Hi, everyone, we are doing the critical care crosstalk today. My name is Alexander Lukic. I'm one of the PAs at Scripps Health in San Diego. I'm serving as the moderator for the talk. Here with me today, I have Sean Nix, who is a trauma medical director at St. Luke's Hospital in Kansas City. Prior to this, he was the critical care director and surgical critical care director, Riverside Regional Medical Center in Newport, Virginia. His experiences include working at the University of Oklahoma as a trauma surgeon intensivist and completed his residency at DeParis Hospital in St. Louis and surgical critical care fellowship at Barnes-Jewish Hospital in St. Louis. His research interests include sepsis, communication between health care team members, and he served in the USMC during the Persian Gulf era. Outside medicine, he enjoys sailing and family activities. All right, Sean, if you'd like to take it away. Yeah, thank you, Alexander. Appreciate it. Yeah, and this is, I think, the third year, and actually, Oklahoma is where I met Ryan, the co-speaker. So, me and Ryan have known each other for a few years now. This third year, we're giving a promise, next year, we're going to have a new face up here. But we'll try to make it interesting, and I will go over some thoughts on this. Myself and Ryan both have done this for a couple of years now, and we both had the experience of having to start two critical care programs. Hopefully, you can see my screen. You cannot yet. I will share my screen if I am able to. I know. How do you like all this share content? There you go. All right. And hopefully, everyone can see my screen now. And if you can, I see a heads up. Anyway, so both of us have had a couple of experiences developing ICUs, and so it's been an interesting process. We tend to gravitate in our careers towards that thing that we enjoy doing. I really enjoy building a team, and I've had to learn a new aspect of it. I'm going to talk about this, and so maybe it's good me and Ryan have done this more than once, because now I can talk about new things that I didn't know I didn't know, right? Isn't that healthcare? It's those things that we didn't know that get us. And so I'm going to bring that topic up, and hopefully, we'll learn something from that. And that's just me all over again. And so if you download this, you can look up more stuff about me there. Disclosures? I have no disclosures. Could you put it in slideshow, please, Sean? Oh, yeah. Apologies. I know. Okay. And again, that's me again. Disclosures? No disclosures. And these are questions. So these are just questions right up that the moderator sent to us. I've added a few on there and changed it a little bit. And so I thought if I give this, this may give – yeah, these are probably similar questions. We all are similar. We all have similar questions and thoughts and ideas on this. And I will elaborate a little bit more on myself. Again, after I finished training, I went to the University of Oklahoma and spent two years there. It was really a hardcore training program, top-notch program, a great director. I learned a tremendous amount from Dr. Albrecht about trauma surgery, building a program, and about an ICU. And after that, I ended up on the coast building an ICU program and a trauma program, and we were wildly successful. That program has grown beyond anybody's thoughts it would go. It went from 900 locum tenants – or 900 patients a year. Locum tenants ran trauma program, really, to 3,000 patients a year now. You know, we had our own ICU before I left. We had a full-competent surgery residence that we're now rotating there and an ER residency, and it really just took off. But it just took, you know, kind of the basics. You've got to build a team, have a team. You've got to say yes all the time. Somebody calls you, asks you, can you do something? The answer is yes, right? That's the number one thing I can tell you. I see Ryan smiling during this. That is the number one thing. Somebody calls you, just say yes and figure it out. And if you can't do it, then that's okay, you know, because you can figure out the resources they need. So someone's calling you because they're calling for help because they can't do it. And that's something the parent com told me once at Wash U. I was middle of the night saying, I can't believe these people calling us about this blood pressure. Why can't they control it on the floor? And he saw me and he goes, Sean, there's no doubt in my mind that you can take care of this. He goes, but they're asking for help for a reason, so they can't. So that's the biggest thing I can tell you. Just say yes all the time. I'm going to go through some of these questions and then I'll kind of talk exemperientially. Define what the intensive care team looks like. So that's an interesting thing. I actually talked to my ICU nurse manager about this, too, because we've had a lot of turnover like everyone else in the ICUs. And I think some of that institutional memory and learning gets lost when you have rapid turnover, especially because, you know, there's no experienced people to stop and train the new people. So you really lose that. So that is a good definition. It's something we need to work on and actually, you know, set up a plan even today to say, hey, let's do an ICU. You can call it safety