Racial Minority Families' Preferences for Communication in Pediatric Intensive Care Often Overlooked.

OBJECTIVE: To compare the communication experiences and preferences of racial/ethnic minority and non-Hispanic white (NHW) families in the pediatric intensive care unit (PICU), including their interactions with bedside nurses. METHODS: Retrospective cohort study performed at a quaternary university-affiliated children's hospital with 70 pediatric intensive care beds. From October 2013 to December 2014, English-speaking family members of children admitted to the PICU were asked about their experiences communicating with PICU caregivers using a survey tool. RESULTS: 107 participants were included for analysis, of which 60 self-identified as a racial minority and 47 as NHW. Overall, 11% of families chose family meetings as their preferred setting for receiving information, as compared to family-centered rounds or unplanned bedside meetings. Only 50% of those with a family meeting felt they learned new information during the meeting. Chi-square statistics or Fisher's exact tests showed that minority families were less likely to report their bedside nurses spent enough time speaking with them (minority 67%, NHW 85%; p = 0.03) and less likely to receive communication from the medical team in their preferred setting (minority 63%, NHW 85%; p = 0.01). Logistic regression, controlling for covariates including education, insurance, and risk of mortality, showed that the relationship between minority status and concordance of preferred setting persisted (OR = 0.32, 95% C·I.: 0.11, 0.91). CONCLUSION: In general, families of PICU patients prefer meeting with the medical team during rounds or unplanned bedside meetings as opposed to formal family meetings. Despite this preference, minority families are less likely to receive communication from the medical team in their preferred settings. Meeting all families' communication setting needs may improve their communication experiences in the PICU.

Communication training for inter-specialty clinicians.

BACKGROUND: Inter-specialty clinicians often co-lead family conferences for hospitalised patients. Families frequently report receiving different messages from different clinicians. We developed a communication training workshop that crosses disciplines and co-trains clinicians in one setting to create a culture of delivering a unified message. METHODS: We developed a 2-day paediatric communication skills workshop to teach the skills necessary to conduct a family conference. The workshop was targeted at nurse-practitioners and faculty clinicians representing the different specialties that co-manage children in an intensive care unit. Our primary outcomes were learner self-assessment of skills attainment and workshop satisfaction. We also evaluated the feasibility of recruiting busy clinicians. RESULTS: Fifteen clinicians, including eight critical care faculty members (80% of eligible participants), three subspecialty faculty members (100% of eligible participants) and four nurse-practitioners (100% of eligible participants), participated. Learners' self-reported confidence improved in all communication metrics assessed. From pre- to post-workshop, confidence increased from 39% to 94% for 'giving bad news' (p < 0.05), from 50% to 83% for 'conducting a family conference' (p < 0.05), and from 39% to 100% for 'eliciting a family's values/preferences (p < 0.05). Every learner rated the workshop as important to their clinical practice and 100% would strongly recommend it to others. All reported the time commitment was not burdensome and 74% would choose this 2-day format over shorter formats. When clinicians learn together, they are more likely to speak the same language when communicating with each other, and ultimately to deliver the same message to families CONCLUSIONS: An inter-specialty communication training workshop for different types of clinician was well received. It is feasible to co-train different types of clinician in a joint session. When clinicians learn together, they are more likely to speak the same language when communicating with each other, and ultimately to deliver the same message to families.

Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent.

INTRODUCTION: To improve patient safety, the Centers for Medicare & Medicaid Services (CMS) has promoted systematically measuring and reporting harm due to patient care. The CMS's Partnership for Patients program identified 9 hospital-acquired conditions (HACs) for reduction, to make care safer, more reliable, and less costly. However, the proportion of inpatient pediatric harm represented by these HACs is unknown. METHODS: We conducted a retrospective review of 240 harms previously identified using the Pediatric All-Cause Harm Measurement Tool, a trigger tool that is applied to medical records to comprehensively identify harms. The original sample included 600 randomly selected patients from 6 children's hospitals in February 2012. Patients with rehabilitation, obstetric, newborn nursery, and psychiatric admissions were excluded. The 240 identified harms were classified as a HAC if the event description potentially met the definition of 1 of the 9 CMS-defined HACs. HAC assessment was performed independently by 2 coauthors and compared using Cohen's Kappa. RESULTS: Two hundred forty harms across 6 children's hospitals were identified in February 2012 using a pediatric global trigger tool. Agreement between the coauthors on HAC classification was high (Kappa = 0.77). After reconciling differences, of the 240 identified harms, 58 (24.2%; 95% confidence interval: 9.1-31.7%) were classified as a CMS-defined HAC. CONCLUSIONS: One-fourth of all harms detected by a pediatric-specific trigger tool are represented by HACs. Although substantial effort is focused on identifying and minimizing HACs, to better understand and ultimately mitigate harm, more comprehensive harm identification and quantification may be needed to address events unidentified using this approach.

