SCCM Resource Library-Mirror, Mirror, Who's the Fairest? Administrative Challenges in Pediatric Critical Care

Video Transcription

Good morning, everyone. We'll go ahead and get started. Thank you all for being here at the last session of the morning. My name is Jackie Elegant.  I'm a nurse practitioner in the Pediatric Intensive Care Unit at Lurie Children's in Chicago.  I'm going to be moderating this session this morning, Mirror, Mirror, Who's the Fairest? Administrative Challenges in Pediatric Critical Care.  I'm going to introduce our speakers as they come up to give their presentations. So I'd first like to introduce Craig Smith from Lurie Children's, who's going to be speaking  on measuring and documenting productivity. Thank you. Thanks Jackie. Thanks to everyone for coming.  This is actually a massive turnout considering the time slot and this extraordinary topic that we're going to talk about, measuring and documenting productivity.  I'm an assistant professor of critical care, pediatrics, and neurology at Robert H. Lurie Children's at Northwestern University.  I have no conflicts of interest to disclose regarding this topic. Are there any others? Oh, how'd that get there?  Probably because this is a little bit on the dry side, but I'd like to stimulate some thought  and maybe some discussion about making this a more meaningful and consistent topic because it is important for all of us as we navigate our careers.  Goals and objectives are to review some commonly utilized performance metrics for critical care practitioners, clinical metrics, academic metrics, and service metrics, and some of  the challenges of applying these in a traditional ICU or in any ICU setting for that matter. And then what I'd really like to do is talk about some alternatives and things we might  consider doing maybe together to make this more consistent and meaningful. Part of this talk is designed to just discuss what a full-time clinical faculty member looks  like and there's some history to this. It goes back to Abraham Flexner, who was a physician at Johns Hopkins back in the early 1900s.  He authored a paper describing what a clinical faculty would look like and proposed that  the faculty should be salaried by the institution and that this would allow the faculty member  to devote time to academic activities and not necessarily suffer an inordinate pay discrepancy  because of limited clinical activities and that the revenue generated in their clinical activities might go back to the institution.  His idea was that acknowledging that medical education would be expensive, that the institution and philanthropy and endowment might cover the physician's salaries.  The problem was that at that point in time, there was only a single institution out of about 80-something medical schools that had any financial resources to accomplish this.  He continued to modify this over the next 20 years until we got something that looks similar to what we have today, although not identical.  There are different standards from institution to institution, but to kind of sum it up, in general, modern descriptions of full-time faculty stipulate that the faculty member  will contribute to the university's missions and goals via patient care and revenue generation. The revenue goes back to the department.  And then via educational activities, which are defined differently, but a common definition is that a physician engages in up to four course equivalents per semester.  And this is comprised of on-the-fly teaching, clinical teaching at the bedside, and also  scheduled and formal didactic sessions, that they would also contribute to faculty governance.  Another commonality for clinical faculty is that they're not eligible for a tenure track,  although they are eligible for promotion up to a professorship, but generally have year-to-year contracts.  Talking about productivity, traditional productivity metrics that we use today are generally measures that are used to design to standardize and justify disbursement of payment.  So our productivity metrics that I'm measured by are traditionally RVUs, and we'll talk about those briefly, but relative value units were not designed or created by clinician  educators to evaluate our performance. They were generally designed by, so I'll get to that in a second.  We have the RVU, there's the diagnosis-related group, and some folks talk about the case mix index as different measures of productivity. So I got ahead of myself.  Let's get to RVUs. RVUs is a value designed by the Center for Medicaid Services to each code, and it represents the cost for providing a service.  And into this equation goes three components. The physician work, the actual physical work that a physician does, the practice expense,  what does it cost to practice in overhead and in materials to provide the service, and then the malpractice overhead that's figured into that.  And depending on what the service is, if you are using more things and doing more stuff, the CMS will advocate for greater fund disbursement.  And if you're doing more intellectual or anticipatory guidance-type activities, there's less of the practice expense that goes into it, and so the disbursements are less.  Medicare payments are determined by these values, multiplied by different factors that are out there, and you can find them, which converts for geographical adjustment and cost  of living, et cetera. This slide is not intended for you to read, but this is, well, you can try to read it,  or you can go to texmed.org, or you can go look up RVU Pediatric Critical Care, and you'll find a million different consulting services that are happy to, for a fee, calculate your  practice, the providers within your practice RVUs, and tell you how many RVUs they're generating.  It's a business, and it does tell you something about what a physician saw and what they did,  although I would argue, well, maybe it doesn't tell you everything about their performance.  This related group, as well, this isn't the focus of my talk, but it's a patient classification  system that standardizes prospective payment to hospitals and encourages cost containment.  It depends on a number of variables, the principal diagnoses, secondary diagnoses, patient's age and sex, discharge status, alive, rehab facility or to outpatient, comorbidities,  complications, procedures performed. The average DRG weight of an institution's discharges is the sum of medical severity discharge referral group.  It's weight of hospital discharges divided by their total discharges. It tells you something about the severity of illness or the intensity of illness of  patients that are moving through your institution. This case mix index is the values to determine the allocation of resources for care and treatments in a group.  It's a relative value assigned to a DRG in a medical care environment. Again, this is looking at severity of illness of patients that are coming through the hospital  and is, again, assist in disbursement of payments. These are all very interesting. They're all developed to assist, as we've said time and again, in payment and reimbursement  for services rendered. This was a way of Medicaid, Medicare, standardizing how they were reimbursing hospitals for the equivalent service from place to place.  They're dependent on physician documentation, so make sure you're using the right words to describe the condition that you're taking care of.  And then they're reliant on documentation review, not necessarily by physicians but by professionals who have been trained in CPT coding or, in other cases, have different  backgrounds.  They can tell us some things about productivity in a particular manner. They can tell us about our patient volume.  If your patient volume is higher and you happen to see more patients, your RVUs will go up.  They can tell us about billing and documentation efficiency, which is important in the modern medical game here in the United States of America. Anyone can argue that.  They can be impacted by your severity of illness. If you work in an environment where you're seeing lots of intermediate care type patients,  your RVUs may go down because those patients required less intensive medical interventions. And they're also dependent on occupied beds in an ICU.  Now, I think in the current environment, I would suspect that most of us are not lacking for patients, but there are times or ICUs in certain environments where you just don't  have the patients, and as the patient volume goes down, your RVUs will go down. And if that's being used as a measure of your productivity, it maybe doesn't tell us everything  we need to know about how a physician is performing. And again, we have little control over our occupancy of ICU beds.  