Pediatric Chronic Critical Illness: Training Teams to Address the Communication Challenges of Patients With Repeated and Prolonged Hospitalizations.

CONTEXT: Children with chronic critical illness (CCI) have repeated and prolonged hospitalizations. Discrete communication challenges characterize their inpatient care. OBJECTIVES: Develop, implement, and evaluate a communication training for inpatient clinicians managing pediatric CCI. METHODS: A one-day communication training for interdisciplinary clinicians, incorporating didactic sessions and simulated family and interdisciplinary team meetings. RESULTS: Learners had an average of 11 years' clinical experience. About 34% lacked prior communication training relevant to pediatric CCI. Mean baseline competence across communication skills was 2.6 (range 2.4-3.2), corresponding to less than somewhat prepared; after the training, this increased to a mean of 4.0 (range 3.5-4.5), corresponding to well prepared. Skills with greatest improvement included conducting a family meeting, delivering bad news, discussing stopping intensive care, and end-of-life communication. After one month, perceived competence was sustained for seven of 10 skills; for remaining skills, perceived competence scores decreased by 0.1-0.2. About 100% of learners would recommend the training to colleagues; 89% advocated it for all clinicians caring for children with CCI. CONCLUSION: Interdisciplinary communication training regarding long stay patients is feasible and valued by novice and seasoned clinicians. The novel integration of intrateam communication skills alongside team-family skills reflects the reality that the care of children with CCI challenges clinicians to communicate well with each other and families. Teaching interdisciplinary teams to share communication skills has the potential to overcome reported limitations of existing inpatient discussions, which can be dominated by one or two physicians and lack contributions from diverse team members.

Pediatric Chronic Critical Illness: Gaps in Inpatient Intrateam Communication.

OBJECTIVES: The number of children with medical complexity and prolonged hospitalizations is rising. Strategies to adapt acute care approaches for this population are falling behind clinical demand. This study aimed to identify how inpatient team communication practices match the needs of teams caring for these patients and families, and to identify priority areas for improvement. DESIGN: Cross-sectional mixed methods survey. SETTING: Academic children's hospital. SUBJECTS: Interdisciplinary healthcare professionals: physicians, nurse practitioners, nurses, resident and fellow trainees, respiratory therapists, clinical pharmacists, occupational therapists, physical therapists, social workers, and child life specialists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four-hundred eight interdisciplinary healthcare professionals participated (33% response rate). Half (53%) worked in ICUs and 37% had greater than 10 years clinical experience. Three overarching themes emerged regarding communication during care of children with prolonged hospitalizations are as follows: 1) Dysfunctional team collaboration: the many involved healthcare providers for these children have inconsistent team meetings and few platforms for reaching clinical consensus; 2) Continuity gaps: time-limited clinician rotations and no designated longitudinal clinical leaders undermine relationships with families and key elements of shared decision-making; and 3) Inadequate communication skills and tools: healthcare professionals have inadequate training to address complex conversations and big picture concerns, and often default to daily management conversations. Nearly half (40%) perceived intra-team conflict to occur more commonly during care of these children compared with those with short hospitalizations, and many feel unskilled to address these conflicts. Healthcare providers working in ICUs were more likely than other healthcare providers to find care of children with chronic critical illness stressful "most of the time" (ICU 46%; 60/131 vs non-ICU 25%; 21/84; p = 0.02). CONCLUSIONS: Acute care inpatient communication practices require modification to meet the needs of healthcare professionals who provide longitudinal care to children with repeated and prolonged hospitalizations. Improvement strategies should prioritize building collaboration, continuity, and communication skills among healthcare professionals.

Two cases of humoral hypercalcemia of malignancy complicating infantile fibrosarcoma.

We report two infants with infantile fibrosarcoma (IFS) complicated by severe hypercalcemia. Assessment demonstrated suppressed parathyroid hormone and 1,25-dihydroxyvitamin D levels with elevated circulating levels of parathyroid hormone related protein, indicating the diagnosis of humoral hypercalcemia of malignancy (HHM). HHM is a paraneoplastic syndrome rarely associated with pediatric malignancies. Hypercalcemia manifested clinically with neurologic symptoms and soft tissue calcium deposition and required aggressive management with intravenous fluids, diuretics, and supplemental electrolytes. Following treatment with neoadjuvant chemotherapy, serum calcium levels precipitously declined requiring calcium repletion. These cases highlight the improvement of hypercalcemia secondary to HHM following chemotherapy.

