Hi, everyone, and thank you for accommodating my request. I love post lunch slots, so I'm hoping over the next 30 minutes I can keep you all awake. And what do you think it is that I'm going to talk to you in the next 30 minutes that you all don't know? Because like critical care is a team sport, right? So these are my disclosures. I do get funding for, as a pediatric subject matter expert for, we are one of the 13 centers in the country for bioterrorism. So regional, we get federal funding for that. And then I also do some consultation work for the Society of Simulation in Healthcare, which I'm a fellow of. So you will hear me talk about simulation, but it's not related to the funding I get, because interprofessional education, one of the arms is simulation. I'm also presenting this topic on behalf of my co-authors, Remy Ukal, who is an APP in Duke, and Ramon Guest, who is a pediatric intensivist at SUNY Downstate. We all wrote this chapter together, so this is just me presenting on the group's behalf. So what am I going to cover today? Defining interprofessional education, and even though we think everybody knows this, this is a pet peeve of mine. When we say multidisciplinary, it is not the same as interprofessional. And you'll see the definition in the subsequent slides. The next one is really the concept of interprofessional education as a continuum of development. The competencies of interprofessional education, or IPEC, the collaborative. And then how did we think about this when we wrote the chapter? We thought of it from an education, practice, and outcomes perspective. And that's what we'll talk about in the Pediatric Intensive Care Unit. So the next slide combines the first and the third objective together. So what does the WHO define interprofessional education as? So if you have a surgeon and if you have an intensivist teaching a group of medical students, that's not interprofessional education. That's multidisciplinary. If you have an APP and you have an OR nurse teaching a group of nurses, that is not interprofessional education. So you see the definition on the slide. I'm now going to read it out to you. But multidisciplinary is not the same as interprofessional. And really what the IPEC collaborative is, it's over four domains. So the first is values and ethics. So the mutual respect between two professions, the shared values, and really ethical conduct. And this seems like it's very obvious, but sometimes it's not. So who has not seen the angry surgeon, you know, having an issue when there is an instrument being, you know, there in the ER? We all see it, right? And this first domain really aligns with that. Roles and responsibilities. So this is a big domain which aligns with crisis resource management principles too. So knowing what your own role is, what your scope of practice is. The third one is communication. And then the last is teams and teamwork. So these are the four domains of IPEC collaborative. And as I said, IPE is defined as shared learning from each other, but from two different professions and not disciplines. Okay. So what's the difference between interprofessional collaboration and interprofessional education? And the reason we are talking about this today is the hope is when you go back, especially because this is going to affect all of us, as some of you may know or many of you may know, ACGME changed the way residents are going to rotate to the pediatric critical care units, right? They actually took out a lot of procedures from the mandated competencies. And after a lot of professional organizations actually gave significant pushback, they put four essential procedures out. But what's the problem? We actually wrote an editorial in the simulation journal about this because there's going to be disparities. What if you don't have a pediatric intensivist in that area? And your resident has never done back mask ventilation. How is that child going to be taken care of if that child shows up sick in the ER? So the reason we are talking about this is that when you have the new generation of learners, nursing, pharmacists, physicians, you have to think about education before collaboration. I was never taught by a nurse formally when I did med school. I was taught on the job when I did fellowship, and I proudly say that a lot of my critical care is because I had excellent nurses at the bedside. But can we have a system where we actually think about the interprofessional education formally before people learn on the job and wing it when they learn interprofessional collaboration? So what are the differences, right? So really, IPE entails learning from each other and with each other. The goal is to learn in a holistic manner, break down silos of learning, and being a lifelong learner. And then it also serves as a prerequisite to interprofessional collaboration. So thinking of IPE before IPC, which we all do on the job, right? All our QI projects, all our MDR and collaboratives are interprofessional collaboration examples. All the QI work, some of which we spoke about transitions of care, have to be interprofessional. Were we ever taught by a nurse when we were in med school how to think about these things? So that's really the aim of this. So as I said, we are going to divide this into three domains, and starting with education. So who's heard of TeamSTEPPS? All right, great. So about one-third to one-fourth of the room. Okay. So TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety. It's by the AHRQ. And for those of us who have issues traveling, which I did too, you can take it virtually now. It's offered free of cost. And if you haven't taken it, I would highly advise you taking it. Despite having done a lot of IHI-QI modules, I still think the TeamSTEPPS was value-added to the way you think about patient safety. So the first study there is from Ken Cashwell's group and MUSC. And all these, by the way, are references in the e-book that you have. If it's not in your e-book, I will tell you what it is. And that's actually a research project in progress. So I'll talk about it when I come to the slide. So you don't have to take notes