I speak with my boss frequently, and we suggest we can't go out into the street and infect people with flu or bang them over the head and give them a TBI so we can fill beds.  Our beds happen to fill, but we have very limited ability to do that as opposed to someone going out and a subspecialist maybe working with a primary care group and saying, send  me your patients with Crohn's disease. So as I said, we have limited ability to recruit ICU patients, and so if the ICU volume is low, it can reflect poorly on our productivity.  My productivity, I get an RVU report quarterly that tells me about... It's my RVUs that have been generated from the notes that I've written, and it's part  of our evaluation on how I'm doing. So let's take a deep breath. We've talked a lot about some commonly used metrics that I think we've all heard of, but  we haven't asked the most important question. And I think the most important question is, what is productivity? What is physician productivity? What is clinician productivity?  So this was fun. I decided to look up in Merriam-Webster's dictionary what a generic definition of productivity was. It's the quality or state of being productive.  It wasn't a very helpful definition. Then it was the rate per unit area, per unit volume at which biomass consumed... Wait, what? That's not it either.  I decided to look up productive and go down that rabbit hole. Having the quality of power of producing, yielding results, benefits, or profits.  I feel like we might be getting into the ballpark. Raising mucus and sputum was actually a definition in there.  And while that does apply to what we do, that is not, I think, what we're looking after. So I think we're in the ballpark here.  I decided to take one more stab at it and use the old Google dictionary and got this definition.  What is the basis of productive effort, especially in industry, as measured in terms of rate of output per unit of input?  And this one I felt fit most closely with what I do and I identify as the productive elements of my career. So what's the work product of an ICU practitioner?  I think this is the question we need to ask and answer and think about. And the elements of this, I think, might help define what a measure of productivity for us looks like.  I think that the work product of my efforts are healthy survivors of critical illness. Who can re-matriculate into society and hopefully one day take care of me.  Well-trained effective critical care practitioners, and that is whether you are participating  in a fellowship program, a residency program, mentoring, or have a nurse practitioner training  program, physician assistant training program, this is a product of what we do for a living. Scientific discovery, new therapies, participation in research are important.  And we have to acknowledge that billing and reimbursement is important. Critical care is expensive. It's not for free. And we need to pay for our efforts.  There are other benchmarks that we use historically. Academic benchmarks. If you're in the academic setting, research funding is an effective benchmark of your  research productivity. Publications, if you're in the beginning of your career, actually throughout your career. Speakerships like this.  This will go on my CV and it will be something that I'll say I've produced and I'm participating in the process.  Mentorship I think is something that's extraordinarily important, especially if you consider that effective and well-trained intensive care professionals as part of your product.  National committee activities are important. There are service benchmarks that don't really fall into these academic measures. Hospital committee work.  What are you doing in the hospital to help your local environment improve care? Community service.  Folks who go and do Doctors Without Borders or who are reaching out into the community for asthma initiatives, for example.  And then institutional leadership roles are other things that we should consider. Because they do enhance the environment you're providing care in.  There's a dichotomy we have in that there are academic positions within critical care and there are non-academic positions.  And they're both equally important, serve overlapping roles. Traditional metrics for academic success aren't going to be as useful in a non-academic environment.  I would argue that while our views are useful for analogous measurements, non-academic colleagues should not be measured just by the productivity financially of what they're doing.  The wellness of children who are leaving their unit is an important metric that should be considered. And so the same limitations apply.  With regard to clinical performance benchmarks that we might consider are patient outcomes. Now I do pediatric critical care.  My mortality rate should be consistently low and consistent with what we see at analogous institutions throughout the country.  But outcomes, length of stay, are things we might consider plugging into this to figure out how to assess how someone's doing. There's limitations to that.  Because I do service for a week and hand a patient off to another provider who may take care of that patient.  And it might be better to look at this with lower acuity illnesses or things like asthma that have shorter lengths of stay.  And consider if someone's able to get an asthmatic in and out of the hospital more rapidly than someone else. I'm not suggesting we penalize folks who may take longer.  But these may be opportunities to recognize achievement. Looking at adverse events, procedures performed, taught, supervised, outside of, again, the  billing ramifications of what procedures can produce. And then I wonder if there's a role for reviews from colleagues, peers, trainees, support staff.  Who knows better how we are performing or leading the team through patients' critical illnesses than our colleagues who are participating in similar activities?  And lastly, patients and families. They're really the end users of it. And shouldn't we ask them something about how we're doing when we're providing critical care services?  At my institution, we use the curriculum vitae as a repository of this information for my yearly review with my boss. There are no financial incentives attached to this.  But it's a place where we plug in our achievements from the last year, and you get to see the things you did.  And in an academic environment, it's useful because that's where I see, oh, I wrote this  many papers, or I participated in these hospital activities, and we accomplished these things. It doesn't include anything about how many patients I saw.  It doesn't include anything about how much money I generated with regard to my RVUs. But it's a separate collection of data points that tells you something about how I'm doing  with those academic activities. I think family experience is a potential resource for determining perceived effectiveness.  And we have to acknowledge that perception is, to a certain degree, reality. Our families are the ones who are going onto Facebook and saying, my doctor's the best  or my doctor's the worst in some cases. And their perceptions of how we're doing things, I think, is useful.  Now we could say many hospitals use, who uses Press Ganey at their hospital and is encouraged to consider what those things say?  But Press Ganey's limitation is that it's administered to families on hospital discharge. Most ICU patients aren't discharged from the ICU except for a small particular subset.  But maybe we could take that bull by the horns and administer a web-based survey as they're leaving the ICU.  They're packing up their belongings and an iPad with a web-based survey that assesses how their perceptions of the physician and team performance might be a useful thing to  capture this data.  It could be done reasonably quickly and at minimal cost. And what are the things I think might be interesting?  How the family perceived I was making judgments about their child's condition and their treatments.  Effectiveness of communication, which is, I think, something that falls by the wayside. It's breathtaking sometimes to realize how little our families know about what's going  on with their patients when you ask them. Perceptions related to how we're leading the team and, again, our clinical management.  And to whether or not the things we were doing were actually helping their child get better. We could brainstorm this for several hours, I'm sure, over a pot of coffee or a bottle  of whiskey. Experts on performance metrics and features that actually define excellence includes, I think, users, as I said, of critical care services.  