SCCM Resource Library-PICU-Associated Parental PTSD: Beyond the First Year

Video Transcription

My name is Andrew Becker, and I am a first-year PICU fellow at the Children's Hospital of Philadelphia.  Today, I am going to be talking about our PICU Overnight Interprofessional Education of Residents, or Project Pointer.  This is an educational curriculum that Megan Bernstein, a senior PICU nurse and clinical nurse expert, and I started in 2020 and continues to this day.  I received a small institutional grant through the Center for Leadership and Innovation in Medical Education at CHOP.  Resident education rarely includes training in the hands-on mechanics of bedside care delivery.  However, these bedside skills and knowledge are necessary for patient care and crucial when time and resources are limited, particularly in the intensive care unit environment.  Nurses and respiratory therapists are content experts in this arena, yet are rarely asked to provide formal education to resident physicians.  Leveraging their bedside experience to enhance resident instruction represents a unique opportunity to address this area of need while working to improve interprofessional collaborative practice through interprofessional education.  Our primary aim was to deliver a supplemental curriculum to improve resident bedside care knowledge and comfort.  Secondary aims were to increase resident participation in bedside care and promote interprofessional collaboration between residents and nurses or respiratory therapists.  Our hypothesis was that the initiation of a nurse and respiratory therapist-facilitated interprofessional curriculum would improve resident bedside care knowledge, comfort, and participation and improve interprofessional collaboration.  A targeted needs assessment led to the development of four hands-on sessions developed by myself, a pediatric critical care clinical nurse expert, and a senior respiratory therapist.  We delivered the same session every night for four nights straight and rotated the session weekly to align with resident Q4 schedule during their one-month rotation in the PICU.  Teaching was conducted in-unit by bedside nurses and respiratory therapists using available materials.  Sessions were held in the evening, but timing was flexible based on unit acuity and educator and resident availability.  Nurses were incentivized by being able to use this teaching as part of their professional advancement profile.  Residents were prospectively surveyed.  We delivered four sessions on topics that the residents wanted more bedside experience with.  Code cart scavenger hunt and push-pull fluid delivery system, arterial line understanding and troubleshooting, central and peripheral venous access, and tracheostomy and airway management.  The first three sessions were delivered by bedside nurses and the tracheostomy and respiratory management session by respiratory therapists.  We developed simple teaching scripts adapted from local and internet resources, and they were designed to be utilized by a bedside nurse or respiratory therapist with minimal preparation or teaching experience.  To help guide the educators, each teaching script had a guiding principles, preparation and materials, and objective section.  Since we wanted our educators to be able to jump right in, despite neither prior teaching experience nor a clear understanding of resident knowledge, we included teacher notes in the scripts.  Some, like the arterial line session, had visual aids, and others utilized Q&A, like the code cart scavenger hunt seen here.  Pointer was prospectively evaluated using pre-post surveys.  Residents were surveyed at three time points, before their PICU rotation, one month later at the end of their PICU rotation, which was before and after the curriculum exposure, as well as at the 6-12 month mark.  The 6-12 month data is not presented here. Knowledge, comfort, and participation were measured using a combination of Likert scale, multiple choice, and open-ended questions.  Interprofessional collaboration was assessed using a modified Jefferson scale of attitudes towards physician-nurse collaboration survey.  We only compared data in residents who filled out a pre- and post-pointer survey.  We grouped questions by question type, knowledge, comfort, participation, or collaboration, and also by session type.  We surveyed 98 residents over a 10-month period. We surveyed 98 residents over a 10-month period.  Survey completion rate, defined as completing both a pre-PICU rotation or curriculum exposure survey and a post-survey one month later, was 51%.  Survey respondents attended a median of three sessions.  When grouping by question type only, residents demonstrated significantly increased bedside care knowledge and comfort.  The improvement in participation did not meet statistical significance.  We then grouped the questions by session type.  When looking only at residents who attended a given session and filled out a pre-session and post-session survey, we had 29 to 35 data points per session.  Medians are presented here, and significant p-values for differences between pre- and post-pointer are in bold and blue.  As you can see, residents who attended a given session demonstrated significant improvement in knowledge and comfort related to that session for all four sessions.  Additionally, residents who attended the arterial line session demonstrated improved participation in arterial line care.  Now the obvious follow-up question to this is how much of the improvement was due to exposure to the PICU rotation rather than the session itself.  We attempted to control for exposure to the PICU, and thus PICU bedside care, by comparing learners who attended a given session to those who did not attend that session, all of whom had rotated through the PICU.  For example, comparing arterial line score improvement in learners who attended the arterial line session versus those who did not attend the session to control for exposure to arterial lines during the course of a normal PICU rotation.  In the rightmost column, you can see the p-values comparing pre- and post-pointer improvements in those who attended a given session to those who did not in bold and blue.  Significant p-values in this column means that those who attended a given session improved more than those who did not attend that session, controlling for the exposure that is the PICU.  Controlling for the exposure that is the PICU rotation.  Those who attended the arterial line session demonstrated improved arterial line knowledge and comfort, and comfort improved in all sessions except for the central and peripheral venous access one.  The self-reported measures were consistent with our hard data.  Residents self-reported that pointer improved their knowledge, made them a better clinician or resident, and thought that pointer should continue.  They also reported that pointer increased their understanding of the nurse or respiratory therapist knowledge base.  We also examined residents' attitudes towards physician-nurse collaboration, which showed no improvement.  However, residents had very high pre-pointer values with a median score of 39 of 40, so we were unlikely to see a change.  Our educators reported that they enjoyed participating in pointer and became better teachers due to the curriculum.  We also evaluated the comments from our participant surveys.  Some themes that emerged from the resident side were the practicality and helpfulness of the curriculum, as well as enjoying the interprofessional collaboration.  Nurses also enjoyed the interprofessional collaboration and gained a better understanding of the resident knowledge base.  Project Pointer utilized nurses and respiratory therapists as the experts in bedside care that they already are to deliver a curriculum to residents that improved their knowledge, comfort, and participation in bedside care.  We developed and implemented a novel interprofessional education-based curriculum that was unique with the use of nurse and respiratory therapists as resident educators, successful, implemented at low cost, and is flexible and sustainable, helpful as it increased resident knowledge, comfort, and participation,  well-liked as the participants appreciated the practical, interdisciplinary nature and residents wanted it to continue, and, I hope, generalizable.  It is a low-effort, low-cost, high-yield intervention, and given Pointer's flexibility and customizability, the idea behind the curriculum is likely applicable to any field with bedside care or any other skill or service provided by non-physicians willing to educate learners.  Limitations to our project and study include, from an assessment standpoint, only 51% of residents filled out a pre- and post-curriculum survey, which may have introduced selection bias. However, using the same residents as the control group in our secondary analysis likely mitigated this effect.  We also studied ICU-specific topics, though some are applicable outside of the intensive care unit, and we believe that the curriculum itself is generalizable to non-ICU topics as well.  And our pre-curriculum interdisciplinary collaboration scores may have influenced the success of our curriculum and limited our ability to test for improvement.  From a curriculum implementation standpoint, this program relies on donated time from bedside nurses and respiratory therapists to teach when they may be involved in bedside care, and requires that residents have time to attend while on service.  Additionally, having different teachers means that there is likely variation in the delivery of the curriculum, resulting in different learner experiences.  Thank yous, starting at the upper left and working counterclockwise.  First, the engine that made this project work and continue to work, Megan Bernstein, our clinical nurse expert.  Gibray Purifoy, a senior respiratory therapist.  Guidance and help from PICU attending Steve Loscalzo, Sam Rosenblatt, and Kelly Martin, as well as PICU hospitalist Philip Cohen.  The CLIMB grant through CHOP.  And finally, a major thank you to the CHOP PICU for support and immense amount of gratitude for all of our dedicated bedside nurses and respiratory therapists who have kept this program running through a pandemic and record high patient volumes.  It goes without saying that we absolutely could not have done this without you.  Thank you, and I will gladly take any questions.

