Patient Safety and Quality During the Pandemic: Women Leaders in Critical Care, Ep. 3

This podcast series aims to highlight the women leaders in critical care medicine. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.

Episode 3: Moderator Jaspal Singh, MD, MHA, MHS, interviews Maya Dewan, MD, MPH, and Anita Reddy, MD, MBA, about their experiences with patient safety and quality during the pandemic, as well as how the pandemic has impacted their patient safety and quality efforts. 

Additional Resources:

• Choosing Wisely Campaign. ABIM Foundation. https://www.choosingwisely.org/
• Pediatric Overflow Planning Contingency Response Network (POPCoRN). Updated January 17, 2021. https://www.popcornetwork.org/ 

Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.

Maya Dewan, MD, MPH, is an attending physician in the Division of Critical Care Medicine at Cincinnati Children's Hospital Medical Center.

Anita Reddy, MD, MBA, is an assistant professor in the Department of Critical Care Medicine, Respiratory Institute, and cochair of the Laboratory Stewardship Committee at the Cleveland Clinic in Cleveland, Ohio.

TRANSCRIPT:

Jaspal Singh: Welcome, everybody. Welcome to episode 3 of our podcast series of Women Leaders in Critical Care. Today I have Dr Anita Reddy from Cleveland Clinic and Dr Maya Dewan from the University of Cincinnati. Welcome, ladies.

Anita Reddy: Thanks, Jaspal. Thanks for having us on. My name is Anita Reddy, and I'm a pulmonary and critical care physician. I've been at the Cleveland Clinic for a bit over 13 years. I have had roles in quality over my career and was a quality officer for our medical ICU for a bit over a decade. I also led the sepsis committee here at Cleveland Clinic for about 5 years. I also was fortunate enough to be able to complete a quality and patient safety fellowship here at the clinic. So, needless to say, quality and patient safety is definitely one of my interests and passions.

Jaspal Singh: Awesome. Maya, yourself?

Maya Dewan: I'm an assistant professor of critical care and biomedical informatics at Cincinnati Children's. I've been here for a little bit over 4 years. I serve as both the head of diagnostic stewardship for the institution, as well as I do funded research through AHRQ on improvement in in-hospital cardiac arrest outcomes.

Jaspal Singh: That’s fantastic. Is there anything particularly, personally that’s driving you to this area of work? That's something that I think a lot of people don't think of as natural careers is in areas of quality and patient safety. At least when I trained back in the day, it wasn't a commonly accepted a pathway for people. It wasn’t recognized commonly. What drove you to this space, Anita?

Anita Reddy: Yeah, so it's quite interesting, actually. When I first came to the clinic, our unit was going through quite a number of changes. We were expanding. We had a new ICU director, and I had arrived at the clinic at the same time as the ICU director. I came from an institution that had a lot of protocols set up.

I was surprised to find there wasn't much already set up in terms of protocols or order sets. So, I was asked by the new director if I wanted to lead some of those initiatives. Of course, being so early in my career, you just say, “Yes, may I have more?” So, I did that. What I found over time is that a lot of the quality and patient safety initiatives and principles really lined up well with my obsessive-compulsive personality.

I really felt a passionate about improving our patients’ care and making sure that that also improved their outcomes. And just a little bit on the personal side, I think it was within about 3 years of me joining the clinic, a distant cousin who also lived in the area ended up being admitted. I guess, long story short, he ended up being in the hospital for over 2 months. He had an undiagnosed brain mass. He had undergone surgery, he was moved to the rehab portion of the hospital, and his family had shared several concerns with the staff there—nursing, RT, etc.

Unfortunately, he ended up having a cardiac arrest and passed away. I think one of the things that drove me from that story is that we have to listen to our patients and their families. We have to identify ways that we can make their experience and their care front of mind, that we're not pushing off concerns. So, I think when they show concerns, it can definitely impact the safety of our patients.

Jaspal Singh: Wow. I'm so sorry about your loss, first of all, and my condolences to you and your family. I mean, it’s a horrible journey to undergo—the horrible tragedy of it. And it sounds like your interests, your needs, and the drive to do this fit well with you and evolved to a very productive career at the Cleveland Clinic. So, thank you for sharing that.

Maya, I'd love to hear your story as well.

Maya Dewan: I came to the safety and quality side as a critical care fellow, I had done a master's in public health with medical school and had seen myself working on more of a system side than on the outpatient, and then went through my pediatric residency and fell in love with critical care.

As a fellow, I struggled to figure out how you bring those 2 things together, and that love of systems learning and driving of improvement from a big-picture standpoint fit nicely with the quality and safety realm.