And this might include physicians, advanced practice nurses, respiratory therapists, nurses, social workers, and, again, patients and families.  So this is kind of getting at the 360-degree evaluation. But a more standardized one might be more useful. So I'll leave you with this question.  Wouldn't it be great if there was a multidisciplinary organizing body comprised of multidisciplinary  critical care professionals who could coordinate and collaborate on accurate, meaningful, reproducible  measurement tool that could be implemented and validated at a wide variety of institutions, academic and non-academic, across the world that might be useful for helping us measure  and define critical care performance for physicians and our clinical partners? With that, I want to thank you all for your attention and your attendance.  I hope everyone has a safe travel home. Thank you.  We'll save some time for questions at the end from everyone. Thank you, Craig. Next up, we have Maureen Madden from Bristol-Myers Squibb Children's Hospital.  She's going to be speaking on advanced practice providers in the pediatric ICU.  Good morning, everybody. Thank you so much for showing up. We really do appreciate you being here through the entire length of this and knowing it's  the last session on the last day, so I'm very appreciative of your presence. I was asked to talk about advanced practice providers in the PACU, so I do not have any  disclosures or conflicts. What I first want to say is, please, I need to acknowledge Charlene Leonard-Pringle, who  is here in the audience, who has given very similar talks in the past, and she was so gracious and shared her slides, and I have really borrowed extensively from her, so I  do appreciate that. This is just a graphic that I want to provide to you. It is very old, and I actually was doing the math today, so it's from 2001, so it's 20  years old in terms of this graphic, but it shows the distribution of the pediatric intensive care beds within the United States.  Just acknowledging that the Northeast Corridor, the West Coast, the South of Texas, Louisiana,  Florida, and Ohio and Illinois really have the preponderance of the beds in that distribution, and I don't think that that has significantly changed.  If anything, they've just continued to grow. So what comes next? You're getting a lot of background data at this point in time, but in terms of the pediatric  intensive care beds, this is the data that came out in 2017, but it's still looking at data that was most recent from 2011.  So we now have 4,687 pediatric intensive care beds as of 2011. So that was a total increase between 2002 to 2011 of 742 beds, so a 12% increase, which  actually exceeds the rate of the population rise, and it also comes in the context that during that time of all pediatric acute care beds, there was actually a decrease of over  1,500 beds. Because we're talking about APPs in the PICU and there were several items that I was tasked with, I want you to acknowledge what the PICU fellowship numbers are.  So looking at this, the last reported data is 2018. So Pediatric Critical Care Medicine had 536 trainees at that point in time.  It's for all the fellowship years, and if you look across the board there from that, it just incrementally is increasing year to year.  Looking at Pediatric Acute Care Nurse Practitioners, 2018 is our last statistics as well. We have launched this in 2005, so since that time we now have approximately 3,000 people  who are credentialed within this specialty, acknowledging that there has always been a preponderance that it is acute care, so it's all of the individuals practicing in acute  care, but by and far, critical care is the preponderance of those individuals. Our Physician Assistants, so this is 2010. So our data is old and it's all over the place.  But looking at it specifically, they have acknowledged that finally they used to lump it together just of pediatric subspecialties and never broke it out, but in 2010 they did.  And though you looked at the critical care, so at that point in time, an estimation of 72 individuals specifically practicing in Pediatric Critical Care.  I'm talking to Chris Newman, who is an individual who is very integral in terms of the PA development and education.  He feels that this data is inaccurate also, partly because many of the individuals do not belong to their actual organization, so it's not reported.  One of the things he did have to say in terms of the Society of Critical Care Medicine, there are approximately six PAs practicing in Pediatric Critical Care that he is aware of.  Whether or not that is accurate as well, it's still a very small number in that regards. So talking about models of practice, and the focus of some of the things I was tasked  with was really to look at the training and the environment within training fellows as well as APPs.  So to acknowledge that there's different models of practice, and we're going to focus a little  bit more heavily on the academic where you have attendings, APPs, fellows in residence.  But depending upon the structure of the environment, there's significant variations in how the clinical management and distribution of responsibilities occur.  One of the key things I want to say, though, is when members of the same team are together, their duties do overlap. And we acknowledge that.  And sometimes that's where we have some stressors, and people highlight that it's stressors.  What I want to highlight, though, is I actually think that there is an advantage there and an opportunity, because it allows each other to learn from the individual strengths of  their partners. So looking at some of these theories of quality, and it goes back and forth in terms of structure and process and outcome.  So as our population has changed, and providers have adapted, and our staffing models have been adjusted, and our technology continues to evolve, our outcomes are transformed.  So really looking at how our interdisciplinary teams are functioning and managing together really is going to significantly impact our outcomes of our population.  So it's a key element of the critical care teams, a key element that's driving quality care in the ICU.  We acknowledge that there's a growing shortage of providers at the attending level. People are looking at their retirement phase. They are looking at burnout.  So they're leaving the profession. So we have a piece of that. We have had the ACGME resident training hour restrictions.  So this is where the APPs have been acknowledged as coming in to help and be, not help, excuse  me, participate, and really be fundamental in helping to drive the quality of these teams.  So some of the literature that's out there, honestly, most of it fits into the adult world, but I think it has value.  So Ruth Kleinpell and her colleagues in 2008 had published Nurse Practitioners and Physicians' Assistance in the Intensive Care Unit, an evidence-based review.  And the big focus of this was actually looking at, after the ACGME resident work hour restrictions  had come into play, and acknowledging that there's a continued and growing physician shortage. And at that point in time, there's a projected intensivist shortage in 2030 of 35%.  So they're looking at growing the supply of APPs and how they can then optimize and meet the gap in ICU coverage. So with our practice models, you can read this.  But what I want to say as the emphasis behind this, and it was a comment that one of my direct bosses had said, acknowledging in terms of the APPs, that this is an environment that  we have chosen. This is our profession. This is our lifelong careers. So to be evaluated and looked at as a professional.  So the professional development model that applies to every provider in a critical care environment needs to be acknowledged.  So there needs to be time and respect, and looking at the direct clinical management, overall accountability for that group of patients.  Whether or not there's protected time that's provided for the other role developments of continuing education, clinical research, and integrating into the leadership of the  unit and the leadership of your profession, as well as mentorship and everything. So as Craig was articulating how we are being evaluated and what metrics we're using, they  tie into your role as a professional and as your professional development. So we know that we work in very effective and highly collaborative teams.  And the authority rests with competence. And you'll understand why I start to talk about competence in a few minutes.  