The reality of teenage driving: the results of a driving educational experience for teens in the juvenile court system.

BACKGROUND: In the United States, one third of all deaths in teens are a result of motor vehicle crashes, accounting for 6,000 deaths annually. Injury Free Coalition for Kids-Worcester in collaboration with Worcester Juvenile Court has developed an interactive program for first-time teenaged driving offenders, Reality Intensive Driver Education (Teen RIDE). This full-day program at the trauma center provides a realistic exposure to the consequences of risky driving behaviors. This article examined the driving offense recidivism rates for Teen RIDE participants versus a comparison group (CG). METHODS: The intervention group (IG) consists of teenagers between 13 years and 17 years who have been arrested for the first time for a serious driving offense and are sentenced by a Worcester Juvenile Court Judge or Magistrate to the Teen RIDE program. They are required to attend the program as a condition of probation, so attendance is mandatory. Each participant in the IG completed the program and was tracked for driving reoffenses for 6 months after completion of the course. The CG consists of also first-time driving offenders. The CG was matched with the IG with respect to age (13-17 years), sex, and offense type. Springfield, Massachusetts, serves as the site for recruitment of the CG, since it is demographically similar to Worcester but 60 mi away. Students in the CG had no exposure to this program. Each CG member was also tracked for 6 months after arrest. RESULTS: The recidivism rate for Teen RIDE participants 6 months after the course is 6% with 0% reoffending more than once. The CG has a recidivism rate of 56% 6 months after the arrest and 14% have more than one reoffense. The CG is 13.062 (4.296-39.713) times more likely to reoffend, and this is significant (p < 0.001). CONCLUSION: The Teen RIDE program provides an impactful exposure of the consequences of risky driving behaviors to teenaged participants. In addition, Teen RIDE participants are significantly less likely to reoffend after completion of the course. LEVEL OF EVIDENCE: Therapeutic study, level III.

The effect of reduction and instrumentation of spondylolisthesis on spinopelvic sagittal alignment.

BACKGROUND: Reduction of severe spondylolisthesis is controversial. Publications have emphasized the techniques of reduction and associated complications, but there is little knowledge about the effect of reduction on the sagittal balance of the spine and pelvis in the postoperative patient. This study evaluated the effect of surgical reduction and instrumented fusion of spondylolisthesis on the pelvic anatomy and spinopelvic sagittal balance. METHODS: This is a retrospective study of 26 adolescents (mean age, 13.1+/-3.3 years) who had partial surgical reduction and posterior instrumented fusion L4 to sacrum to treat high-grade spondylolisthesis. All patients had radiographs that allowed measurement of sagittal spinopelvic parameters at preoperative, postoperative, and at a minimum of 2 years' follow-up (mean, 7.5+/-5.4 years). A 10-degree reduction in lumbosacral angle and/or 10% reduction of anterior listhesis confirmed the reduction. Radiographic measurements were statistically compared to determine correlations between reduction and sagittal balance. RESULTS: Pelvic incidence increased in 5 (24%) of 21 patients who had posterior instrumented fusion. Pelvic version improved in patients with unbalanced spondylolisthesis as evidenced by reduction of pelvic tilt or/and increased sacral slope. Mean pelvic tilt improved by 5.7 degrees (95% confidence interval, 1.5-9.8 degrees), and mean sacral slope improved by 11.4 degrees (95% confidence interval, 5.9-17.0 degrees). Two of 6 patients with a balanced spondylolisthesis developed a retroverted sacrum at follow-up.There was poor correlation between the amount of surgical reduction (improvement in L5 slip and lumbosacral angle) and the changes in pelvic version. CLINICAL RELEVANCE: Partial reduction and instrumented fusion of spondylolisthesis may lead to increased pelvic incidence due to sacroiliac joint motion or sacral remodeling. In unbalanced spondylolisthesis, pelvic sagittal balanced improved in 75% of patients but did not correlate to the amount of reduction of spondylolisthesis. Other factors, such as achievement of solid arthrodesis, may be more important than reduction of spondylolisthesis in determining spinopelvic sagittal balance. LEVEL OF EVIDENCE: IV-case series.