Coping in the CICU

Coping in the CICU

Nicole Snyder: Hi, I'm Nicole Snyder. I am a heart parent to a little girl named Olivia, and I'm also a member of the Family Advisory Council for CHOP's Cardiac Center. Today I'm going to be interviewing Maryam Naim.

Maryam Naim, MD, MSCE: Hi, I'm Maryam Naeem. I'm one of the cardiac intensivists at the Children's Hospital of Philadelphia.

I'm also an Associate Professor of Anesthesiology, Critical Care Medicine and Pediatrics at the University of Pennsylvania, also a member of the Family Advisory Council.

Nicole Snyder: Thanks for joining me, Maryam. So one question I have, what motivates you on a daily basis in the ICU?

Maryam Naim, MD, MSCE: I would say that the, our primary motivator, at least mine, is our patients.

Those little babies and big kids and even sometimes adults are just absolutely incredible. Being able to take care of them and seeing them, from sometimes prior to surgery, through their surgery, having multiple touch points with them, sometimes through their lives is a big motivator. So I would say, first and foremost, our patients, they're just incredible, resilient, the families are incredible, and I'm very inspired and always feel privileged to be the person taking care of them after surgery or even before surgery when they're critically ill. The other driver, I would say, is our team. You know, what we do, we don't do alone. And we just have a phenomenal team that starts from our cardiologists that take care of kids or, you know, expectant mothers from fetal life to, our neonatologists that work and stabilize the babies in the special delivery unit, the ICU nurses, our respiratory therapists, our trainees. It's just an incredible, incredible team. I love working because I get to work in a highly skilled team and work is very inspiring because of that and I learn a new thing every day.

Every day one of our fellows or nurse practitioners teaches me something and I just feel very privileged to do what I do, I have to say.

Nicole Snyder: Great. Thank you. Now, in the early stages of post surgery, what do you find to be the most challenging once the child or young adult comes out of surgery? What are those aspects?

Maryam Naim, MD, MSCE: There's one aspect that is very, very important, which is you have to know what's going on with a patient, and details are really, really important. By gaining knowledge, even prior to a patient coming to the ICU, you can really anticipate what the problems are going to be and prevent them.

So, knowing what happened to the child before surgery. What was going on before surgery in the ICU or what were they struggling with at home? Really impacts how we take care of kids after surgery. Knowing the details of what happened in the operating room Was there any heart rhythm problem that resolved but may happen in the ICU?

Did the child bleed a lot in the OR and then it stopped? But is that something I may have to anticipate in the ICU? Those are some of the things that are very important and also really having details, like what did their echocardiogram look like after surgery in the OR and knowing really honing down on the details of that really helps me to anticipate what the problems are going to be after surgery.

So very specifically, we worry about, in any patient that's had heart surgery, bleeding is like our main concern, and we worry about rhythm issues. There's a syndrome that happens after baby or neonatal surgery called low cardiac output syndrome, that's been very well described, which we don't see as much in the current era with medications that we use currently and kind of anticipating that it may happen. Again, just knowing the details of what happened before the OR and in the OR and really being very vigilant at the bedside is how we kind of anticipate postoperative issues. And the main things, as I said, is bleeding, rhythm disturbances, low cardiac output syndrome. If a kid's struggling for whatever reason, just making sure that, you know, we change the way we think about a child and kind of go back and look at their repair again in terms of getting another echo or a chest x ray or something else. It's a tough job because you have to have the pattern recognition.

So you have to know how, you know, for example, if a child has had an arterial switch operation or a BTT shunt. You have to know how 50 of these kids do post operatively in order to see that one kid that deviates from the pattern. So really anticipating problems from really learning typical patterns after surgery is how we take care of patients.

Nicole Snyder: Great. And as a parent who has had a child undergo a couple heart surgeries, I really see the aspect of the team being involved in that post operative care. So do you as the intensivist oversee that? How do you communicate with the rest of the team what to look out for?

Maryam Naim, MD, MSCE: First of all, even before a child comes in, we have a conference where we review patients.

It's our surgical conference, and then we have another conference the week prior to the child's surgery, where again, we review issues on that patient. After a child comes back from the OR, there's a multidisciplinary team at the bedside. We get handoff from the OR team, and during that handoff, it's great to watch because it's the person who's speaking, is speaking and there's no other conversations around and say if you're in a busy pod where they're like three other children, there's silence in that room so that everyone can hear what happened in the OR and then our respiratory therapists are there. The bedside nurses are there. We have our frontline clinicians, which include our fellows and APPs.