committee, quality committee on care. We have an ICU committee that just looks at dashboards and infection rates and things like that. I'm talking about something that's really, I really want it critical care nurse driven. And I'm, you know, certainly part of the whole team is going to be there. But I want that team to really take active roles so we can kind of educate the new folks who have come in. It's what we do. So what does it look like on paper and what does it look like in real life? Well, on paper, you've got the physician led team, the charge nurse, the bedside nurse, the respiratory therapist, the physical therapist, the nutritionist, as well as the case manager even can be in on that. And some place of interesting chaplains is part of it, which is an important part. That's what it looks like on paper. In real life, what does it look like? Everybody's busy, right? Those people are all part of my team. And I was even saying that to the nurse because of the nurse manager today because he was talking. I said, well, I don't want the care managers there because I meet with care manager every morning about the entire trauma team. And twice a week, I have discharge planning. So they are part of the team, but they meet differently. Physical therapy, kind of the same thing. We have limited resources. So it's hard for me to get a physical therapist there every day to occupy their time and rounds. However, you know, walkthroughs and things like that nature and actuality, when you can walk through with the physical therapist covering your unit that day, say this one can walk, this one can't walk. Let's do this one. Let's do that one. So even respiratory therapy, at times, I have to just do walkthroughs with them in the morning for rounds. Oh, yeah. I'm married to a pharmacist. I shouldn't have forgot the pharmacy team. They're part of it. So, yeah, so that's, you know, so they're all part of the team. Sometimes they're not all there in rounds, but I do try to integrate each one of those aspects in. And then rounds for us is mostly the attending, the house staff, respiratory therapy, a fair amount of time, but not always. Sometimes we do walkthroughs if they're taking care of COVID patients in the back ICU or something like that. So we just have to crowd them. The pharmacist, the bedside nurse and charge nurse. And that's kind of the minimum team we have during rounds. But in actuality, I do integrate that entire team into it. So does everyone have the same goals and thoughts? That's why I talk to my ICU manager. Interestingly enough, sometimes we don't see eye to eye. I'm a trauma surgeon. That's kind of the way the world is. But really, me and him have the exact same thoughts. In my last session, we had the same thoughts of what should the team be? What should the team be focused on? What should the team be doing? But you do got to spend some time communicating that. And that's where I think we fall down on. And it costs you time when you don't stop and spend some time planning, creating a vision, strategy and goals for your ICU and your team. I think that's the most important part. We all like the team. We love the team. It works. We love the concept. We've all been raised in it. But unless you really have a vision, right, then develop your goals to say you're accomplishing that vision and strategy how to accomplish those goals. So vision, goals and strategy. Unless you have those three things, it's going to be hard. You're going to have to make it up day by day. And as a leader, I've really had to learn that. Kind of the hard way is you kind of get tired of you just kind of think to yourself, man, I'm getting a lot of phone calls on stuff I think they should know. But they're still calling me every day on stuff that I think they should know. Well, it's because I haven't really relayed enough. Believe me, everybody knows my vision. Everybody interviews here when I'm recruiting. They're like, you know, everybody says you have vision. I have a vision. But I've got to make sure they also know what the goals are to accomplish that vision and the strategies. So, so critical. I can't stress it enough. Does everyone have the same goals, thoughts? Yes. We just kind of verbalize that. And how does an ICU accomplish that goal? Well, again, that is the $64,000 question. How do you accomplish your goals to achieve that vision? Right. You develop a strategy. If you don't have enough physical therapy in your patients, then we put together work groups of physical therapy and nurses and research therapy and make sure we get early emulation going. Right. We had a tracheostomy issue. So we put together a work group to look at, you know, difficult airways and tracheostomy changes and reinsertions when fresh trachs fall out. And we develop algorithms and protocols for that. But biggest thing, you can write algorithms all day long, put them on the wall or on the glass doors like at Barnes they're doing. It doesn't matter. You got to get a group of people, a common interest, right, and a common goal and a shared strategy to achieve it. And that's called a team. And you got to do a lot of education and get them on board. And that's how you accomplish those goals. It's kind of simple. It's like high school football. It's the same. I mean, I mean, it really is. And so that's what