SCCM Resource Library-When I Was You: Adept Career Guidance for the Ambitious (Flipped Classroom)

Video Transcription

For the Kentucky farmer with tobacco stains, long haul daddy leaving Texas for Maine. Hello everyone, and thank you for joining us for this session.  This session is when I was you a depth career guidance for the ambitious.  And so we have some great speakers with with us today we have Dr. Chris farmer who will be starting us off. We have our Dr. Stallings, who's a farm B from Vanderbilt University, and we have Ms.  Elmer from Mayo Clinic sorry my eyes are a little tired at the end of the day.  And I let you guys tell a little bit about yourselves when it's your turn to speak and give us a little bit more information about where you are right now and your career, etc.  And so I'm going to turn it over to you, Dr. Farmer.  Okay, thank you very much. Good afternoon, and good evening everyone. Thank you for joining us today. My name is Chris farmer. I am a critical care physician and I'm one of your past presidents of the Society of critical care medicine.  Several of these talks including mine I think will have a futurist bent to them, and I'm excited to talk about that the Coronavirus pandemic that we've had over the last year has been a really big problem for each of us.  I don't think there's a silver lining but it has pushed us forward in some ways that will help us advance critical care, and I'm going to hit on some of those themes when I talk to you today.  So let me share my screen.  Let me do that right now. Okay, we good everybody got that.  Okay, so let's talk about where we're going for the future, and obviously, this is not something to pick up your pens and take a bunch of notes about or write things down because what we say is conjecture.  It's crystal ball kind of talk. But what I'm going to try to do is connect some dots for you that are already in place and show you how these can potentially shape our future so let's jump right in.  So here are my disclosures.  I've been through two retirements now one from the Air Force is a retired Air Force Colonel, and then most recently about not quite two years ago from Mayo Clinic and as now as an emeritus professor.  And I decided this was my opportunity to go out and do some of the things I like to do. So I'm looking at things related to how we provide acute and advanced care and resource limited settings.  A lot of things around telemedicine things about focus critical care and dashboards and so forth. And even all the way to architecture and stuff so I'm going to do a lot of different things right now.  So these are my words here. So let's read these together. I believe that this is the most pivotal time in the history of critical care medicine.  As we transition away from our critical care responsibilities, ending at the ICU door and we've talked about that for a long time, the ICU without walls, but this may even mean the hospital.  We must solve unique and important challenges and we've seen some of these with Corona viruses. So for many critical care is not a place, but in fact critical care is a process failure.  So let's talk about some of this together. So the first thing that we have to acknowledge is where we're going. Yeah, we're connecting dots but we're going to a different place.  So same old thinking, same old results. That's not what we want. Therefore, our reality requires new thinking.  And we must acknowledge that our critical care solutions as we go forward in the future. They're not more. We're not going to fix what we need with more ICUs.  More ICU nurses, critical care physicians, and all of our other critical care professionals. It is a form of austerity. And as is quoted here, austerity is all about making the right choice. So let's talk some more about this.  So let me challenge you almost teleologically. When you think of health care, is that one word or is that two words? And when you divide it into two words, health and care, you begin to see that what we're bringing together really has some disparate components to it that we need to match up if we go forward.  So if you do that and you think about health is the first part of this. Who owns health and who is responsible for care? And we've somewhat divided these up but we've also somewhat compartmentalized them across other boundaries with the patients and eating healthy and all of those things. But especially with critical care, it's a different approach to health. It's a different definition for health.  So this Venn diagram illustrates exactly that. On the one side, you see intensive care. On the other side, you see health. And in the middle, it's the coexistence of these two. And we speak about this with our patients who have problems like chronic critical illness and so forth.  So these folks, they're in the hospital, they go home, we lose touch, somebody else assumes their care responsibilities, and then a lot of them come back a month later. Same problems that have now unwound and we see the cycle repeat itself. That's not going to get us where we need to be. So defining health specific to the individuals becomes important. And how do we do this?  And in fact, it is our responsibility to assist with these patients, even when they're not in a critical care environment.  So what that means next is changing the role of critical care. So where we are now in our entire healthcare system is that the patient finds the care. And that means that we do this according to geography. A patient is sick, they get in a car, they get in an ambulance, some of the worst ones are even on helicopters or airplanes or however they arrive at your facility, and we stand at the door and we greet them and then we initiate their care.  But where we're going with our future in lots of different ways, this new absolute state is that the care finds the patient. And we're going to talk about that.  So where we've been, I mentioned the geography. The ICU, yes, it is a defined space and it will continue to be a defined space. But critical care itself, the provision of this care, that's not space constrained. Critical care is not a place and it is not defined by geography.  And as we begin to think that way and look beyond the ICU and even beyond the hospital, where are these patients and how can we help them, it takes on an entirely different meaning.  One quick example. During the coronavirus, with the use of telemedicine, one of the systems that I've been involved with, and I'll show you this in a couple of minutes, we have provided very sophisticated advanced care in the home setting as a resource preservation activity for the hospitals.  So patients up to and including high flow nasal cannula that are being managed at home and watched with the surveillance being provided by critical care teams.  So I already alluded to the fact that critical care can be a process failure. What does that mean? Well, it means lots of things, but the easiest thing to think of are the patient crashes.  How many of these are preventable? How many times have we stood shoulder to shoulder in the ICU and said, man, I wish I would have gotten to this guy 12 hours ago? Why didn't somebody make a rapid response team call on this patient? We could have stopped this.  Therefore, when you look at this and where we're going in the future, our most important job is critical care prevention. It's not just taking care of these patients, but preventing the critical care.  And what is rescue? When the building is ablaze or the patient has already dived off the cliff, it's too late for that. And if you think that's rescue, then really that's just self delusion, just like pulling in your stomach when you step on the scales.  