The ICU attending is there, the surgeon is there, and our other trainees are there. And during that time, there's a great sign out process. And after that is done, then we assess the patient and then we go through what we're going to anticipate after surgery. And very often the surgeon is going to tell you.

I'm a little worried about X, Y, and Z, and that kind of clues you into what's going to be the priority of things, but at the same time, you want to be looking out for everything. And, and we go through, for example, after Tetralogy of Fallot repair we worry about bleeding foremost, but then we talk a lot about arrhythmias, right heart dysfunction. There are things that are very typical to each repair that we try to anticipate and discuss. The other great thing at CHOP is that we're really big into clinical pathways and so for many of our post operative patients, there's a kind of a routine way of managing them post operatively that's actually published on the intranet, and so sometimes we can even bring those pathways up.

Well, I would say the best way to describe it is they have a pathway of care. So, you know, when a patient comes back, this is what we're going to do in terms of how often we're going to get labs. This is what we're going to do in terms of if something is abnormal, how you should kind of react to it.

These are the medications that the patient should be on every patient doesn't fall on the pathway, but it's at least a guidance, so we can standardize care and know what to anticipate post operatively for them as well. So that's another great thing that we have at CHOP and those pathways also help our team, especially if there's someone who's relatively new to CHOP or has just joined the team, you can always refer them to, oh, there's a Tetralogy of Fallot pathway, why don't you take a peek at that? You know, these are some of the things we talked about right now, but there's a pathway for that as well. So that's sometimes great as well so that, you know, we can standardize the care we provide with all the different providers.

Nicole Snyder: That's great. So as we talk about this multidisciplinary team one group comes to mind that I'm curious how you might involve them and that is the parents.

Maryam Naim, MD, MSCE: Yeah.

Nicole Snyder: And so, you know, what advice do you have to parents on how they can be involved in these early postoperative meetings at the bedside during rounding to help optimize that outcome for the child?

Maryam Naim, MD, MSCE: Parents are a very integral part of the post op recovery and care of the child. There is no amount of sedation or pain medication that I can give a child that is as effective as a parent at the bedside comforting their child. So they are a huge part of the care and nobody knows their child or nobody knows a patient better than a parent, a mother or father.

They can tell you what's worked in the past, what hasn't worked in the past, what comforts their child, what the medical issues have been with a child previously. We can read a medical record or we can read, you know, or we can attend conferences, but there's nothing kind of replaces the history you get from a family and then really having them involved at the bedside is integral, especially during the post operative course, because again, they're going to help us guide what medications was the child on prior to surgery? What's worked in terms of pain medication in the past? What didn't work? Some kids are very sensitive to noise, for example, or some kids like to be in a dark space, or some kids have comforted by playing video games, even, you know, a couple of hours after surgery.

And parents really help us with that aspect of it. So it's not only the medical kind of history or what that child has been through, but it's also, you know, really helping the child recover and give us that really important knowledge that we wouldn't know, that we couldn't do what we do without families.

And when I was training. We actually didn't have the families round with us and rounding at CHOP especially in a cardiac ICU, we sometimes don't round, we don't round without the bedside nurse and we sometimes don't round without the parent if they're there in the hospital and they want to participate in rounds, like we don't round without them.

It's important to involve them. It's very, for a new parent, it's very important for health literacy actually to have them involved because they're going to be doing a lot of the things as they kind of work their child towards getting home. They're going to be, you know, involved in like, sometimes placing nasogastric tubes or giving them medication.

So I think that those, those aspects are very, very important as well. So having a parent involved is important. And the last year, and especially during COVID, it was harder for parents to be at the bedside. Parents were working from home. They had to be with their other kids at home. So we try to implement a routine way of having families participate through iPad rounding, even over the phone sometimes.

And that's that's been, there's some parents who have valued it so much. And one mom actually told me recently after her child had left the ICU that she's like. I still wake up at seven and I'm like, oh, I have to call the ICU. And so she, you know, I have to figure out what time they're going to round on my baby and she missed that, you know, because she was so used to calling from either work or from home when she was working from home.

So yeah, it's something that we, you know, we always try to involve families as much as we can.

Nicole Snyder: That's a program I love that you guys have started. With the iPads and ...

Maryam Naim, MD, MSCE: We're trying.

Nicole Snyder: Making sure that families are able to be bedside, even if they're, they need to be at work or with their children.

Maryam Naim, MD, MSCE: Yeah.

Nicole Snyder: So another aspect of being an ICU intensivist is transitioning the child from the ICU to the CCU. What do you look for in your patients to really see that they're ready for transition? And, you know how might that change their plan.