we've done. We've identified an issue. We put together a work group. We identify the protocol for it to solve that issue. And then and then we do the change. Goal is objective, multidisciplinary team. Well, you know, the basic goal is get rid of my patients. Right. No, it's to, you know, liberate them from the bed, then liberate them from the ICU. And we know that it's a good team, that we're taking care of their infections, their injuries. We're preventing secondary injury. Right. You know, all those things that we work together to accomplish. The steps for building the team. I think, number one, and this is me. It may be different ways. And Ryan, hopefully he'll give his perspective. I know it's great. Is first, you've got to have that vision. You've got to say, you know, I expect every day for rounds to occur. And I expect, you know, this kind of teamwork to occur and these folks to show up. And you've got to have that really high bar, high expectation. And folks, if they don't, if they're not used to it, they may inadvertently kind of oppose you a little. And it's not because they don't like you or they don't like, you know, doing good care. Just they want to kind of continue the way they were. Right. And so part of your goal in leading that team is trying to express why we want to change and what we want to accomplish. And again, it goes back to your vision. I think that's the biggest first step, you know, is setting that standard, integrating them into practice decisions. Right. Daily care goals and daily decisions. I think just doing that repetitively builds that team. How do we communicate and streamline information with this large team? Again, that's hard. We do education staff meetings once like the once we have a protocol like for trade changes or something like that. We actually try to develop a small information handout for people who weren't part of the process. The biggest thing is have as many people as you can as part of that process. And so we have a lot of buy in. And then you try to educate those others. Are there specific EMR items used to promote a team? Yeah, I mean, there's various communication things. I guess I'm not the best person to answer that because there are some tools in EPICS and Cerner that do allow for good promotion and team communication kind of out of the chart. So I know they're there. I just haven't been great about using them. Yes. Was there team roundings where I did my training? Certainly. I tell people, you know, I was a resident and a fellow. Rounds started at 730. They concluded at 1230. We had seminar and we did work until 3 from 3 to 5. We did afternoon rounds. And from 8 to 11, we did nighttime rounds. And from 1.30 a.m. to 3.30 a.m., we did fellow rounds. And 6.30, we did checkout. So, yes, definitely rounds. Lots of rounds. Rounds all day, every day. It's good care. I mean, going back and looking at patient re-exam, re-examine, it's great. In what ways does it enhance patient care? I really think it does a really good job because you can see changes and patterns. In my last establishment where I built that service because they had no critical care program, I built that. One of the long-time surgeons there was like, man, I've just never seen anybody, you know, pay so much attention, so much focus on these critical care patients. And they had a critical care program. They were just not critical care. And not the other guys aren't great. They are. I just had this different level of attention and just my constant need for reassessment of the patient. So, I think it does, one, gets the patient out faster. You identify issues earlier. Hopefully, you can avoid sepsis and things of that nature. So, that's what I did. Is there multidisciplinary education available at respective institutions? You know, we don't have that here. And I'm going to take that back. Alexander, thank you for putting that on here. Because it is a good idea to think about maybe we need to actually have some team education on how each person, you know, fits into a role and contributes and maybe some kind of corporate team building training. I hate to use that word, but it's probably a good idea. Was there multidisciplinary team rounding when you did your training? Oh, it's a repeat. Sorry. Apologies. Yes. What to do when they leave, right, in training and replacements. They leave, right? You have partners that will come and go. Americans stay at jobs about four to five years now, you know. When I interview folks, I tell them that statement. It's a truism, right? It's a fact. Because we're portable. Retirements, we pay for our own retirements, right? You can take it with you. And other reasons, Americans do leave. And so I tell them, you know, number one, when I hire you as a partner, whether you're a physician or an MP or something, I want you at the end of that time period to be better, right? To build your career, build your CV, and to be a better clinician and colleague, number one. So I was trying to train folks in my department. And it's been hard because I came here. I built this team. I built this service. You know, we have doubled our trauma volume. We have a critical care service now. And suddenly, I've had two folks who have moved on, and I've had to recruit and expand. And then you get these new people with expansion or replacement