We also pride ourselves in multidisciplinary teams. Very, very important. But as we think about this going in the future, who's on the team? Well, we've talked about the folks that are in the ICU that make rounds with us in all aspects of care and the physiotherapy, the nutritional medicine, the vital role that our pharmacists play.  Now we move beyond that. When you look at others involved in this, advanced practice providers, hospitalists, primary care, rehabilitation, subspecialty care that happens in and out of the hospital, how do we make this into a continuum with continuity and coordination of care? So this redefines what the critical care team looks like.  Now, with telemedicine, we've learned this, but in other ways as well. I'll give you a quick example. Somebody comes to your hospital and they place an LVAC. And when all of that is finished and you have that patient back to some sort of an equilibrium state, they tell you, you know, I live in Wyoming and it's 150 miles from the nearest hospital.  How are you going to provide the proper management and surveillance for that patient? So this gap, this chasm is something as we move into the future where people live with limited resources, that means resources are limited. How are we going to provide sophisticated care to these folks? Not by telephone. So what about telemedicine? And we're going to talk about that.  So the first notion that I want to dispel is that e-care is anything but care. It is care. It's comprehensive care. It can be the entire continuum of care. And it can match the things. It's not just what you can see via camera in episodic or uber-type things or whatever it may be in the way you approach this.  But it presents challenges for us. We must have detection across this continuum. I use the phrase total asset visibility. So I've diagrammed here for you the continuum of care. And to the left you see the ICU all the way to home care.  And you look at all the things that we do, the data sampling as you move from left to right becomes less and less. And also the data sources also become less and less. So alert systems, communications, coordination of care, all of those things I have listed there. As you move towards the right, those become more and more difficult.  So we move away from rapid response teams and failure to recognize is the dominant problem to also include failure to measure for these patients. So we have to solve some of these problems. And that brings us to monitoring. And how are we going to do that? Is it just vital signs monitoring or what can we do?  So I've got a few examples here just to show you. And up towards the left upper side, you see the things everybody talks about, robots and Apple watches and so forth. But there's other things here that are important. Take a look in the middle to the right. You see the insert for the shoes? That performs impedance plethysmography.  What we don't think about are that patients who have worsening or decompensating heart failure. As one example, they change their gait. So it's not just did you have pizza for dinner last night and what's your salt intake look like? But these patients will begin to change their gait as they start to get in trouble.  So thinking like this and leveraging some of these technologies, this wasn't designed for that, but it works very well for these kinds of things. And you see other monitoring applications that can be there. The one in the bottom right will measure edematous changes as those things will occur with the tautness of the skin that happens with it. So lots of possibilities and opportunities there.  But before we go there with these things, another thing that we need to look at first is the variables themselves. And if you ask 10 different people, what do you think those variables are that are most important? You're going to get a lot of different answers from the different people.  One of the things that's interesting that was published about a decade ago by my colleagues at Mayo Clinic had to do with what variables do we use to make medical decisions. Independent of the diagnosis, about two dozen of the same variables pop up over and over. And we use those same things. Now we're data rich. In fact, we are data saturated with the problems that occur for these patients.  But in reality, we're not sure which of these variables are most important.  The next thing I want to show you is where do we become involved with the intensities? Now this takes us historically from the left side to the right side, where low risk monitoring patients like rule out MIs, we don't really do that anymore, but we did, all the way to actively trying to die.  And the red arrows show the varying points over time, historically, when we became more and more involved with these patients. Now you can see that that's moving towards the right.  I'm submitting to you, though, that this may change as these patients are outside of a critical care environment. I should say a traditional critical care environment, and we've become more involved with them.  In the same way that critical care is not a place, EICU is also not a place. It's not just beaming in with your camera and looking at the monitor and looking at the waveforms on the ventilator.  You see home, pre-hospital emergency departments, skilled nursing facilities, wards, and so forth with that. A telepresence across that continuum begins to address some of the things that I just showed you in a whole ability to monitor these patients as they go through the system, both getting sicker and also getting better.  So what does this mean? Well, the system that we need to go to doesn't sit in a room that we call a hub. It needs to be anywhere to anywhere. And that means the providers can be anywhere that are providing the surveillance for these patients, and the patients themselves can be anywhere.  So the rooms and the hubs where we have 34-inch monitors and multiple of them on a desk and all the EHRs and those things, that's great. It serves us well right now. But in the future, our ability to exchange data and be anywhere to see these patients anywhere becomes more and more important.  Now, lastly, I want to talk about a project that I've been involved with for about a year. There's a national program as coronavirus has ramped up that's referred to as NETCEN. In fact, the Society of Critical Care Medicine, as you can see, is one of the co-sponsors of this program. And NETCEN stands for National Emergency Telecritical Care Network.  And the premise of this entire program is that you can have a portable device, a smartphone, a tablet, a laptop computer, and that with that, either the patient or the provider, independent of other network connections, cellular only, and not requiring EHRs or all of those things, that they are able to connect with each other, to communicate, to have video linkups, whatever may be necessary.  And in fact, when I mentioned earlier about what we've been doing with the home care patients with coronavirus, this is exactly the system we've been using to accomplish this.  Okay, so where does that bring us? Well, I think it brings us to an entirely different definition for personalized or individualized medicine. As you can see to the right, we focus on genetics and genomics and genetic markers and all of those things and tailoring the specific therapies according to those. That's all really important.  But it's also individualized medicine when you use these devices to begin to connect to the patients individually and not waiting for them. This is what I'm talking about when I say the care goes to the patient. That's the individualized medicine.  So with that, I will stop and stop sharing. And I thank you and look forward to your questions in a short while.  My name is Joanna Stallings and I am the medical ICU pharmacist at Vanderbilt. So today I'm going to talk to you about farming for future success, planting the seeds.  