Video Summary

Project Pointer is an educational curriculum developed by Andrew Becker and Megan Bernstein at the Children's Hospital of Philadelphia. The curriculum aims to improve resident education in bedside care by leveraging the expertise of nurses and respiratory therapists. The curriculum includes hands-on sessions on topics such as code cart scavenger hunt, arterial line understanding, central and peripheral venous access, and tracheostomy and airway management. Pre and post-surveys were conducted to measure the effectiveness of the curriculum, which showed significant improvement in resident knowledge and comfort related to the sessions. The curriculum was well-received by residents and educators, and it is seen as a low-cost and sustainable intervention for interprofessional education.

Asset Subtitle

Administration, Behavioral Health and Well Being, 2022

Asset Caption

INTRODUCTION: Post-Traumatic Stress Disorder (PTSD) is a trauma and stress related alteration in mental health which continues greater than 30 days after the inciting event and causes significant impairment in daily functioning. Pediatric Intensive Care Unit (PICU) associated parental PTSD occurs in 13-22% of parents within the 12 months following discharge from the PICU. We hypothesize that parental PTSD remains prevalent in the 18-30 months post discharge and is associated with specific identifiable factors. METHODS: Prospective cohort study running over 42 months evaluating 265 parents of patients unexpectedly admitted to two mixed medical/surgical PICUs from June 2016- August 2017. RESULTS: 175 (66%) parents completed the PTSD Symptom Scale Interview at 18 – 30 months post-discharge. 22 parents (12.5%) qualified for PTSD and 59 (33.7%) had significant PTSD symptoms. On univariate regression analysis, the following parents were significantly more likely to develop PTSD: those diagnosed with Acute Stress Disorder (ASD) prior to PICU discharge (p= 0.002); those who had concerns of potential death of their child (p=0.008); those who had concerns of permanent injury to their child (p=0.002); and/or those who had concerns about their child’s susceptibility to death post-discharge (p < 0.001). Parents who qualified for PTSD were also more likely to have gotten divorced/separated (p=0.002) and/or had their income decline(p=0.002) during the follow up period. Child associated univariate risk factors included new home ventilation requirement (p=0.005), previous ICU admission (p=0.034), intubation (p=0.014), ECMO (p=0.029) and PICU length of stay (p=0.016). On multivariate regression modeling, the following parents were significantly more likely to develop PTSD: those diagnosed with ASD (p=0.034); those whose child had a previous ICU admission (p=0.0015); those who experienced income decline (p=0.010); and those who had concerns of child susceptibility to death post-discharge (p=0.001). CONCLUSION: Two years after discharge 1 in 8 parents still qualified for PTSD and remarkably 1 in 3 had significant PTSD symptoms. Our study showed that there are identifiable factors associated with parental PTSD that are present during admission, potentially showing a path towards inpatient intervention for high-risk groups.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Behavioral Health and Well Being

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Pediatric Intensive Care Unit PICU

Tag Patient and Family Support

Tag Post-Traumatic Stress Disorder PTSD

Year 2022

Keywords

Project Pointer

educational curriculum

bedside care

resident education

nurses

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