that, how do they fit in your team? And I tell you, it is something I did not think I would have to worry about or how I would fit that new person in as a team member. It's hard to see them on equal footing, especially from the inaugural team, right? That team you built it originally with, they're always going to kind of be in your heart as the people you built this with, the original founders. And it's hard intellectually to run off the bat except these other folks, even though, I mean, I hired them, right? But you have to, you know, you have to flip that switch in your mind. This is a new team member. And so how do you integrate them? You know, you try to make sure they know all your policies and protocols. And you try to, you know, model the type of grounding, type of behavior that you want them to exhibit when they're in your ICU or senior trauma patient or something like that. And so you try to give them that institutional learning. This is the way we do it here. And it's so interesting because one of the folks I hired was a resident from a couple of years ago here. And one, she can tell you, oh, it's just such a huge difference. Two, at the same time, we hired somebody who wasn't here and goes, guy, you guys have such an efficient system. Everything's well on. It runs great. You have a great way you do everything. And it wasn't always that way. So it's nice to see these two different views. One person knew it before. One person didn't. And so it's nice that they fit in your team. So that's the biggest thing is when you get somebody new to kind of keep your program running, you've got to make sure you have a process for introducing them to your protocols. You know, you've got to spend some mentoring time with those folks. You know, if you're a surgeon, maybe you do. Pop your head in the OR sometimes. Maybe you pop your head in the trauma bay, walk to the ICU and see how things are going and make sure they know where everything is. And make sure you're kind of fostering that system that you built. But at the same token, you've got to be open that they may bring in some new ideas, which is great. Which is why it's great to get new people. So it doesn't mean it changes your system. It just means that you have, you know, new ideas that are going to augment it. Do that. And always train your replacement. If you want it to succeed you, which I hope you do, anytime you have something, please train your replacement. And have somebody that you're kind of, you know, thinking about moving into your role. You know, maybe it's not director of trauma. Maybe it's director of ICU. But right now I'm training my replacement because I hope we have a viable working system that's going to continue to grow and develop as time goes on. And so I think that's critical. What do you do when they leave? What do you do when you leave? You've got to have your replacement already done. And because you don't want, you know, this team and all these people who have come and gone through it, all their work and sacrifice be for nothing. You want to continue to grow and be a resource for your community and your hospital. So, Alexander, do you have any questions for me? That's kind of my spill. No, I thought that was a good discussion, Sean. I appreciated you kind of going through each one individually. I think both of you have an incredible breadth of experience. I appreciate you sharing it with this team here and for SCCM as well. I know you are a busy, busy person right now. So if you have to jump off, I totally understand. But thank you for being here with us. All right. Thank you. Thanks, John. All right. Ryan, we're still recording. Looks like we have about 20-ish minutes left, if that's enough time for us to have a good discussion. Sure. Sure. Well, thank you for the opportunity, and thank you to SCCM and the organizers. Sorry to cut you off. I just realized I didn't introduce you because we went right into Sean. Can I have one second to tell SCCM about your background? All right. So Ryan Hakeem is here with us today. We greatly appreciate it. He's the director of the NeuroICU and transcranial Doppler ultrasound service at Prisma Health in upstate Greenville, South Carolina. Additionally, he's a professor in the Department of Medicine for Neurology Services at the University of South Carolina Greenville School of Medicine. Additionally, he's the chair of the Pharmacy and Therapeutics Committee for his health system. Immediate past chair of the SCCM Osteopathy Section and Medicine Drug Shortages and Medication Safety Committee. Completed a two-year fellowship in neurocritical care and stroke at Duke University Medical Center. He's board certified in neurology, neurocritical care, neurosynology, and is a neurovascular specialist. I mean, Ryan, I read that right before we came on, and I was very impressed just reading it. I appreciate all the knowledge you bring here to this topic. Sure. Well, thank you for the opportunity, and thank you to Sean for setting the table for us here. Today we'll be sharing my thoughts and concepts about building a multidisciplinary, multiprofessional neuroICU team. I do not have any disclosures. So Sean mentioned this earlier, but I can't emphasize how important this is. You have to have a vision. So I was one of those crazy people who graduated from