But at least specifically, APNs are a distinct group by training and experience. And the consideration that they're interchangeable with other health care providers is really  not an effective model. And one of the pieces that I will say, and Jake Kane, I don't know if he's in the room, he was one of the individuals who helped develop this session.  And he knows at times that I don't shy away from speaking my mind. So he tasked me with a few items of potential controversy. And I get to see how far I want to take that today.  So I'll take the temperature of the room as we go along. But we do, as APNs, have a distinct set of skills that distinguish us both from physicians as well as PAs.  But I'm talking about that highly evolved, interdependent, collaborative model. And we really can do effective things and drive our outcomes.  But it's dependent upon the individual's education, their certification, years of experience, and characteristics of the practice setting.  So we come into these environments, all of us, with very different pathways. And have to acknowledge that and respect that with our growth.  Because there is a learning curve to where you can be independent. So some of what they wanted me to also talk about is, OK, why do we want you people? Why should you be here?  We are potentially expensive. But can we offset that in terms of our productivity and our contributions?  So Anne-Marie Brown and her colleagues, this is distinctly a development of a Pediatric Intensive Care Unit Nurse Practitioner Program.  They were actually able to show, because they had a period of time in one year, they had to divert 48 patients from their pediatric ICU.  And the diversion was specifically because inadequate medical staffing or the acuity level of the ICU.  So it wasn't a nursing staffing issue, which I know we all struggle with at times. But it was medical staffing. So they wanted to look at that.  And when they did, they had structured, they brought four NPs onto their team. And in the next year, what they were able to do and fill those potential 29 beds with  their patients without an increased length of stay, without looking at indirect revenue, which can be radiology, pharmacy, pathology.  But the offset, they increased their revenue by $186,000. So they kept their patients local. They increased their facility resources. They increased their community satisfaction.  One of the things they also looked at with the implementation of those additional nurse  practitioners into their environment to minimize delayed discharge from the PICU to the general care units.  And I know every single one of you can sympathize with this and say this happens every day.  But what they did, they had tasked the attending from overnight and the NP to evaluate the population in the morning and who was going out and to decrease the throughput.  So they managed to change the average delay from time of transfer orders written to physical transfer of the patient to 1.96 hours compared to 5 hours.  So they significantly increased their throughput and their ability to admit more patients.  April Kapu and her colleagues are very strong in terms of demonstrating outcomes and productivity  for the adult acute care nurse practitioners. But I think to mention it here is quite important because it is data that's out there even and it supports the relevance of it.  This looked at the financial impact of adding NPs to inpatient teams at Vanderbilt University Hospitals. They added 5 teams. And they looked at them over the course of 2 years.  What they were able to abstract was billing, length of stay, acuity, and NP associated quality metrics.  So they looked at their gross collections compared with expenses for those 4 NP teams and they had an increase in revenues that ranged from 32% to 66% with the implementation  of those teams. So that's a huge economic impact for that institution. The project also demonstrated the value of adding the NP to inpatient teams, not just  the revenue generated, but they demonstrated a reduction in the length of stay. They standardized quality care by helping diminish potential costs associated with complications  by consistent application of the evidence-based practice guidelines and algorithms. And specifically, the last team that they had put in place was their trauma team, which  had never had advanced practice providers on that service line at that point in time. When they looked at it, they looked at the hospital charges assessed and they had $28  million saved. That's enormous to that institution. What they looked at, and particularly with underinsured or uninsured patients, the reduction  in the length of stay was where a preponderance of that revenue was generated. They also had a selected literature review in this article.  And these 9 studies looked at, and consistently what they showed with the introduction, and  I apologize, I'm talking about APPs, but these are specific to NPs, decreased length of stay, decreased costs associated with drugs, skin breakdown or other complications, decreased  ventilator length of days, and increased charge capture. So really what I want to focus on when we talk on this slide, we're going to focus on the culture of the environment.  So I am very strong about team, team processes, and the things that drive those team processes to excellence. So it is team communication and it's effective communication.  It's team leadership, and I don't care who is the leader. I think at different points in time, different individuals are going to be the leader of that team.  It's team coordination and team decision making. So the complexity of our population over the recent years has really necessitated the  presence of a large multidisciplinary care team. It's led by our intensivists, thoroughly acknowledging that and their leadership to provide optimum care.  But there are many members and their contributions need to be equal and respected for that. So we need to know that there's collegiality and collaboration.  But the piece to that is to acknowledge what the structure of the team is of itself. So we have to acknowledge what people can provide in their contributions.  So Jake wanted me to be a little bit touch on this. So like I said, taking the temperature of the room, I can take this briefly or I could take this pretty far.  But talking about procedures, and I hope you get what the image represents, the tug of war. So really talking about in-training professionals and APPs.  And essentially, who gets the procedure? When do they get the procedure? Why do they get the procedure?  So we need to absolutely acknowledge, and I think that we do, that the in-training fellows need to be able to complete their training program and be able to leave and independently  and competently perform all the skills. There are stipulations in terms of what they need to achieve during their limited time in training, and they must do so.  Talking about that academic environment, though, where the fellows are and the APPs are, so we need to have an environment that ensures the competency of all, depending upon what  the expectations have been set up as within that environment. And there is a vast variability across it.  So I have surveyed a number of my colleagues, and I appreciate all of their input. But they do acknowledge that at times their attention, some of them have been able to  successfully place items into place for how to minimize that tension and to ensure that competency. But most of it talks about first-year fellows or fellows as learners in general.  They get priority, or they get the right of first refusal. So depending upon the individual rather than the culture, sometimes there are more tensions than not.  Others have set up processes that they've talked about as first-year fellows.  Typically, they're coming in. They need to obtain this skill set and to optimize it and obtain competency. So they've carved out the first six months.  Maybe those fellows get every single opportunity that they can participate in. But other people have looked at, depending upon how many fellows they are and how they  can staff their unit, the days the fellows are off, well, that's the APP's opportunity. And they prioritize to those.  Others have said after that first window of time, then it really is, if your team is set up and it's an APP team and the other one is a fellow team, or if you have a collaborative  team with both, that if it's a senior fellow, then they're there to help, to supervise,  to manage if complications happen, but really to ensure that the competency of all the providers  are there and to recognize that some people have incredibly large units and have many different things going on simultaneously.  So there is more work than any one individual can do simultaneously. So you do need to have a group of individuals that have that competency and skill set and  can do it independently. So needs to have that recognition. The piece to that also is people are looking at simulation now.  