or whatever. They're all in your references. So what they did was they actually took TeamSTEPPS and taught it, nurses and doctors taught it to a group of residents and nurses. And they actually looked at hospital quality indicators, not in pediatrics. So the first one is not pediatrics. The next two are pediatric critical care. And they looked at length of stay, ICU days, and then hospital-acquired infections. They could not find causality, meaning they found an association, but could not prove that TeamSTEPPS, teaching TeamSTEPPS, was why that happened. So that's the first study. The next one is in a NICU and a PICU together in Germany. So this is from Merzei. And what they did was nurses and physicians taught a group of nurses and residents a really mechanical ventilation curriculum. And they did it by a pre-test. They had a multiple-choice exam and then did a post-test. If you think about the practice levels, if anybody knows what I'm talking about, there are four levels, right? One is knowledge, skills, attitude. Two is care delivery. Three is outcomes. And four is health system changes. The days have gone when you did an intervention and the learner felt that they were more comfortable afterwards, that it's going to show a benefit because you just can't prove anything. Now the question is, does it really change how we practice? Does it really change how we deliver care? So the third one, and I'm not answering any of this question. I'm just telling you those are the four levels. The last study is actually from Children's Hospital of Philadelphia, which is the Poynter study, which was really a one-month curriculum for the residents rotating through the PICU, and the nurses and the RTs actually filled up a calendar. It was one hour of administrative work a week, so not a lot of work, and they just picked up these modules and taught the residents overnight. And this is the level one I was talking about. The study proved that their knowledge and comfort level was better, but does that mean that the health care delivery is different? That's a little far from where we are, and that's why we need more research, and I'll talk about what's going on, but that's really the education part. So who are the educators for IPE, right? How do you pick them? And if you go to all the adult learning theories, it's really the context matters. And when I say context matters, you have to write the goals. You have to write the objectives for what you're doing. You're not going to be able to do everything in those 30 minutes. One of the tables back there during lunchtime, you were having a discussion about what the attention span is of the present generation of learners, and how are they going to learn? What's the best modality of delivering this learning, right? So when I say, you know, context matters, so who debriefs, you know, where do you debrief? Do you do interprofessional clinical debriefing? Do you do interprofessional post-simulation debriefing, hot and cold debriefing? There's a lot of stuff written about cold debriefing from actually CHOP, again, about the incident happening two weeks back, and then you have a cold debriefing just for passive learners who are not involved in the incident to listen to the lessons learned about what happened, right? So that's cold clinical debriefing. Co-debriefing is a very good role modeling teaching lesson where you can have an interprofessional co-debriefer, and that value and respect thing you'd actually role model during the simulation debriefing. So what are these pictures, right? So the picture on the left is there is some theory about how you debrief clinical or simulation. You cannot sit in this mode. You cannot be the debriefer and the learners or the participants are sitting where you guys are sitting. It has to be in a circle. It has to be like a discussion. As a debriefer, there is no didactic, right? All you're doing is facilitating the self-reflection, which is the most important part of debriefing. In fact, there's in simulation best practices, one of the evaluation questions is, did the learner talk as much as the debriefer or the debriefer spoke more? And if the debriefer spoke more, that's a red flag because you are supposed to do less of the talking. You're just supposed to reflect, facilitate the self-reflection. The right-hand side one is some simulations on our unit where we actually, I just do interprofessional simulation because, again, I firmly believe critical care is a team sport. So we have the, this is a post-cardiac surgical handoff where the surgeon, the anesthesiologist, everybody's in the room. The other thing about interprofessional simulation and or education is really breaking down the assumptions we all make about scope of practice. And that will become evident to you in some of the subsequent slides. Okay. So I'm doing okay on time. All right. So what's the next study? So if some of you heard, there was a very big study, 13 centers participated. The PIs were in Mayo. And what they did was they really did a virtual curriculum and a pre and a post-test survey on best practices during COVID. And it was taught in an interprofessional manner. So there were nurses, respiratory therapists, physicians who were the educators. And the group of learners was also interprofessional. And it was a, it was a, you know, reasonably robust design. And what they really showed was there was a difference in the post-education, you know, scores that they achieved. And this QR code on your screen takes you directly to the PDF. But it's also in your reference manual. So I mean, in your reference ebook. Okay. So this is all great, right? How do you take it home? What does it really mean to any of us? So this, these next few slides are of a study that we are presently part of. This is a multi-centered pediatric critical care simulation study. The PIs are Christina Wong from Montefiore Children's. And then she's an otolaryngologist, Tenzing Ma from Nationwide, and Akira Nishizaki from CHOP. And what this is, is really an in-situ simulation study to mitigate tracheostomy latent safety threats and improve tracheostomy emergency