimize them would result in improved patient care. Among critical factors identified as global research priorities in the area of patient safety is the reported lack of communication and coordination between providers.

The high incidence of medical errors that results in a lack of safe care within the existing system Most people view medical mistakes as an individual provider issue rather than a failure in the process of delivering care within a complex delivery system. Disruptive behavior Issues of inter-professional collaborations Kohn et al 2000 The Joint commission (TJC) cites “Improving the effectiveness of communication among care givers as Goal 2 among the National Patient Safety Goals

Convert a team of experts… to an expert team!

Team Training…building competence to Excellence!

John Adabie Appiah Head, PICU KATH Nurse Physician Partnership in Managing Critically Ill Children a Paradigm Shift John Adabie Appiah Head, PICU KATH

Physician - Nurse collaboration = improved patient outcome

Collaboration The situation of two or more people working together to create or achieve the same thing Oxford English Dictionary Synonyms: cooperation, alliance, partnership, concert, association, gang up synergy, harness, tandem

Challenges to collaboration Background Similar training Different emphasis Same goal/target – better patient outcome Working together cannot be over emphasized in PICU

Aviation –for a successful Boeing airbus flight Team approach Aviation –for a successful Boeing airbus flight Pilots Hostess Engineers on the ground All too often we don’t such teamwork in healthcare system where we have been trained to work as Doctors issuing orders Nurses carrying out orders Barely make contribution during patient evaluation

Getting it right from the beginning Need to respect each ones role and unique attributes Football team analogy Defense Offence Need to train together to understand how each member will play out During formative training in respective school med and nursing schools More interaction as a team During continuous professional training Sharing common meetings

Shifting attitudes – intensive care units DCH - KATH approach Initiated subspecialty training of medical personnel Doctors mostly sent out to train including Ped Critical Care APFP PICU emphasis Physician nurse team work by adoption of SBAR approach and Red Zone Combined ward rounds Team approach to incidence reporting and review together Had reduced our number of adverse events Increased confidence in team members

Communication – SBAR approach For efficient and effective information transfer S – Situation B – Background A – Assessment R – Recommendation

Reducing errors together Red zone concept Incidence reporting and evaluation together.