So how can we optimize this competency and this psychomotor skill set and maybe do it with alternative learning experiences? So simulation is just growing by leaps and bounds.  So that is an opportunity that people are also looking at. My next thing to poke at a little bit is patient assignments. So I put it on the teeter-totter and it's a balancing game.  So really when you look at it in terms of these in-training professionals and the APPs, oftentimes what you hear that the APP team now has the chronically critically ill child  or the complex child that is now becoming a much larger population within our ICUs. So they get those. Or they get the individuals who may have a lesser acuity.  I will say based on conversations, when you look at it, you have higher satisfaction,  higher retention rates, and improved professional development when the patient acuity, the diagnosis mix, and the total patient load are equivalent between those groups.  So again, that comes down to the culture. And it comes down to what expectations and items that need to be created within that environment.  I'm not going to say that we're going to create one big happy family everywhere. That's not the reality. Everybody has different drivers and different pieces of that.  Clearly when you are in a non-academic setting where you have APPs or you're in an academic setting that doesn't have fellowship programs, these priorities are realigned.  Looking at this, and this came out in 2016 by Foster and colleagues. The one I want to highlight is JOFFE.  They were looking at mixed provider models of care and effect on resident fellow education.  And JOFFE is the one specifically that talks about in the outcomes that APPs had a positive impact on fellows' training experience.  So I think as we said, we can respect the strengths that we all bring to the environment and move from that platform to expand upon it.  So you really have objectives and desired outcomes for the interprofessional team.  You want to allow the development of leadership and teaching skills with multiple interprofessional learners.  There needs to be a service and an education balance where every learner is appropriately challenged but not burdened by the individual patient care responsibilities.  You need to have interprofessional collaboration. There's now this big push for interprofessional education.  And it moves on then into the clinical environment where it continues as collaboration. And it needs to be there.  So you have to create an interprofessional learning environment where each and every learner has the opportunity to learn from and with each other.  So talking again to some of these colleagues, how are they looking at these environments and how have they promoted that collegiality and collaboration?  Orientation and didactic bedside teaching of residents and fellows by the APPs who have been there, who have a depth of experience.  One example specifically that warmed my heart because I'm involved highly is with the Pediatric Fundamentals of Critical Care support course.  Seattle Children's in particular provides that educational program to their fellows and it's run by the APPs. So it's something in that regards.  So it's affected a culture shift they've seen with their first year fellows. Also to talk about that people are involved in common staff meetings and workshops that  are inclusive of everybody and fosters that collaborative and team-based environment. Protected at rounding and lecture time and providing resources for rotating teams.  So I've said, and I'm not going to elaborate more on this, but in terms of professional  role development, everybody needs this, desires this, and is going to benefit from this because you're going to have the longevity. You're going to mitigate some of the burnout.  You're going to improve your retention. And there's many pieces of this. And again, this is from Charlene and I do appreciate that.  So what I want to say in conclusion, we're one team. That's what we have to do. That's how we have to recognize this.  We must collaborate and work as one team for the optimal patient outcomes and professional satisfaction.  So both the critical care attending, the fellows in training, and APP leadership all must have similar goals and understanding to optimize that team.  And therefore, we are going to then pass that on to our patients and our families and ideally optimize our patient outcomes.  So I really do want to thank my friends and colleagues who were very generous with their data and their insights. And as we said, we'll do questions at the end. Thank you.  Thank you, Maureen. Last we have Managing Throughput Adults in My Pediatric Beds from Paul Keckia from Texas Children's Hospital.  All right. Thank you very much. All right. So bringing up the last of it. A little shift in gears. So I also thought there could be a nice way to flip this around.  This is the reverse equivalent of, hey, you kids, get off my lawn. There seems to be a lot of angry, white-haired gentlemen in the world right now, but we actually  want to have the adults in our units, and you'll see why by the end of this. Here's a clinical scenario to start this out. So your ICU all-comer census is about 110%.  Three children with influenza in the ER waiting for beds. They're on non-invasive positive pressure ventilation. You have a full OR schedule in the morning.  You have two adult-age patients on ventilator support. Now you get the transport call for a newborn with hypoplast. So what do you do besides having your own blood pressure elevate?  We'll get to this in a minute. So my disclosures, I have none, except that I actually love being a pediatrician. It's just awesome, right? We do a great job in the PICU.  It is a joy to work in a pediatric hospital. If I were to be hospitalized, I would prefer to be hospitalized in a pediatric hospital. Everybody is shaking their heads.  And apparently JAMA agrees, because this was back in 2013 when a med student said, if I ever get sick, I want to be taken here. The culture is just different, right?  You can't have a bad day around kids. The care delivery is a bit more personalized. And we have done an amazing job with outcomes.  Maybe we do too good of a job, and we'll get to that. So what people think we as PICU docs do, right?  What my friends think I do, what parents think I do, what administrators think I do. I think we just clock in and clock out on shift.  What the adult patients that I take care of in the ICU think we do, they have no idea. What adult ICU docs think I do is play with dolls and clowns.  What I actually do is what we all do, right? We're all the same. Now, it is slightly different, because only in pediatrics do you get this.  As I was researching this, this is actually therapeutic clowns and a systematic review and meta. This got published. And look at the statistics. So statistics favor clowns, right?  Now I would change this to clowns on rounds in pediatrics, and then it would favor the cardiac surgeon. But anyway, that's a whole different story.  So we as pediatricians have succeeded. Over 90% of our children with chronic diseases are now surviving into adulthood for some conditions such as malignancy, CP.  Admissions to pediatric institutions are growing at a faster rate in adult age patients with those conditions than in children.  And no matter how we look at it, adults are a growth industry for pediatrics. And any pun you're thinking of right now is valid.  But we're going to talk about the money when it comes to the growth industry. The birth rate in the United States has plateaued. So competition for children is going to be harder.  So this is a growth industry. And if you look, a good friend of mine, Denise Goodman, published in 2011 the trends.  It's not hard to see that everything, whether it be transitional adults, which are sort of the late teen years, or actual adults, that the forecast is nothing but growth.  And if you look specifically within malignant neoplasms, lots of growth. Within cerebral palsy and epilepsy, lots of growth.  In my world, adult congenital heart disease, nothing but growth, huge growth. So it's all about the money.  And this is estimated adult congenital heart disease procedure margin per patient. An inpatient with surgery yields $100,000 of margin. And we all know that's profit, right?  That's just the fancy way of a non-for-profit to say that we're making money. But even outpatient with a cath lab, $26,000 per patient per encounter.  So we have to adopt what the adults, through the American Heart Association, have adopted as one of their themes, from fetus to 50.  