readiness. And I'm going to sort of take this to a spectrum of what interprofessional education, delivery, and outcomes could translate if you're thinking of these studies. And how you could think of some of these things back home. So what this study does is it has a very basic five-minute simulation scenario, which is outside the pediatric critical care unit, either on the floor or in a unit where you may be taking care of tracheostomy patients without a ventilator. If you have a chronic care, you know, chronic facility or a step-down unit, that's the other place too. And it really talks about how the team would perform if there is a tracheostomy emergency. Meaning suctioning the trach and changing the trach, those are the two outcomes in addition to the other outcomes. So what we did was, we, this is the team in our center, we did this study. And what we really were surprised by is that neither the physicians, the nurses, or the respiratory therapists knew what the scope of practice or the competency requirements are for a trach change. And nobody would own the responsibility. And when we took this information back to the centers who were doing this study, the non-freestanding children's hospitals had similar practices. Their RTs were not having annual competencies in trach changes. So nobody was really owning the trach. So now, thinking of the education part, the practice part, and the outcome part, so how do we design it? So we took our entire group, meaning nursing, physicians, and RTs, and did a just-in-time training with the trach mannequin, where we signed them off in red cap on the lip and cot competencies for trach. So that was the interprofessional education part of it. Then as far as practice part of it, we designed a tracheostomy checklist for the bedside, which had a front and a back, which was really how they would practice when they really got a tracheostomy patient, a safety checklist with all the details, collaborating with their ENT surgeons. And then we did pre-intervention and post-intervention and saw if there was a decrease in the latent safety threats and or time to change the trach or time to suction. That's how the study was designed. So why was this important? Why do we do this? So we really had different understanding of how we would all respond in an emergency, because we've never studied together, and we've never thought of this as a collaborative project together. We really, you know, sat down, thought of the problem solving and what the sustainable solutions were, with the ultimate goal being really care of the patient. So where has this been applied to as far as QI outcomes go, and what's the data? So if you know, the big pick-you-up study, which is a huge success, the practice where because illness doesn't mean stillness is what Dr. Kurt Zuckerberg famously says. So if you are ill, it does not mean you cannot be moved. So the delirium prevention strategies, the out-of-bed with your occupational therapist and physical therapist. So that's a very interprofessional QI study, right, with nursing, with PTOT, and with the physician. So that study is the first one. The second one, which is really a systematic review of how does interprofessional collaboration improve professional practice and healthcare outcomes. This study is relatively old, and they actually say in the first statement that they could not find a relationship. However, by the time they had even started to analyze the data, there were more studies on this. As I said, that level four of the healthcare outcomes is really difficult to make, let alone in pediatrics, but even in adult care. But that doesn't mean that we stop the work. I think we just need to do more robust research interventions and study the question that we are trying to answer. And then the last study is really how do you link these interprofessional education interventions to delivering safe and effective patient care. So that's a scoping review. And it again talks about the difficulties in really studying the question. One of the other examples of interprofessional collaboration where we can affect outcomes, and there's data on that, is interprofessional rounding, right? So we've never studied from each other as formally in nursing school or med school, and it's not a medical school problem. In fact, I visited several nursing schools for the simulation work I do, and there is no non-nursing educator on their faculty either. So I think it's a systematic issue, and we just need to think of whether we need a change in paradigm on how we think about it. In fact, in the GME world, there's a big question about whether medical education should be titled medical education or the title be changed into professional education. So think of it from like planting the roots rather than thinking of it when it's too late. But so multi-professional rounds have been, you know, associated with improved patient outcomes. There's a lot of data. You'll see the references there. You really, when you round with your colleagues, you break those silos and you learn what each other's strengths are, what the scope of practice is, and then the values and ethics domain in the first IPEC collaborative and the roles and responsibilities, you're really cultivating autonomy, mutual respect, and psychological safety. The first one, psychological safety, is a big, big pillar. If you haven't read Amy Edmondson's work in high reliability organizations and psychological safety, it's a big, if you don't want to read the whole book, just read the Harvard Business Review of Psychological Safety. Really important, really related to improved patient outcomes. And then the last one, which is actually in the pediatric QI journal, is minimizing interruptions, right? So I think if all these things are followed, then you really improve patient outcomes and it's all related to thinking of it from a team perspective and now not from a I perspective or me perspective. Okay, and that is my last slide. Thank you very much for your attention.

interprofessional education

critical care

pediatric settings

collaboration

healthcare outcomes

medical education