fellowship and went straight out to start a brand new program. And I remember one of my mentors saying, you're making the biggest mistake of your life. And we all come from excellent programs, you know, places that we all trained at points in our career. Those are places with legacy, history, longstanding processes that are well run. And, you know, the battles are over and the wars are won, usually at those locations. However, when you go to a new program, it sometimes feels like you're sort of reinventing the wheel and you have to have a plan. So you have to think about it from an administrator's standpoint. So I remember during my first interview at University of Oklahoma, which is where I started, they said, why do you want this job? And I said, well, somebody's got to be first. So you have to have a plan and you have to have done that thinking. You know, that, that time where you pour yourself a glass of scotch and you think deep thoughts about what it is that you want to accomplish in your life. So for me, I was thinking about what, what are the key constituents of a team? And I'm biased. My mother was an advanced practice provider. So I've always been a strong advocate for advanced practice providers. And I remember at my first center, there were no advanced practice providers in neurology other than those who had lesser tasks, let's just say. And the concept of patients coming to a university medical center to see an advanced practice provider was highly questioned. But having come from a place with very strong advanced practice providers, I always say that I was trained by advanced practice providers. You know, I had to push that, push that thought forward. Learners, so residents, fellows, medical students, PA students, NP students, pharmacy residents, all of those folks. You know, the larger you build your group, the more support you have and they're good PR for your program because they sort of spread the word about your program. So incorporating learners is a very important part. Clinical pharmacists. So I'm extremely biased towards pharmacists. I think they are the greatest cost-efficient healthcare provider in critical care. In fact, there have been numerous presentations that the average pharmacist will save you something in the neighborhood of $200,000 a year from waste, from medication side effects, from all these kinds of other drug-drug interactions, things that we always are trying to prevent. But two sets of eyes are always better than one. Respiratory therapy. Respiratory therapy, unit-based respiratory therapy is the most effective way because you build a rapport with the individuals that are there and they're physically there in the unit. You don't have to use the telephone or texting or things like that. Now, unit-based physical therapy, occupational and speech therapy, that's a lot harder to come by, but that's something that I've always strived for. And when you have sort of a dedicated unit-based physical therapy team or overall therapy team, again, that rapport, they're your friends. They're 10 feet away. You get their attention. They give you feedback. That's quite useful. And then social worker and case management. So a lot of the nursing distress in their job is about the sort of family interactions and they're the ones on the front line, family members contesting the plan of care, family members contesting other family members, family members contesting who's the medical decision maker, all of these types of things, as well as correct identification of the patient, making sure their insurance status is correct. So that you don't make statements that somebody is going to go to LTAC when they're unfunded. And then a lot of others. At our program, we have a transcranial Doppler ultrasound program. So we have a lot of vascular sonographers. We have six of those. Coding and documentation specialists. Most providers, these are their enemies. These are the annoying emails that come to your inbox contesting the care you provided, the charge you entered, the necessity of what you did or things like that. So I sort of took it upon myself to go and educate myself. And I went and got the same certification that these individuals have. So I'm a certified professional biller. I will tell you that I gained tremendous respect for them. The exam is five hours and 40 minutes long with a 30% pass rate. So these are quite intelligent people that send you these emails. They're not people that they're just trying to annoy you and things like that. But they're making you better. And so learning to talk their language. So we all learn medicine, but we don't learn how to communicate medicine in the EMR especially. And then business analysts. Understand the finances of what you are suggesting. Just because they had something at Duke or Wash U where Sean came from or perhaps even Cleveland Clinic where you came from, Alex, doesn't necessarily mean that the financial structure at your current organization could support it. So one of my mentors always said the more you know how to do other people's job, the better a job you can do. And so learning, for example, a very typical thing is that, you know, what is the market on advanced practice providers and how many shifts they work? How many hours do they work? How many patients do they carry? What are the