The objectives today are going to be to identify common career pitfalls and obstacles of early  and mid-career practitioners to discuss strategies for screening responsibilities to optimize  job satisfaction, and finally, to evaluate methods for achieving productivity and efficiency. So I thought it was important to start this presentation out by giving you a little bit  of my background. I'm from very, very rural West Virginia. I grew up in Boone County, and this is my hometown, Madison. I actually grew up like 15 minutes outside of here.  It has about 5,000 people, three stoplights, and I put the picture on the right because  this was where coal was actually first discovered, and most people that live here are coal miners. So I'm a coal miner's daughter. I grew up in a hauler.  They can make a song about me, but I thought it was important to share this with you before I went into some of the stuff that I was going to share with you today.  So what is the day in a life of a typical ICU pharmacist? So my typical day would look like I get to work, I immediately go to nurse practitioner  rounds between 7 and 8.30, I'm processing orders, I'm doing pharmacokinetics consults, there might be a code like there was this morning, I might be getting questions already  from physicians, I'm following up on spontaneous awakening trials, making sure that spontaneous breathing trials are occurring, and then I would proceed on to house staff rounds.  I'm still entering orders. I'm also doing pharmacokinetics consults between 8.30 and 11, and then between 11 and 1, I'm  trying to eat, work up a second house staff team, follow up with the second house staff team.  I might be going to journal clubs or case presentations or various other meetings, going over patients with a student or resident if I have them on rotation with me, answering  questions from nurses or nurse practitioners, and then two Fridays a month, I'll be going to a post-ICU recovery center from 1 to 3 every afternoon.  So a lot of different things to juggle. So what is my advice to avoid common pitfalls and obstacles of new practitioners?  So first of all, I would say when you start a new job, to establish your clinical practice first. I had the privilege of working with Chris Farmer and Jen Elmer at Mayo and moved to  Vanderbilt almost nine years ago, and when I started here, that was something that I had to hold myself true to.  So starting with first establishing my clinical practice before I got involved in more professional organizations or before I really started to dig deep into research.  Second, be very observant, because many of the things that you'll see on rounds every day can be a quality improvement or research projects that you can get involved in.  Start small. I think that we all kind of get excited and have the tendency to overextend ourselves,  but what you should start with is one small project, one small idea in your ICU, not in multiple ICUs, not in multiple hospitals. And then finding your team.  So not just you, but physicians, nurses, nurse practitioner, respiratory therapist, physical therapist, find the people that you want to work with that are going to help you achieve  your goal. And then find a passion or two, three at most, had to keep myself honest because I'm going to talk about three different passions within this talk.  And then learn to incorporate your research into your job so that while you're doing your job every day, you're also trying to answer questions.  Remember that everyone can teach you something, and that's something that my parents taught  me at a very young age, to make sure to learn everyone's name, learn something about everyone because everyone can teach you something, and that's definitely something that I think  about every day. And then also not being afraid to ask for help. I definitely don't know everything, and I think it's always important to learn from  everyone because you can always, like I said, learn something. So I'm sure many of you in the audience are familiar with the awakening and breathing algorithm.  So the ABC study that Tim Gerrard conducted a number of years ago, showing that if we coordinate a spontaneous awakening trial with a spontaneous breathing trial, that patients  spent three fewer days in the vent, four fewer days in the ICU, four fewer days in the hospital, and they had a 14% reduction in one year mortality.  So I bring this up because this study was coordinated by Vanderbilt, but when I first started at Vanderbilt, believe it or not, this was not being conducted as regularly  as it should have been in the medical ICU. And this was not that people did not care about this.  The problem was there wasn't a local champion to make sure this happened every single day. We know a lot of our nurses tend to leave to go on to nurse practitioner school and  nurse anesthesia school, and I work with 20 different intensive care physicians. So they're on service maybe two or three weeks a year.  So they weren't there to help as new nurses were coming in, new respiratory therapists were coming in. So it made sense for a pharmacist to champion this.  So I talked to some of the physicians I work with. Art Wheeler was my medical director at the time, and Todd Rice was my assistant medical director.  I talked to Wes Ely and Tim Gerrard, our nurse manager at the time, Julie Foss, and then also Anna Ambrose, who was a respiratory therapist.  And so I led this project to help improve compliance with this in our medical ICU. So as you can see here, our spontaneous awakening trial safety screens performed in past increased  between our pre-quality improvement project and our post-quality improvement project implementation.  And looking here on the left side, you can see that before the quality improvement project,  we only had 43 ventilator days with past safety screen, versus on the right, we had 444 ventilator days with past safety screen.  So a much bigger number, and as you can see, we helped improve the number of SATs that were performed and those that were passed as well.  We also helped to decrease the number of patients that were on continuous infusions of sedations  and analgesia, increase the number of patients that were on nothing at all, and also to increase the use of just intermittent analgesia as well.  So I tell you all of this because this was my start. This was my very first very small project at Vanderbilt, and it really just turned into  a huge passion of mine and really just helped enhance my career tremendously. So these are some of the results of that initial project.  So I am, as we are starting Krongos now, I'm now the past chair, I was one of the co-chairs  for the ICU liberation committee, so helping implement the A through F bundle at all different types of institutions throughout the U.S.  I had the privilege of sharing that with Jaspal Singh. In the top left-hand corner, you can see that I was invited to be one of the faculty members  for the ICU liberation collaborative that SCCM led, which we helped implement the A through F bundle in over 15,000 adult patients and showed a reduction in mortality and multiple  morbidities. I also helped establish myself at Vanderbilt as a member of the critical illness brain  dysfunction survivorship center, in which I helped to help with study design and conduction of two different studies.  So most recently published last week, the men's two study comparing dexmedetomidine to propofol for sedation in adults with sepsis.  And then also the MindUSA study, look at how to all two, comparing how to all two is a precedent for placebo and for treatment of delirium in critical illness.  So one small thing can really turn into many bigger things. So this is the members of the critical illness brain dysfunction survivorship center, so  the sib center group, that I'm very thankful for every single day that I get to work from them and definitely learn many things from them every single day.  