Evaluating Palliative Care Resources Available to the Public Using the Internet and Social Media.

BACKGROUND: Accessible information about palliative care available to the public on the Internet is growing. We do not know whether this information is consistent with the current accepted definition of palliative care. AIM: To identify resources on the Internet and social media regarding palliative care and evaluate the information conveyed. DESIGN: A cross-sectional study of "palliative care" search results. SETTING: Top 10 Google websites, top 10 most viewed YouTube videos, and social media platforms, Facebook and Twitter, were searched. RESULTS: The most popular Google websites were mostly from national organizations promoting palliative care, whose definitions of palliative care consistently mention "quality of life" and "relief from symptoms and stress." None of the websites mentioned children, and 77% cited palliative care as treatment for cancer with less focus on other diseases. No personal stories were included in Google websites, while 60% of YouTube videos included personal stories. Five main themes were generated from 266 YouTube video comments analyzed. The most common theme was emotionality, of which 91% were positive statements. Facebook and Twitter were mostly used by health-care professionals and not the public. CONCLUSIONS: Palliative care resources are mostly positive and consistent with the current definition of palliative care. Major Internet search engines such as Google and YouTube provide valuable insight into information the public receives about palliative care. Future development of Internet resources on palliative care should consider including children and emphasizing palliative care for all life-limiting illnesses.

Investigation of Public Perception of Brain Death Using the Internet.

BACKGROUND: Brain death is a difficult concept for the public to comprehend, resulting in a reliance on alternative resources for clarity. This study aims to understand the public's perception of brain death via analysis of information on the Internet, determine the accuracy of that information, and understand how its perception affects the physician-patient relationship. METHODS: We conducted a prospective cross-sectional study to evaluate information available to the public about brain death. The top 10 Google websites were analyzed for language complexity and accuracy in describing brain death. The top 10 YouTube videos were examined for content and the comments qualitatively analyzed for themes. RESULTS: Inaccuracies describing brain death inconsistent with national guidelines were prevalent amongst 4 of 10 Google websites, 6 of 10 YouTube videos, and 80% of YouTube comments. On average, Google websites were written at a 12th grade level and 90% mentioned organ donation. Videos were frequently emotional (78%); 33% included negative comments toward physicians, of which 50% mentioned organ donation. All videos included clarification comments questioning the differences between brain death, death, coma, and persistent vegetative states. CONCLUSIONS: The study revealed a significant amount of inaccurate information about brain death, affecting the public's understanding of the concept of brain death and resulting in negative emotions specifically toward physicians, and the link between brain death and organ donation. The medical community can improve understanding through consistent, simplified language, dissociating brain death from organ donation, and recognizing the emotions tied to discussions of brain death.

Is it my turn to speak? An analysis of the dialogue in the family-physician intensive care unit conference.

OBJECTIVE: Apply turn analysis to family conferences in the pediatric intensive care unit. METHODS: We analyzed 39 audio-recorded family conferences using the Roter Interaction Analysis System. A turn was defined as a continuous block of uninterrupted statements by a speaker. RESULTS: Opening turns by the healthcare team (HCT) averaged 207s, compared to 28s for families. Turn density (number of statements/turn) was 6 for the HCT versus 2 for families (p<0.0001). An average of 21 turns (26%) occurred between HCT members, resulting in substantial sections of dialogue excluding the family. Average HCT dialogue reflected a literacy demand of a 9th grade level, whereas family dialogue averaged a 5th grade level (p<0.0001). More HCT turns were related to higher reading level demand (r=0.34; p=0.03) and lower levels of patient-centeredness (r=-0.35, p=0.03). CONCLUSION: The healthcare team can improve the communication experience for families by encouraging and facilitating family engagement in conference dialogue. PRACTICE IMPLICATIONS: Changing how the healthcare team engages with families during communication events is vital to improving the experience for families. Our data suggests simple adjustments, such as limiting medical jargon and inter-team turns may lead to increased family participation and more family-centered care.