expectations of them? What are the salaries that are across the nation for these individuals? Same thing for pharmacists. How many ventilated patients can an average respiratory therapist cover in a university academic medical center? So the more you learn these things, the better you can do in terms of advocating for people. So when the organization wants to suggest a profoundly low salary for an advanced practice provider, you're very quick to jump on that and say that that's not reasonable. You're not going to recruit anybody of value with that. And if so, you'll turn into the training center for advanced practice providers where they'll come get your onboarding and your education and they'll go with all these excellent skills and off to the next job that actually appreciates them from a financial standpoint. So learning all of these things is really your thought. And in the business world, they talk about a 5, 10 and 15 year plan. You clearly cannot accomplish all of these things on day one, week one, month one, year two, all of these things. You have to be thinking, what is it I want to do next? And so you have to spend a lot of time thinking about these things if you're the medical director. So one of the ways that you can be successful is to have an administrator's perspective. You always have to remember that the person that says no to you has to answer to somebody else. So if they say yes to you, they have to go explain to somebody else why did they say yes and knowing that that individual may tell them no. So you have to have an administrator's perspective. And one of the best tools that you have is certification. So if a third party, for example, the Joint Commission mandates that you have a certain service, a certain specialist, a certain staffing par or any of those types of things, use that as a tool and make yourself more knowledgeable. So, for example, in neurocritical care, it mandates that you have either an advanced practice provider, a physician or a dedicated resident to that service, resident or fellow, at night to take care of these patients. So, great. So go use that as a tool to say to the organization, OK, well, we don't have fellows yet. But we can train advanced practice providers and have them partner with a physician instead of having two physicians, which are harder to come by and also are more expensive to you. We can have one advanced practice provider with a physician at night taking care of these patients so that at all times somebody can handle an admission and the other one can handle an emergency. And so those kinds of knowledge pieces, you know, learn like and you can get all this information on the Internet. You can just sit there and scroll through hundreds of pages of documentation from the Joint Commission about what the rules of the game are. Use those rules to your benefit. When you come to an administrator and you have screenshotted those three lines that say, you know, you have to have a dedicated provider in the unit at all times, then they say, oh, OK, well, we don't have fellows. We don't want to hire two physicians to do that task. OK, we like your idea. So go back to the drawing board and tell us how many you need and what's it going to take and those types of things. Understanding the competition. So this is something that appears that we lost our share screen. One moment. All right. There we go. So understand the competition. So what is it? Who is your competition? You know, there's a concept called triangular diplomacy from the Nixon administration. It's called your enemy's enemy is your friend. So understanding who who the competition are and how to leverage them to say that, well, you don't want patients to bypass your hospital for something, because if they bypass your hospital for one thing, what then they'll choose to. That will change the referral pattern. Elective surgeries will get bypassed from your hospital to down the road. So it's not just what kind of patient doesn't come to your hospital. And overall, just sort of understand the finances, understand things like diagnostic related groups, DRGs. How does a hospital get paid for things and so on and so forth? This takes a lot of your personal time. And there are things that you're just doing in the background that nobody's aware of. But that makes you better at your job. And in the end, you have to be the leader of your program. Here's a very important one. Determine what your organization defines as success. We recently had a publication in the Neurocritical Care Journal called Currents. And each organization defines success very differently. So, for example, there are some organizations that define it by physician work RVUs. So I can tell you that our organization, for example, does not hold advanced practice providers accountable for their work RVUs. The objective is for the advanced practice provider to function at the highest possible level to collect physician work RVUs. At other places, they have a cost model. So they look at the cost of taking care of, let's say, 20 patients and divide it by the cost of the personnel responsible for taking care of those patients. So obviously, if you had a very heavy advanced practice provider group and only had one physician overseeing them, that cost model would be very efficient. That would not be a model