And to really look at the entire spectrum of the patients we create. It is something that adults with congenital heart disease, we have now owned this.  In other words, we created these survivors. They're now surviving into adulthood. We are responsible for them. I picked these two clowns over here for a reason.  Because actually, we all know that Schwarzenegger had actually an adult, was an adult congenital heart disease survivor.  He had an aortic valve stenosis, congenital aortic valve stenosis that was repaired. In an adult hospital, and he had a worse outcome. He had to go back to the OR.  And I'll highlight that in a second. But we will have to know what 50 will look like. Since I'm on the other side of 50, apparently this is what it looks like.  It's kind of depressing. But life after childhood, we thought, was a straight line. We make them survive. They go on to adulthood.  Well, it turns out that the road traveled is not straight at all. And ultimately, the adult survivor of pediatric disease lives in both worlds.  We must prove who is actually better at caring for these patients. We have to pick which model, or we have to develop a new model.  And by that road, let's spend the next few minutes with an outline of the speed bumps that are on the road that we're going to travel with the adults.  When it comes to outcomes, certifications, care delivery models, and resources utilized. So let's start driving down that road. And obviously, this is a cardiac surgeon's car.  So let's have a pediatrician's car. There we go. So pediatric providers and hospitals that provide optimal care for adult congenital heart disease patients.  It is clear that in-hospital death rates for patients operated on by pediatric heart surgeons in pediatric centers are lower, period. We provide good care.  When it comes to adolescents and young adults with various leukemias, it is clear that frontline  treatment in pediatric versus adult centers had a better outcome and significantly superior survival.  However, on the flip side, when we look at this multi-institutional profile that came out in 2013, first, it's striking the numbers.  Up to 13.5% of all admissions over that time period were adults.  But look here. The patients aged 21 to 29 years of age had a two-time higher risk of odds of mortality when admitted to a PICU.  And being 30 years of age or older was associated with a 3.5 greater odds of mortality if you're admitted to a PICU.  Now that could be because we are the sort of the place of last resort and the patients are sicker. And we know that. These are just data from Texas Children's.  That of 73% of adult congenital heart disease patients at Texas Children's have moderate or severe complexities when they come to us.  That's compared to the average adult hospital having about 28% of moderate to severe complexities.  So we are taking care of the sicker adult, not just the adult, because nobody else wants to touch them. Now what about errors?  Because that would be an area that we are not comfortable with, right? Well, we actually looked at it when it comes to dosing adjustments.  And we published back in 2014 prescribing errors of adult congenital heart disease patients admitted to our pediatric unit.  And it turned out that there were fewer medication prescribing errors in the adult population compared with the pediatric patients that are just large as adults.  In fact, those with adult-size pediatric populations, so in other words, greater than 70 kilos, had far more prescriber errors than the adults did.  And it is Texas, so they were all big. So in the end, we need to know, we don't actually have data to support whether each one of us are doing really the better job.  And so now we're going to start doing that. This is just one initiative. It's being headed up by one of our faculty members, Jamie Cossie.  The Adult Congenital Cardiac Care Consortium, AC4. Many of you who do pediatric cardiac critical care know PC4. This is the offshoot.  She's working with Michael Gayas to develop an actual risk adjustment quality assessment program to get those patients that are falling through the cracks currently.  So now, what about certifications? So the certifications, we not only have to have ACLS, but we also have to have PALS. That's a requirement. It's costly.  That means the entire institution, whoever touches the adult, has to be ACLS and PALS certified. It's every member of the care team. And then there's the comfort factor.  How many people have had where a pediatric ID doc comes into your unit and it's like, well, I'm not comfortable taking care of that 50-year-old?  I'm like, OK, I'm going to be a little comfortable. I'm sorry, but I thought strep was not age-based. So I don't understand how that makes you comfortable or not.  So the question is, are people hiding behind certification due to their discomfort in their skill sets and knowledge?  It is incumbent on the institution to provide all the necessary education and resources to the entire team caring for these patients.  We have adult congenital heart disease as a certified subspecialty. But what about adult slash pediatric ICU care?  That would be another hand grenade that gets the pin pulled on it if that's what we need to have done.  And then what about the knowledge recommendations and requirements for CMS, insurance, et cetera?  This is just a partial list of everybody who has standards of care in adult ICU and adult cardiac ICU care.  So everybody wants to say that the adults are being cared for in a way that's up to standard.  These are the CMS core measurements for adults, including things like tobacco screening and cessation counseling.  And if you don't fulfill these core measurements as an adult institution, you don't get paid as much, right?  So the bottom line when it comes to this is, this is what we already do plus. And if you're going to dip your toe in the water of taking care of an adult, you better  be prepared to swim with the sharks because these guys are highly competitive and highly value-based in terms of reimbursement.  So once you do one adult, you have to play by the rules of CMS. And that's a significant issue.  When it comes to care delivery models, another thing that once you dip your toe in that water, we need to learn what the adults can do, what they do that are much better than us.  They are far ahead of us when it comes to length of stay driven finances, DRGs, profits and a competitive marketplace, things like bundled care.  They're much better at ICU liberation and sedation practice and also the patient experience. So let's talk about the first part. This is the infamous APR DRG. It's created by 3M.  And if you look on their website, there is a dollar value that is tied to every single documented procedure that they do. And they will stop getting paid after that dollar amount.  And that's the world that we have been shielded in pediatrics because, oh, well, we take care of kids. We don't have to deal with that as much.  Some people in the room, I'm sure, already have to, right? It's an evolving practice within pediatrics. But this is the world that we're going to live in.  And when it comes to care delivery models, it's important to always have the data on that delivery, whether it be through the APR DRG.  It is an evil empire, but it's a reality of actual measurement and external measurement of the quality of our care. So are we hiding behind our hate of this whole system?  Because we don't actually want people to look at whether we're performing standard good quality care.  Why is it that a bronchiolytic in one hospital is out in three days, but in other hospitals, it's in eight days? Because well, I'm uncomfortable sending them home.  Well, do you have data for that? So this is one way to do it. But we need to take charge of this, not 3M. Let's talk about ICU liberation sedation practice.  This is some data that Barbara Jo Ackoff at our institution produced. These are 110,000 bolus doses over a five-year period in our ICU, in our cardiac ICU of fentanyl  in blue and midazolam in orange, spread out over a 24-hour period. So this represents every single bolus dose throughout five years over a 24-hour period.  It's not hard to see that we sedate patients more at night than we do during the day. And also, these spikes, 4 AM, that's when the portable chest x-ray comes through, and  then 7 AM shift change and 7 PM shift change. So is that really good ICU sedation and liberation practice?  And if we only look at that same exact data with only the adults, that distribution goes away, except for, interestingly, a spike of midaz at 9 PM. Go to sleep. There you go.  