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Teamwork: Achieving True Collaboration in the Care of Pediatric VAD Patients


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Monica Horn, RN, CCRN, CCTC
Children's Hospital Los Angeles
Los Angeles, CA, USA
mhorn@chla.usc.edu



Currently, collaboration is a word frequently used in the healthcare environment. However, verbal repetition does not guarantee the genuine accomplishment of this valuable concept. This thoughtful insight became reality when our multidisciplinary team began to manage an increased number of young ventricular assist device patients awaiting heart transplantation. Even though we each possessed the knowledge to execute our individual professional responsibilities, realizing the exceptional outcomes achieved through genuine teamwork confirmed the need for all of us to ensure that we are able to develop this talent.

Children suffering from advanced decompensated heart failure often present a miserable image. Infants may be inconsolable, crying, irritable, intolerant of feeding, and experiencing physical discomfort from poor perfusion to the vital organs. Toddlers through adolescents show similar, but more age-typical responses to the ravages of a poorly functioning heart. Young children are unable to understand why they are so ill and may have frequent outbursts of frustration. This, along with life threatening symptoms of hypotension or dysrhythmias, leaves parents exhausted and grief stricken. Adolescents with extreme exercise intolerance may become depressed and are emotionally ill-prepared to deal with extended illness in an unfamiliar environment, away from friends and family. Staff caring for these patients and their families have been known to benefit from assignment rotation simply to prevent compassion fatigue.

Before the only currently FDA -approved ventricular assist device for small children, the Berlin Heart EXCOR, was available, ECMO could be offered when conventional medical therapy was exhausted. ECMO's inherent issues of course-limiting complications, including immobility, certainly made the pediatric VAD a more viable option. Families and healthcare teams were relieved to see a child who had previously been so ill and visibly suffering from heart failure, now be awake, speaking, playing, and even achieving developmental milestones. What a relief!

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Then, the wait for a heart continues. It is well known that the number of pediatric donors is far less than for adults. The wait for an appropriate donor can extend many months. During this time, because the device is not approved yet for home use, the healthcare team must meet the challenges of maintaining stability and prevention of complications, all while promoting growth and development, and addressing any medical challenges unique to childhood. Among the typical care plan objectives are wound care and nutrition to promote healing and stability of cannula sites, management of anticoagulation to prevent embolic or hemorrhagic complications, and support for behavioral issues resulting from interruption of family systems. For an ill child, there may be additional tasks to recognize, such as food intolerance, pediatric medication metabolism and interactions, as well as family and culturally centered therapeutic needs.

Many talented professionals exist in the busy transplant and critical care arena. However, getting them to stop long enough to confer with yet another group isn't always realistic. A mix of personalities, varying levels of experience and distinct individualities all complicate total agreement in the workplace. Then, one day, a routine email "call for abstracts" stimulated an idea: would a multidisciplinary team effort to produce an abstract about our collaborative work stimulate harmony?

Inspired by an enthusiastic request by a less experienced colleague to learn how to submit an abstract proposal, our process began with choosing the topic of simply working together to support this complex patient population, followed by assignments of key team members to search the literature for current evidence based practice related to our topic. The organizer set deadlines by which certain steps of the process needed to be completed and sent regular reminders to request summaries of findings, approvals of rough draft abstracts, and input for poster endorsement. It progressed with each co-author turning in their literature reviews, clinical experts discussing their interpretation of the reviews, obtaining agreement for a united effort towards common goals, defining roles, maintaining strong team presence and open communication. Team acceptance seemed inevitable.

When two posters describing our efforts were accepted for presentation by two national/international nursing conferences, the organizer selected co-authors to attend and present each of the sessions. Team effort seems routine now. Transplant/VAD surgeons and cardiologists, unit physicians, transplant/VAD RN coordinators, CTICU nurses, step-down unit nurses, unit nursing managers, pharmacists, child life therapists physical therapists, a social worker and a dietician all speak daily regarding each case with the transplant/VAD coordinators as the team communication liaisons. Team members have all familiarized themselves with this practice and with their other colleagues. We are in the process of pursuing further study of clinical measures of our results.

We are all inspired by the strength and courage of our pediatric VAD patients and families as they navigate the throes of advanced heart failure and mechanical circulatory support. We are impressed by their willingness to work with us during this sort of resource intensive process. Thanks Team! ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Castleberry C, White-Williams C, Naftel D, et al. Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients. Pediatr Transplantation 2014:18;280-287.
  2. Almond C, Morales D, Blackstone E, et al. Berlin Heart EXCOR Pediatric Ventricular Assist Device for Bridge to Heart Transplantation in US Children. Circulation. 2013;127:1702-1711.
  3. Holbrook A, Pereira J, Labiris R, et al. Systematic Overview of Warfarin and Its Drug and Food Interactions. Arch Intern Med. 2005;165:1095-1106.
  4. Schultz G, Sibbald R, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Rep Reg 2003;11:1-28.
  5. Harris M, Spiro K, Heywood M, et al. NICH: Innovative Treatment for Youth with Complex Medical Conditions. Clinical Practice in Pediatric Psychology 2013;Vol. 1, No.2, 137-145.
  6. Rose L, L Bloomberg. Interprofessional collaboration in the ICU: how to define? BACN Nursing in Critical Care 2011; Vol 16 No 1, 5-10.




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