that would work if you're using the physician work RVU model. There's a sort of a surgical model where your university ICU has a lot of post-ops. Well, post-ops, their care is part of what's called a global fee. So meaning that the fee that the hospital receives includes the surgeon's fee and a 90-day care fee. So any kind of personnel you employ to make sure that the patient doesn't have a complication, there's no reimbursement for that. So every hospital defines success very differently. And so what you might have experienced at your excellent training center may not be how your hospital defines it. So figure those things out and then build your staffing plan, not the other way around. We all came from various centers with a variety of different staffing plans. But those staffing plans don't necessarily work when the definition of success is different at your organization. Quality and safety data. Become familiar with these terms. Everybody knows what a CLABSI is or a CAUTI. But do you know all the technical definitions? Do you know that if the urinalysis was collected within 48 hours of the hospital admission, then it's going to be attributable to whether it's a CAUTI or not, depending on certain circumstances. Do you know that community rates of C. diff are usually higher than hospital rates of C. diff? And so if you inappropriately test people, you're going to get a lot of positives, and it's not necessarily going to be helping the patient or guiding your treatment. Understanding pressure injuries and the value of documenting them. These are called these PSI events. Cost of care. So understanding, like we talked about, the staffing models and how does your hospital pay for things? Is it that you get sort of indirect costs? Is it based on provider billing? Is it based on global fees? Is it based on the DRG of, for example, a non-interventional stroke patient versus an interventional stroke patient, and the DRG is about fourfold different between those? Patient experience scores. So some hospitals have a tremendous concern about patient experience scores, especially now with the CMS has what's called the hospital star ratings. It's very interesting to note that although we think the centers of excellence are the places that have fellowships and subspecialty care, I can tell you that in neurocritical care, there are 76 centers with neurocritical care fellowships, which intrinsically you would assume are the best places in the country to receive your care. However, only 13 of those are five-star hospitals. So there's a difference in those statistics and understanding those statistics. Know your allies, the emergency department, the referral center in neurocritical care, it's neurosurgery and the other critical care teams. As Sean mentioned, he said always say yes. I say be the path of least resistance. So no patient falls into one singular diagnosis with one singular problem. That's almost never an ICU patient. And so there's always a stroke patient in DKA. There's always a surgical critical care patient with sepsis. There's always a medical critical care patient who's in status epilepticus. So as soon as you see one part of the diagnosis that you're very comfortable with and is in your collection of diagnoses, then you should be the path of least resistance. Tell the ED we'll admit those patients. At my first center, we took call for neurosurgery. So that was very – that's how we built the alliance with the chair of neurosurgery. We said you take the call pay. The vast majority of calls to neurosurgery from the emergency departments and community hospitals are nonsurgical by far, at least 80%, if not greater than that. So if we're going to end up admitting those patients to the neuro-ICU anyway, then why should you be taking those calls? And so therefore when we determined that the patient were in surgery by our assessment, the surgeons were very much more willing to acquiesce and go along with our thoughts because we've screened out that 80% for them. So they only get calls for real types of things. That's how you build allies when you come from somewhere that one program is really strong and your program was nonexistent before you showed up. So you build these alliances with people and then people recognize that you're willing to work and you're a team player and that gets you pretty far. When at all possible, be an admitting service. Everybody wants to be a consultant because they perceive it's less work and it depends on what kind of – if you're in a true academic medical center where the consultant doesn't write orders or things like that, it truly is less work. But many places have what's called consultant-managed model where even though you're the consultant, you still have to order the appropriate tests relevant to the area that you've been consulted. You have to manage those aspects and you have to have the family meetings related to those aspects. So there's really not as much of a benefit of being a consultant. In addition, administrators are often looking at your admissions and discharges as a marker for how busy you are. So when you're a consultant, you don't have that data and there's a perception that you're of less value. So be an admitting service and that will be music to the ears of the emergency department and the referral center and