But it's because the adults are actually conversing with us, and we're utilizing their response as to whether they need more sedation, not just what we think we should be doing.  That's something we can learn. And then about throughput and expectations of the patient experience. Craig touched on this a little bit.  This is an entire entity now of how we are going to be judged. And it is not just, oh, well, the child did well, and so we must be good at what we do.  No, there is an entire experience. And the adult world gets paid based on that experience, specifically the HCAP score.  And if your scores are not good, you will not be reimbursed as well. Well, that's coming for pediatrics.  There is now the development of the pediatric inpatient experience and of care measure. So we will be judged on the entire experience of the patient. Final road bump is resources.  So again, with this clinical scenario, so do you transfer the adult? They're ventilated. Do you send out the children from the ER?  Well, that's some money being sent right out the door. Do you cancel cases in the morning? I don't know about you, but if I have to cancel a cardiac OR case in the morning, it  almost reaches the CEO, just shy of the CEO. Do you refuse the newborn? Well, where else are they going to go? This is a child with high plastic left heart syndrome.  Only a quaternary care ICU can care for him. So in Texas, what we do is we just build more hospital. And I'm not kidding, actually.  So this is the pavilion for women owned by Texas Children's only for adult women. It's 77 inpatient beds, six ICU beds, and then 42 new NICU beds.  And then right next to it is the Smith Legacy Tower, which we just opened a year ago, 84 PICU beds and 54 CICU beds.  And we're building even more because on the top, on the 24th floor of the Legacy Tower, we're going to create an inpatient adult congenital heart disease program.  It will have 14 ICU beds, multi-use ICU beds. And then the five-year plan is on top of the pavilion for women, five more stories and  turn it into the pavilion for adult survivors of pediatric disease, where we'll take all those inpatients. But I get it. Go big or go home. And we do everything bigger in Texas.  We don't screw around. There's a lot of oil money. But this is not reality. I get it. It is incredibly resource intensive. I don't have a good answer for this problem.  But we have to model for your institution and partner wherever possible. The initiatives to develop new approaches for care triage and delivery.  We all know as we get older, age is just a number. So why only base geography on the birth date?  We should leverage the expertise found in institutions regardless of age-based classification,  triage based on that expertise, and institution within the community that you are practicing. And this talk could easily be given in the exact reverse perspective of the adults who  say, well, he's a trauma patient and he's 12. I think he should come with us. We would never allow that. But they could make that argument.  And finally, regardless of your approach, you have to commit to gathering the data. Because this issue is simply not going away.  We all will get pressure to say, this is where the money is. And we should do it. And I'll conclude with the golden rule of pediatrics. We know that kids are not just little adults.  But we also know that adults are just big babies. So thank you very much. Thank you.  Thank you, Paul. We have a few minutes for questions. There's a few microphones in the room. And our speakers will be sitting up here.  Hello. I'm Susan Morris. I work in Huntsville, Alabama. I work in a small hospital within an adult hospital system.  And so my question really is, sometimes I have teenagers that need adult services. And for instance, I had a 17-year-old with massive bilateral PEs.  And I was told by the pulmonologist, the adult critical care doc, I can't take care of them because I'm not covered from an insurance standpoint.  Kind of sort of a little bit different, but kind of piggybacking on what you're talking about in terms of, what are they credentialed to take care of? What will insurance reimburse?  And so I had to find somebody that was willing to go out on a limb. I don't know if you have any thoughts. I have experience with it. And it's annoying. Right?  And yes, that's the standard they walk up and like, well, I'm not, I can't do this. We've circumvented that because the Pavilion for Women is adult-based, but under our one  operating license. So they're credentialed by just having credential. Basically, all of us who are at Texas Children's are credentialed to do the same procedures on an adult.  But that's why I said there has to be partnerships within your own institution, your own local environment. And you know, everybody always loves a burning platform.  To me, that would be the burning platform for you to say, well, we have to fix this. And the myth is much greater than the reality.  The odds are, if you're doing the right thing with a credentialed provider, even if they're for the adults, the birth date, they're still going to get reimbursed.  They're still going to get covered. You just need to make sure that you have that set out ahead of time. But it's a great burning platform to yell about.  You can just yell. So I'm Chris Newman from Children's Colorado. And my question is actually about the joy. So in our institution, we take a fair number of adults.  If you are an adult managed by one of our subspecialty services, you're entitled to come into our hospital regardless of your age. And if you're really sick, you end up in our ICU.  And because the residents are supposed to be learning to take care of kids, they don't really want to put those patients on the resident team.  And because the PNPs get a little bit nervous about caring for patients over the age of 21, they don't really want to take.  So the PAs end up preferentially admitting and managing the adults, even though we made a conscious decision not to take care of adults.  And a lot of us struggle with a sense of joy and fulfillment being taken away from us as we are asked to manage a group of people we deliberately chose to move away from, despite  all societal pressure pushing the PAs towards the adult world. So I'm just wondering, how do you make people want to take care of a population they generally  self-selected to not take care of? That's an absolutely excellent, excellent point. And let's just be clear, I think adults are big and smelly.  I don't really want to take care of them either. But I think that's where it comes to not looking at these as individual one-off patients, but  to developing an entire team and program around that entity. And so then you may actually find that there are many residents who have a career goal  of an adult congenital heart disease provider or are MedPeds trained. There are ways to make sure that those voices are heard and leverage the ones who actually  do want to take care of them. But because we're still stuck in this one-off mentality, even though, as you said, there's  several adults in your institution, it's probably still looked at as, well, we're dealing with them versus actually providing a service.  And once we make that frame shift, and I said I don't have all the answers, but that frame shift is what does it.  Because you probably have some people who actually enjoy an adult every now and then. Adult conversation is kind of nice.  If I could add something to that, I think it's a reflection on how the field of pediatrics is fundamentally changing. These patients didn't exist years ago.  When the AAP wrote guidelines for residencies, there weren't surgeries to correct hypoplastic left heart syndrome.  The reality is children with tracheostomies and chronic ventilation is something that happens in pediatrics. It's not just critical care.  They're going to show up in your clinic or in your private practice. And adult survivors of congenital disease are increasingly going to be cared for by pediatricians.  So there may be an opportunity for us to help move the needle with the American Academy of Pediatrics.  I run into my own institution where sleep studies and obstructive sleep apnea is a critical care disease because non-invasive is not managed in an acute care environment.  But you can buy BiPAP machines in the back of your airport airplane magazine, and it's a reality of modern pediatrics.  Obesity and obstructive sleep apnea is a general pediatrics problem. So the needle may need to move within pediatrics, and this may be an opportunity to find a population  of pediatric training that needs to happen. Great. Well, thank you to our speakers, and thank you for everyone for attending. Thank you.