So my next passion that I will share with you is post-intensive care syndrome. So for those of you that are not familiar, essentially this is mainly patients that have  either had acute respiratory distress syndrome or sepsis, and that they have a lot of different impairments once they get out of the ICU.  So they have physical impairments, they can't walk quite as far, they also have a lot of pulmonary impairments, and they have cognitive impairment, primarily executive dysfunction,  so they can't do things like balance their checkbook. And then lastly, mental health issues as well, so depression, anxiety, post-traumatic stress disorder.  So Art Wheeler, who was my medical director at the time, actually his mother, had been very sick, and he, who was intensivist, and his wife, who was a critical care nurse, were  trying to take care of her at home and realize how stressful that was for them, and if they couldn't do it, how could anyone really do that?  So that really developed into an idea to develop a clinic to deal with the needs of patients following critical illness.  So I got invited to participate in this, honestly, partially because of my quality improvement project, and that we also wanted to model our team in this clinic after the team in  the medical ICU. So once again, here's my team. So we have two different case managers here.  We have Jim Jackson, our neuropsychologist, Carla Seven, who is a pulmonologist, and then we have two nurse practitioners, Tess Huggins and Sarah Bloom. We started very small.  We did a clinic once a month for three hours. We did it on Friday afternoons because nobody else wanted that slot in the pulmonary clinic.  We all volunteered for free, and honestly, we just had to figure it out. I made a list of questions that I thought would be appropriate to ask from an outpatient standpoint.  I mean, I'm a critical care pharmacist. I had never worked in an outpatient clinic.  I had to talk to our outpatient pulmonary pharmacist and learn about insurance and prioritizations and samples, et cetera. She has also taught me a lot.  But I wanted to show you what was accomplished from this clinic.  So from a pharmacy standpoint, we published a paper a couple years ago to show all the pharmacy interventions we made in these patients.  So we made a median of four interventions per patient in our initial 62 patients we saw in this clinic.  So as you can see here, we stopped a number of medications that were inappropriately continued. We started a lot of different medications.  We also prevented or implemented measures to prevent, I should say, adverse drug events and also identified adverse drug events in these patients.  And we also gave a number of immunizations to these patients as well. So what did this result in? Once again, very small idea. What did this result in? So now, there used to be one.  Now there are 40 different post-ICU clinics that have pharmacists. And we just published this paper a few months ago as an opinion paper to show how important  it is to have a pharmacist in your post-ICU recovery center. So I made this map. As you can see, we're a little heavier on the East Coast than we are on the West Coast.  And to show how many different ICU recovery centers have pharmacists. And I would say it's not uncommon.  I already got one this week to get an email, especially with COVID right now, with people asking how can they start a post-ICU clinic and how do I juggle working in ICU and also  working in this post-ICU clinic. So the last passion that I will talk to you about is pragmatic critical care trials.  So once again, this honestly resulted just from my clinical practice every day. I had gotten to know Matt Simler, who's the lead author on this paper, who was a fellow  at the time, and obviously my medical director that I'm very fortunate to get to work with every day, Todd Rice.  And they had asked me if I would help them conduct a study where they were comparing balanced fluids to normal saline in critically ill adults.  So what my role was just essentially was on rounds every day to make sure that if the wrong fluid was prescribed, that that didn't happen, if the nurse had charted that the  wrong fluid was given to make sure that that was corrected, to make sure the right fluids were stocked in the ICU every day.  And then once we accomplished that, once again, starting small in the medical ICU for a few months, then myself and Matt Simler, we would talk to different members of the different  ICUs and teach them how to roll it out in their ICU. So we eventually rolled this out into all the ICUs with the exception of the burn ICU in our institution here at Vanderbilt.  And so as you can see here, we show that balanced fluids resulted in a statistically significant  reduction in MIG-30, so major adverse kidney events at 30 days by using balanced fluids. So once again, why am I telling you about this? Because this snowballed.  Now we have a pragmatic critical care research group, which I'm fortunate to be a member of.  And we've done a subgroup analysis of this, specifically in septic patients, to show there's a mortality reduction if you use balanced fluids.  We've also looked at DKA and shown that patients' gaps close faster and they have faster resolution of DKA if we use balanced fluids.  And now another project has resulted off of this where I'm working with an allergist. So once again, just as a part of my routine clinical practice every day where I assess  all patients that have penicillin allergies, I go talk to them, find out about their allergy,  and if it's low risk, I can send them, give them a dose of penicillin right there on the spot and help de-label them.  And this project is currently ongoing, but we've already successfully, I personally have successfully de-labeled over 200 patients in our medical ICU. So once again, who's my team?  So this is a picture of me and Matt and Todd at SCCM a couple years ago when Matt revealed the SMART study with looking at balanced fluids as compared to normal saline.  And I can say that I'm very, very fortunate to work with these two guys every day. They've taught me a lot about study design and have definitely made me a fan of pragmatic  critical care trials, taught me a lot about statistics and research conduction, and also just taught me how to, how important it is to have fun on rounds every day as well.  So the other question that I wanted to talk about today was how to be more efficient and productive.  So I cannot talk about this without mentioning my father, who was an industrial engineer. I actually have two older sisters who also are industrial engineering, so you can imagine  what it was like to grow up in my house every day. It was kind of like the movie or the book Cheaper by the Dozen, if you've ever seen that, everything had to be efficient.  And I have definitely taken that to heart every day in my life and definitely at work for sure. So the first recommendation I would make is to use your resources wisely.  So I carry an iPad around with me to rounds every single day. Not only am I working at patients, but I might be writing notes at the same time, or maybe  I am sticking behind when the team moves on to see a different patient really quickly so I can consider a patient for penicillin testing.  Also using layered learning. So in other words, when you have students and residents on rotation, not only teaching  them a lot, but also making sure that you get some value from having them on rotation with you too.  So maybe you go see patients in the post ICU clinic with them, but then maybe they write the note, which of course you will read and check later while you're doing something  else that's productive for your day. Learning to multitask. I already kind of hit a little bit about this, just making sure that there's never a dull  moment. Maybe when something's going on in rounds that you're not a part of, some teaching about  x-rays or something that you are writing notes or doing something productive in the background, you can always be doing something to make your day more efficient.  