Maryam Naim, MD, MSCE: Yeah, I think that you really start thinking about transitioning a child to the step down unit when they're off vasoactive medications or medications to support their heart, when they're coming off respiratory support or breathing support.

Those are the times that we really think that the child is getting ready to leave the ICU. And sometimes we have kids on sedation medications as well that are going through infusion. So we want to get children off that. And I try and encourage our trainees to do this when we're rounding as well, is that every day, state why the child is still in the ICU and what's left.

You know, what are the ICU therapies that we're providing for parents to hear that sometimes? That's kind of a segue for me saying, Hey, I think you're about one or two days away from going out to the step down unit. So that kind of prepares families for leaving. I would say that once they're off these medications and once they no longer require ICU level care, it's time to transition them to the CCU.

But I think that it can be really hard for families, especially if they've been there or been in the ICU for a long period of time. There's definitely anxiety from leaving the ICU. We've got a different level of nursing, the different care providers in each unit and so just anticipating or letting families know in advance versus on the day of transfer that, hey, time to go out and just kind of talking about it maybe every, you know, sometimes every day, or, you know at least letting them know 24 to 48 hours in advance. It's a time where you know, errors can occur, especially in medications. So there are sometimes medications that the child was on before they came to the hospital that we don't always restart in the ICU, but it may be a medication the child needs eventually, or we start a medication the ICU short term that our intention was to discontinue it. For example, we try not to send children home on sedatives, but at least in the adult world, sometimes adults get started on medications, for example, delirium, in the ICU, which is not uncommon, but then they sometimes get discharged home on them. So that's just an example of medication errors or not a good handoff for how long a medication needs to be on. You know, somebody gets discharged home on a medication where that was never the intention. So having a very thorough sign out between the ICU team and our CCU or our step down team is really, really important.

And what we do at our institution is that we have the attending sign out to one another, and then our fellows or nurse practitioners, physician assistants sign out to one another, so, and our nurses sign out to one another. So there's multiple levels of sign out, you know, either over the phone or face to face for our single ventricle stage 1 babies, it's a face to face sign out and what's called a stage 1 huddle prior to them going out to the step down unit and the value of that is, is that, we all develop a shared mental model about the patient. It's not just, you know, this baby had XYZ surgery and is doing great. It's more like this is what happened in the OR.

This is what we've been a little worried about. This is what their echocardiogram shows now. This is what we're still monitoring or we anticipate that we still need to monitor the child for, and this is how far they are from discharge. And you know, that discharge process, or at least the thinking of discharge should actually start in the ICU as well, especially if a new medication has started that may be a discharge medication.

We start, you know, that process, at least in the ICU, seeing if getting our case managers to, preapprove medications for some medications is helpful. So I would say that, you know, the transition process is a time where it's a vulnerable time for families. There can be medication errors and it's very important to have a very thorough and good handoff so that we all have a similar or shared mental model on the trajectory of a patient, because the worst thing that we could do is give incomplete sign out and the plan completely changes when the child leaves the ICU. And it may change because their clinical situation may be different, but you want to have a good kind of continuity of care.

Nicole Snyder: And then lastly, I wanted to ask you, you see families right after they've just had a child, newborn baby might have been born in the SDU, are coming in from another hospital, all the way up through young adults. Along that spectrum, what advice do you have to parents that are coming in for surgeries?

What are some of the maybe top one or two things that you might want to share with them because it is a, as a parent who has gone through this a couple of times, that it is, you know, a very nerve wracking time. It can be, there can be a lot of anxieties. What advice do you have.

Maryam Naim, MD, MSCE: First and foremost, don't be intimidated by us. You have given us the privilege of taking care of your child. Even though we're doctors and nurses and health care providers, we feel a tremendous privilege of taking care of your child and we want to partner with you and work with you to get your child better. So, educate yourself. You know, no one knows your child as well as you do. And I would say that for families, who are really having a lot of anxiety during, for example, fetal life, or even when the baby's just been born, ask questions. No question is simple or stupid, or I just want everyone to feel very safe, in asking questions and advocating for their child.

And, you know, I may think everything's okay with a baby, but a very experienced nurse or a parent tells me, something's not quite right. My bells and whistles go. Like, I am worried.

Nicole Snyder: Yeah.

Maryam Naim, MD, MSCE: So, I really would say that tell us what works. Tell us what's worked in the past. Don't feel intimidated. We're really here.

You know, we're here to get your baby home with you. You know, we just value your input so much.

Nicole Snyder: Great. Yeah. Really appreciate that. Thank you so much, Maryam.

Maryam Naim, MD, MSCE: Thank you.