Video Summary

The speakers discussed the challenges of caring for adult patients in pediatric critical care units. They touched on topics such as measuring and documenting productivity, the role of advanced practice providers in the pediatric ICU, and the administrative challenges of managing adult patients in pediatric settings. They highlighted the need for collaboration between pediatric and adult healthcare providers to ensure optimal care for adult patients with pediatric conditions. The speakers also discussed the importance of certifications, care delivery models, and resources in providing quality care for adult patients in pediatric settings. They emphasized the need for data collection and evaluation to ensure that patients are receiving the best care possible. Overall, the speakers outlined the unique challenges and opportunities that come with caring for adult patients in pediatric critical care units.

Asset Subtitle

Pediatrics, Administration, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Compare the national definitions of full-time clinical faculty and contrast models of physician workload
Describe opportunities for advanced practice providers in the pediatric ICU and highlight financial challenges currently facing hospitals
Review productivity models for clinicians, including traditional relative value unit benchmarks, and alternative measures of both clinical and scholarly productivity
Describe the epidemiology of adult patients in the pediatric ICU and the challenges faced by pediatric staff

Measuring and Documenting Productivity

Craig Martin Smith

Advanced Practice Providers in the Pediatric ICU

Maureen A. Madden

Managing Throughput: Adults in My Pediatric Beds

Paul A. Checchia

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Administration

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Economics

Tag Pediatric Intensive Care Unit PICU

Tag APP Administration

Year 2020

Keywords

challenges

caring

adult patients

pediatric critical care units

measuring

documenting productivity

administrative challenges

collaboration

pediatric healthcare providers

data collection

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