And then lastly, you got to have some work-life balance. So I'm an avid runner. I'm a marathoner. I run almost every day before work.  That definitely helps with me balancing stress in my life for sure.  I like to travel a lot too. You got to figure out what your passion is outside of work too. And I can promise you that will make you more efficient at work if you take time away  from work too.  So in conclusion, establishing your clinical practice first, being observant, starting small, finding your team and your passion, incorporating your research into your work,  remembering everyone can teach you something and not being afraid to ask for help will help avoid pitfalls and obstacles of new practitioners.  The above tactics will improve your job satisfaction. I can promise it.  Enhance productivity and efficiency by using your resources wisely, using layered learning, learning to multitask and having work-life balance.  And that concludes my presentation. And now I am going to hand the talk over to Dr. Jen Elmer as she talks to us about a nursing perspective. Thanks, Joanna.  I'm going to try and share my screen here.  Everybody see that okay?  Good. Thank you.  Like Joanna said, I'm Jen Elmer. I'm a clinical nurse specialist.  I'm a clinical nurse specialist at the Mayo Clinic.  For the past 23 years, I've worked in the medical ICU, currently now cover all the ICUs as a clinical nurse specialist supervisor.  I am pleased to be here with all you tonight and pleased to be with such esteemed fellow presenters, as you've heard, both that I've had the privilege to work alongside with and  learn from during my career.  And I'm excited to discuss the topic that I'm very passionate about, following Joanna's lead on passion, which is teamwork.  I do not have any financial relationships or conflicts of interest.  The overarching theme of today's session is mid-career guidance. I was asked to talk about how it takes a team to cure a patient.  Rather than focus on a single discipline of the team, such as nursing or advanced practice  nursing, I'd like to talk about how to optimize job satisfaction by creating highly effective teams and how we may improve productivity and efficiencies, and again, achieve higher  levels of job satisfaction through multidisciplinary team training and identify opportunities where team training can be beneficial.  Many may remember the 1999 IOM report to AIR is Human, which highlighted how healthcare providers are usually trained as individuals, but almost always function as a member of  the team.  This report also emphasized the need for more opportunities for interdisciplinary training.  Most care delivered today is done by teams of people, yet training often remains focused on the individual responsibilities, leaving practitioners inadequately prepared to enter  complex settings.  Improved patient safety also requires some understanding of systems theory in order to effectively analyze the many contributing factors that influence errors.  Again, the silos created through training and organization of care impede safety improvements.  Ultimately, we need to train in teams, those that are prepared to take on the challenges of care, and in teams, those that are expected to work in teams.  People work together in small groups throughout healthcare, whether in a multi-specialty group  practice or interdisciplinary teams assembled for the care of a specific clinical condition,  whether that be for teams that care for children with congenital problems, oncology teams, end-of-life care teams, palliative care teams, in our operating rooms, and in our ICUs.  Teams are typically trained in separate disciplines and educational programs.  They may not appreciate each other's strengths or recognize each other's weakness except in  crisis situations, and they may not have been trained together to use new or well-established technologies.  When processes are planned and standardized, each member of the team knows his or her  responsibility as well as those of the teammates, and the members tend to look out for one another. They notice errors before they can cause an incident or an error.  And in an effective interdisciplinary team, members come to trust one another's judgment and attend to each other's safety concerns.  So we'll talk more about the benefits of working together and training together as a team.  So we can't talk about teamwork without defining what is a team. And here I've chosen to take the parts of a group of individuals who must work together to  perform to achieve a common goal. The team should also be able to achieve the goal, goals of the work and more efficiently  and safely than the individuals. In order to achieve this goals, teams need to have effective communication and have an  effective team leader. Teams can actually be counterproductive if they're not able to function together. So if you remember  back to 1992, the US Olympic dream team was described as by American journalists as the greatest sports team ever assembled. As you can see here, some of the familiar faces,  these athletes were some of the best, arguably some of the greatest to ever play the game. So to this day, the team included superstars like Michael Jordan, Scottie Pippen, Carl  Malone, Magic Johnson, Larry Bird, Patrick Ewing, and Charles Barkley, a lot of very famous names. On paper, this was the  most dominant team in the world. But believers of the of this would be shocked by the reality this team could lose. On June 24 1992. The dream team scrimmaged a college all star  team. Of course, the odds were in the favor of Team USA and how they should easily beat this college team, but never underestimate the underdog. The final score of the scrimmage,  the collegians 62 and dream teams was 54. Players such as Barkley and Jordan were eager to have a rematch, but coach Daly decided to deny the request hoping they would take in the  fact that the greatest team ever assembled just lost to amateur athletes. Scottie Pippen said in the documentary, documenting  the 1992 dream team, that these young kids were killing us, noting that we didn't know how to play with each other as a  team. That was the wake up call, and emphasize the importance of training as a team, and how the dream, how the dream of becoming  the greatest team ever can be realized. So the opportunity to practice together is such an important aspect for successful teams. To be successful teams who again train together,  respond together should train together. This is an example of our rapid response team in action. And one of an example of a team that we train together, as we want them to  respond together. Again, it's rarely done with interdisciplinary teams in healthcare. So why interdisciplinary team training? To me, it's really about the  what versus the how. Let's take resuscitation. Resuscitation is a common event in our ICU environment. I imagine many if not all of you on this presentation have participated  in ACLS courses. ACLS courses teach learners what to do. Interdisciplinary team training courses allows the team member to practice how to do it together to become the ultimate  dream team. So why team training, team training leads to high performing teams. These high performing teams are able to better predict the needs of each other. They can provide  quality information and feedback. They engage in higher level decision making. They're able to manage conflict more skillfully. They understand their roles and  responsibilities, not only of their own role, but the roles of the team members. And all of this together reduces the stress on the team as a whole, because