Speaking a Different Language: A Qualitative Analysis Comparing Language of Palliative Care and Pediatric Intensive Care Unit Physicians.

BACKGROUND: Family conferences in the pediatric intensive care unit (ICU) often include palliative care (PC) providers. We do not know how ICU communication differs when the PC team is present. AIM: To compare language used by PC team and ICU physicians during family conferences. DESIGN: A retrospective cohort review of ICU family conferences with and without the PC team. SETTING: Forty-four bed pediatric ICU in a tertiary medical center. PARTICIPANTS: Nine ICU physicians and 4 PC providers who participated in 18 audio-recorded family conferences. RESULTS: Of the 9 transcripts without the PC team, we identified 526 ICU physician statements, generating 10 thematic categories. The most common themes were giving medical information and discussing medical options. Themes unique to ICU physicians included statements of hopelessness, insensitivity, and "health-care provider challenges." Among the 9 transcripts with the PC team, there were 280 statements, generating 10 thematic categories. Most commonly, the PC team offered statements of support, giving medical information, and quality of life. Both teams promoted family engagement by soliciting questions; however, the PC team was more likely to use open-ended questions, offer support, and discuss quality of life. CONCLUSION: Pediatric ICU physicians spend more time giving medical information, whereas the PC team more commonly offers emotional support. The addition of the PC team to ICU family conferences may provide a balanced approach to communication.

Characteristics of Physician Empathetic Statements During Pediatric Intensive Care Conferences With Family Members: A Qualitative Study.

Importance: Pediatric intensive care unit care conferences often involve high-stakes decisions regarding critically ill children, resulting in strong family emotions. Families often report the need for physician empathy. Objective: To evaluate the characteristics of physician empathetic statements during pediatric intensive care unit care conferences. Design, Setting, and Participants: In this single-center, cross-sectional, qualitative phenomenology study, 68 transcripts of audio-recorded care conferences were analyzed from an urban, quaternary medical center from January 3, 2013, to January 5, 2017. Thirty physicians and 179 family members of 68 children participated in care conferences. Data analysis was conducted from June 5, 2017, to October 12, 2017. Main Outcomes and Measures: A qualitative thematic analysis was conducted to code physician empathetic statements and family's responses to these statements. Empathetic statements were classified using the previously published NURSE pneumonic (naming, understanding, respecting, supporting, exploring) and coded as unburied (statement followed by a pause allowing the family time to respond) or buried (empathetic statement encased in medical talk or terminated with a closed-ended statement). Family responses were categorized into 3 themes: alliance (emotion continued), cognitive (medical talk), or none. Missed opportunities for physicians to respond with empathy were identified. Results: Thirty physicians participated, of whom 13 (43%) were male, 24 (80%) were white, 24 (80%) had more than 5 years of practice, 10 (33%) specialized in critical care, and 7 (23%) specialized in hematology/oncology. Within 68 care conferences, physicians recognized families' emotional cues 74% of the time, making 364 empathetic statements. Of these statements, 224 (61.5%) were unburied and 140 (38.5%) were buried. Buried statements were most commonly followed by medical talk (133 [95.0%]). Unburied empathetic statements were associated with alliance responses from the family 71.4% of the time compared with 12.1% of the time when the statement was buried (odds ratio, 18; 95% CI, 10.1-32.4; P < .001). Physicians missed an opportunity to address emotion 26% of the time, with at least 1 missed opportunity occurring in 53 conferences (78%). Physicians attended to all family emotions in only 5 conferences (7%). Conclusions and Relevance: In this analysis, physicians responded with empathy frequently, but responses were buried within other pieces of medical data or missed entirely in nearly one-third of conferences. When physicians responded using unburied empathetic statements and allowed time for family members to respond, they were more likely to learn important information about the family's fears, values, and motivations.

Parent Satisfaction With Communication Is Associated With Physician's Patient-Centered Communication Patterns During Family Conferences.

OBJECTIVES: To evaluate the association between physician's patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU. DESIGN: Single-site, cross-sectional study. SETTING: Forty-four-bed PICUs in a free-standing children's hospital. PARTICIPANTS: Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians. MEASUREMENTS AND MAIN RESULTS: Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System-based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family's goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (SD, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (ß = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (ß = -4.34; p = 0.0003), controlling for previously mentioned factors in the model. CONCLUSIONS: Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child's severity of illness.