others. And put in the work. It's a grind battling antiquated historical processes at each hospital. So you come some places and they've been doing something in what you perceive to be a ridiculous way because of your experiences at a high-functioning center. So you just have to move the line, the border, keep moving it forward a little at a time and don't offend people by coming and saying like that's a ridiculous way to do things. And then a great sports analogy that I really like and Sean mentioned it too is be accessible. The best ability is availability. So when somebody calls you and you're with your family at Disney World which actually happened to me and they say there's a critical issue at the hospital. We'd like to speak with you for an hour and pull you into a meeting. Well, you're just going to have to do it. That's your job. If you want to be successful, you got to put in the time and nobody cares that you're at Disney World with your family. You just say, OK, kids, why don't you go with mom and I got to conduct this meeting. So you put your headset in and you go find a quiet place and you go from there. But I hope this is of value for people and don't be scared to be first. Whether you're the first APP, whether you're the first physician, whether you're the first clinical pharmacist, whatever you are, whatever role you're going to play, there's nothing wrong with being first. But just recognize that there's going to be a tremendous amount of work and leadership is not about the name on the door or the badge or the title under your name and your email. It's about wanting to do the work of a leader. So if you want to do the work of a leader, then you have to have a plan and you have to be willing to put in the work. So that's all I have. Ryan, thank you so much. I really liked how we set this up actually. It was kind of unplanned, but Sean kind of walked us through the vision, the end of the vision, which is the multidisciplinary team and some suggestions and things, creativity, and what happens on a daily basis with the multidisciplinary team. And your approach, I learned so much from what you said of actually creating and developing that team. Ideally, it probably would have been for you to go first and explain this all and have Sean bring us home. But I really liked how we kind of reversed it here. Great takeaways from what you said. I really liked the part about learning how to do everyone else's job. It makes you do a better job in understanding their role. I think that's a good perspective that a lot of people lose, and sometimes you have the approach of you're meeting a lot of people that say, that's not my job. So they don't have an understanding. And one more football analogy just to bring the multidisciplinary team home that one of my mentors taught me was that if you look over a huddle of a football team and on the ground is the ball, that's the patient, and our goal is to get them to the end zone, get them home. And you have a ton of different people integrating together that all have different skill sets. And the medical director in my mind is the quarterback, and he's orchestrating everything, and the respiratory therapist, and the pharmacist, and every single player is on that field together and is doing something to get that patient better, length of stay down, everything in between that goes along with it. I think you hit on so many of those points on how you get there. So I really appreciated this talk. I think we're about at the time limit. Anything else that you wanted to add in there to close with? No, I think the only other thing that I didn't mention is that and Sean very briefly mentioned it is you have to, even if you're an extremely busy service and maybe you're starting out with only one physician like I did, you still have to sit down and write those emails. You still have to sit down and go to meetings because you have to sometimes stop the conveyor belt of patient care momentarily to advance the process. Otherwise, if you don't send those emails, if you don't go to those meetings, you just continue to sort of just keep going in a circle at the same level and never advancing. And so that's something that is, again, underappreciated with the volume of emails that you get. And from certain people's perspective, it's just, well, go take care. Patient care comes first. Well, patient care comes first, but you have to take a bigger global picture of patient care too, that if your patient care is not where you want it to be, you have to pause and reduce your patient care to some degree, some way, somehow, squeeze that time in, whatever the case is, so that you can advance the cause for the entire group. Otherwise, you just stay at the same level and you never improve. That's a great take-home message. I appreciate that. Okay. I think that brings us about to our time limit. So, again, Ryan and I know Sean left us earlier, but so much appreciate you sharing all of the wide range of knowledge that you guys have on these topics, and hopefully they will provide a lot of value to the folks at SCCM. Thank you so much. Thank you. Thank you for having us and thank you to SCCM. Good afternoon. Bye-bye.

Alexander Lukic

Sean Nix

Ryan Hakeem

critical care

multidisciplinary team

communication

collaboration

healthcare professionals