it creates better team  performance. One model of team training that was developed by the Agency for Healthcare Research and Quality AHRQ that  many of you familiar with, and that within partnership with the Department of Defense, and the American Institute of Research  in 2002, was set out to help identify best practice and best practices and set the standard for medical team training. The  outcome of the development of the curriculum was team steps, which stands for team strategies and tools for enhancing performance and patient safety. I was fortunate enough to work  with my Mayo Clinic colleagues and a couple other institutions around the country to help AHRQ develop this program. You can see that communication is the core of the team steps  framework. And I'll illustrate that more in the next few slides. High performing teams have a clear team structure, their clarity of roles on the team, everybody knows their role,  and they know the roles of the other team members. It has clear leadership. High performing teams have situation monitoring  and shared mental models, that they're on the same page. So keeping people on every member of the team on the same page,  they offer a mutual support to each other, and can ebb and flow as the team needs it. Again, communication is a key principle  for a high performing team. These attributes create better performance, increase the attitudes and increase the knowledge of the team itself. As emphasized over the last few  slides, communication is the heart of effective teams. If your team doesn't communicate, they can't be successful. Communication barriers exist when following traditional  hierarchy structure, and it can be disempowering thus resulting in errors. This is a team steps critical language mantra that we  at Mayo Clinic have adopted to empower those to speak up and alert the team that something is not right. The mantra of I am  concerned, I am uncomfortable, stop, this is a safety issue. It escalates the level of concern with the intention of bringing the intention of bringing everyone on the same page of  common understanding and have that shared mental model. 10 years after instituting this communication tool, it's still  widely used here at Mayo Clinic, particularly when communicating concerns around a deterring patient. It also helps  standardize our practices. It's truly about building cohesion and leveling the playing field. You need to have trust and you  need to recognize each other as being part of the team. Next, I'd like to take a few moments to discuss the benefits of  training as a team. Again, we've talked about teams who respond together should train together. Simulation based team training  allows mistakes to be made in a safe learning environment. And it affords the opportunity to learn from each other and understand each team member's contributions, realizing that  they are team much like the transformation of the dream team had to become. So some of the research surrounding the benefits of interdisciplinary team training, Don and colleagues  studied interprofessional shared decision making in a neonatal intensive care unit to determine if there are any differences and  perspectives across professional groups, and found that shared decision making leads to a well informed decision and left the participants feeling valued. Merrill and group showed  multidisciplinary team training can lead to more accurate identification of deteriorating patients. And similarly, Wu and  team perceptions were enhanced patient safety and care quality while reducing practice errors. All of these groups reported  increase in satisfaction among team members in addition to the patient care benefits. A study by Brodsky and colleagues use TeamSTEPPS in their NICU to provide staff with formal  teamwork skills, and to introduce team new team based practices, showing that staff had greater job fulfillment,  believe that their abilities were being utilized properly, and felt more respected. Figueroa's findings show that simulation based team training is an effective is effective at  increasing teamwork skills. This study showed that simulation based team training to be an effective effective in improving  communication and increasing confidence among members of the multidisciplinary team, especially during crisis scenarios. There are many opportunities throughout our  institutions to implement team training. These include the common everyday tasks that we do together in the ICU like ICU rounding with a multidisciplinary team, to  greater risk events like critical care transport, or to low volume high risk events like disaster response and mass casualties. This photo is a simulated critical care  transport event with our emergency response system within our HPO center, or hyperbaric oxygen center. They simulated an emergency event in their area and incorporated transporting  the patient to a higher level of care from one part of the care through the continuum. Other examples of team training are listed here. And on the next slide. So we do both full  simulation center and in situ training for our code and RRT teams to scan a picture of our RRT team going to an event or code team going to an event, training the team together as  they respond together. Other opportunities to consider training together as interdisciplinary teams are  other response situations such as behavioral response or response to the violent patient. We run monthly mock events for behavioral and violent patient response in our ICU. You can  also think about interdisciplinary team training for events that occur in your ICU or ward such as emergency airways or sepsis response. Definitely want to focus on that  team aspect, what the roles are for each of the team members,  the good leadership, good communication, good mutual support, and good, common understanding or shared mental models. So in this brief time today, I've hoped I've  illustrated the benefits of training as a team along with some opportunities to explore employing team training in your healthcare system is it truly takes a team to cure a patient  and let's make those dream teams. I want to extend my gratitude to my Mayo Clinic team, which I am honored to be a part of. And I appreciate the invitation from SCCM to  participate in this session, especially with such esteemed colleagues. Thank you for your time and I'll turn it back to Dr. Taylor. I'll stop sharing my screen here.  All right, well, thank you. Dr. Drs. Farmer, Stallings and Elmore. That was a very insightful presentations that you just gave. And we have a couple questions. We have about  eight to nine minutes. So let's take those questions. The first question is for Dr. Stallings. Dr. Stallings, as you integrate  research into your everyday practice, how are you supported in funding and protective time because you have a lot of things that you do a lot of hats you're wearing, how do you find  time for it all?  Well, I am funded by no one. Just to be honest. So, like I said, I mean, honestly, I've just tried to I think that's one of the biggest take home points of my talk is just that  try to incorporate it into your real job. The research for me is more fun. And so I add that in there is kind of a bonus, but  bonus, but I'm able to do it because I make it part of my clinical practice.  Awesome. I think that's what we all do. We kind of find where if we have something we're passionate about, there's always time, isn't there? A couple questions for you, Dr. Farmer.  What opportunities do you see for the different professions in that continuum outside of the ICU that e care to work beyond  the walls together as a team? How would you see that happening between critical illness and recovery that communication?  Yeah, that's, that's really a good question. And Joanna hit on some of that with the survivor clinics and involving the  pharmacists. And, and that's not that's not just a fad. I think that the communications, they think about how we have done  things. So someone leaves the ICU, and we call whomever those people are that are going to take care of the patient, and they complete their hospitalization. And then maybe  it's a skilled nursing facility where it's a different set of physicians and nurses taking care of them. And there's some calls there many times, it's just a social worker, and not  provider to provider. I don't mean the social workers, not that, but the ones who provided the clinical care for the path  of physiology aren't the ones talking there, and then they go home. And then there's somebody taking care of that patient who's got 2500 patients in their panel. So there's just all  these opportunities for things to fall through the cracks. And so the survivor clinic is good. But some of the things that I  see, for example, how many of our patients with low ejection fractions on dialysis need on calling requirements for OT and PT and da da da da da, why do we send all those different  places? Why can't they go to the dialysis unit and all that happens right there? And why can't we beam into the dialysis  unit while the patient is there, and check on them and talk to them and do those things, and then have folks that are assigned to them that meet with them that know their names,  that talk to them multiple times a week, and those kinds of things. And that's how you stop this vortex of in and out of the hospital with it, or at least substantially slow it  down. And it's better for the patients too. They care. They know you care. Everybody's involved with it. And there's in the health and healthcare, there's some ownership now,  because you're interfacing with the patient and they're owning some of this stuff and participating in the decisions. So, I mean, that's one way to look at it. There are others,  but we've got to just approach this differently.  Yeah, so it seems like in your vision, you would still need some brick and mortar type places, especially maybe those  who couldn't afford internet, let's say, to have the device, because then there's also getting the device into the hands of the patient, right, to send the information back. So  you're kind of seeing that we may have smaller pockets or smaller places where they can meet many people at once if they needed to go to brick and mortar and couldn't do  telehealth. Absolutely, Beth. That's required. And you know what? One of the things we learned with the home care thing with  coronavirus, there's still a lot of flip phones out there,  particularly in the... Like my parents.  What do you do?  Yeah, the answer is stand at the doorway of the emergency department and wait for them to come to you.  Very good. Dr. Elmer, I have to ask you, so you talked about training as a team, if you're going to be performing something as a team. And I can see that working really well  in the community setting where maybe those members don't turn over. But then I think of the teaching hospital, like I'm in a teaching hospital and I'm thinking that physician  could be different every week, that nurse could be different every week. So how do you think about it in those terms when you're trying to form these teams?  I think that's an excellent question. And working in an academic center like I do as well, really knowing what the role. So if you're training as a team to know your role, even  if there's a new person standing in that role, you know how to work with them better because you know their role and they know your role. So I think some of it is maybe not the  individual person, but you're training as a group of people that are responding to an event like a code or a behavioral emergency. But me as the clinical specialist, I know my  role in that and I know your role or whoever's standing in your role, the team leader role or the nurse role, whatever it might be so that we can ebb and flow. And if we all kind of  have those standardized principles and standardized practices, I think we can switch out the people and be more role dependent.  All right. So you kind of have a blueprint for whoever's in the role at the time, right? That's a great word. Yeah, thank you.  All right. And then every one of your talks really focused on teamwork in some way. I heard that from Dr. Farmer saying, you  know, as a team, we're going to figure out how to take care to the patients and we might work in different ways. And then,  Dr. Stallings, you talked about no matter where I went, there was something for me to learn and you kind of got out of what I'd say your lane as a pharmacist as you did different  work and learn different things and same for you, Dr. Elmer. So in our last few minutes, I'd like for you to leave everyone  with the words of wisdom on the importance of, you know, working as a team, no matter what your profession that sometimes you  don't want to hear it's not my job that as a critical care community, how do you think we can best utilize our teams to  get the job done that way? Dr. Farmer, would you like to start?  Thank you very much. I don't know about the wisdom part.  We keep each other out of trouble.  Different eyes see different things. And when we communicate and talk to each other, it's not just the role that you're assigned that's there. If you are walking past the patient's  room in the ICU and the housekeeper says, hey, you know, when I was here yesterday, this guy looked different. You better go look at it. Everybody's everybody matters in this  process and put down not that we do this per se, but put down the pretenses. And pride is not a good thing. And it afflicts  all of us. Just put it down and listen. Two ears, one mouth, the whole thing. I like that. So that is words of wisdom. Put down and listen. Those are good words. Dr. Stallings.  I have to agree with what Dr. Farmer said. Honestly, like I have learned so much, like, like you said, getting out of my lane a little bit with the spontaneous breathing trials.  I have learned every respiratory therapist names and obviously no other nurses names. And they really like when you identify a  problem, you really need to go talk to people and figure out why that really is a problem. And if you don't talk to them and figure out like why that is happening, you will never be  able to fix it. I think that's my biggest piece of advice, because until I like sat down and talked to some of these people that were in different disciplines and I was like I  would have ran in circles all day with regards to the compliance of spontaneous waking trials and breathing trials. But once you talk to them and figure out why, then  it was an easy fix. Yeah, I kind of reminds me of some of my own that each area seems to have its own language, doesn't it? And so like even when you transition from maybe one area  to another, you have to learn those that language, what they're using, and also those policies and everything. So it's really challenging. So Dr. Allard, tell us about one of  your favorite teams and what you've learned working with a team. I have a lot of favorite teams. When you ask why I stay and do what I do, it's the people. We all have great jobs.  We all have things that we're passionate about. But what keeps me here is the people or keeps me part of a team. I think most recently our high-consequence infectious  disease team that's had to morph into a COVID team, I think  really showed the power of teamwork and something I very much enjoy being a part of. Well, I'm going to say that your talks kind of gave me chills because it was just very  exciting. And it just gets you fired up to really kind of go out there and help solve some of these issues. And that's how  we'll do it as a team. So with that, we'll say goodnight to everyone out there and have a great evening. Thanks for joining us.

Video Summary

During a session on career guidance, Dr. Chris Farmer, Dr. Joanna Stallings, and Dr. Jen Elmer discussed the importance of teamwork in healthcare. They highlighted the need for interdisciplinary teams and the benefits of training together. Dr. Farmer emphasized the importance of strong communication and the need for teams to find ways to work together beyond the walls of the ICU. He suggested that telemedicine and remote monitoring could be used to provide acute and advanced care in resource-limited settings. Dr. Stallings discussed the benefits of team training, citing examples of how it improves communication and leads to higher levels of job satisfaction. She also emphasized the importance of trust and recognition within the team. Dr. Elmer focused on the benefits of interdisciplinary team training, citing research that shows it leads to better performance and increased job satisfaction. She also highlighted the importance of effective communication and provided examples of programs such as Team Steps that promote clear communication within a team. Overall, the speakers stressed the importance of teamwork in healthcare and the need for interdisciplinary collaboration to achieve better patient outcomes.

Asset Subtitle

Professional Development and Education, 2021

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 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Identify common career pitfalls and obstacles of early and mid-career practitioners
Discuss strategies for screening responsibilities to optimize job satisfaction
Evaluate methods for achieving productivity and efficiency

Modifying Medicine: Back to the Future
J. Christopher Farmer

Pharming for Future Success: Planting the Seeds
Joanna Stollings

It Takes a Team to Cure a Patient
Jennifer Elmer

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Healthcare Delivery

Tag Team Leadership

Tag Fellowship Training

Year 2021

Keywords

teamwork in healthcare

interdisciplinary teams

training together

strong communication

telemedicine

remote monitoring

team training

trust and recognition

patient outcomes

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.