For us in the pediatric ICU, children and families are at their most vulnerable when they are hospitalized, and we often will have bad outcomes, even if everything is done right. For me it was really about making sure that I was providing a high-quality and safe experience, so that way, I was sure for myself, for my team, and for patients and families that we had truly done everything we could for them. And that really has driven my work, moving forward, both on more of the operations quality and safety side, as well as the research.

Jaspal Singh: That’s a very interesting background. I'm going to piggyback on that a little bit. I'm an adult ICU doctor, as a lot of listeners will be. Pediatrics seems a little bit different and seems like a lot of the needs are similar. What are you seeing in that space that's different or similar?

Maya Dewan: Well, first, I think we, in general, as critical care doctors focus on our differences the most. Whether it's a cardiac ICU, med surge ICU, pediatric NICU, etc. We focus on our differences, and I think we have a lot more similarities than we give ourselves credit for.

I think the key difference in pediatrics is (1) the developmental shift of our patients and being able to prepare to provide a safe space, whether you're 2 kilos or 150 kilos; (2) Being sure that we're incorporating the understanding of the vision of the families, especially for our chronic critically ill patients who come in and out of the ICU very much, whose parents practically run an ICU in they're living room at home; (3) making sure we're incorporating their knowledge and engagement for their child and often for their child's rare disease into how we’re caring for them, and (4) then just the confusion around the fact that children change over time.

They grow, so their vital signs change. There's a wide range of what's a normal vital sign based upon age and size. Dosing and making sure dosing is safe over a large range of weights and then being sure that we are training and preparing for whether it's a resuscitation or placing a line or whatever for, again, this broad range of both clinical issues as well as size and developmental milestones.

While I can get away with doing some local in a central line in the 18-year-old, that is never going to work in an 18-month-old. I mean, you usually can't even get them to let you listen to them with a stethoscope. So, it is it is figuring out how to practice across that spectrum. And that's what we love about it, but it does bring some unique challenges as well.

Jaspal Singh: That's true. That's well stated. Anita, I want to talk about something that you and I have talked about before, something you are involved with at the clinic and society group for critical medicine, which is the Choosing Wisely campaign. I wonder if you could talk a little bit about that with our audience.

Anita Reddy: Absolutely. The Choosing Wisely campaign was something that was set up by the American Board of Internal Medicine (ABIM), the ABIM Foundation in 2012.

It all started, actually, in 2010 when Howard Brody wrote an article in New England Journal of Medicine when he challenged the United States medical specialty societies to identify 5 tests or treatments that are overused and don't provide any meaningful benefit to patient care.

So, the ABIM foundation set up the Choosing Wisely campaign to promote conversations between clinicians and their patients, and encourage them to choose care that supported by the literature—the evidence—and was not duplicative, it wasn't harming them, and pick tests and procedures that are truly necessary.

So then, the campaign suggested that these societies identify certain tests or procedures where the necessity should be questioned and discussed. As a result of this effort, they've been able to involve over 80 national societies, and those societies have provided over 550 recommendations on tests and procedures that are potentially unnecessary. They've also made a lot of effort in creating webinars, newsletters, and even patient-facing material. It's a very successful, broad campaign.

Jaspal Singh: It's very helpful. Great oversight. A lot of experience across a whole range of patient safety, quality, and—Maya, my apologies, we haven’t even talked about all your informatics stuff and all the interesting stuff in health information technology in the space.

I'm sure we could talk forever, but to keep the podcast within a reasonable time frame, I'm hoping the 2 of you can leave our audiences—now up to this point, we've been talking about pre-pandemic. What are some key lessons you've learned in your body of work, if you don't mind sharing with us?

Maya Dewan: I think the key things that I've learned is that we as a group of critical care doctors are actually pretty far along the systems improvement path. It's engrossed in our journals. We talked about it in meetings, and it's something that we've embraced as a group. I think we've now moved to the next level, in which we need to make it easy for people to do the right thing.

I would say we need to switch from just making a list of what you need to do and say, “How does this fit into your workflow? How do I improve the usability, the human factors to make the right thing the natural thing? Where do you have to reach in a room to get the supplies that you need to do the safe scrub of your central line to reduce your CLABSIs? How do we then take it there and make things simpler for people?” I think that's one.

I think the second is creating a shared vision or a true north for your group, because, again, we have done so much in this realm that it often feels like [sigh] another quality improvement project. [Sigh] another thing, somebody's asking me to document or 2. What is our true north?

The PICUE is something that we've developed in our institution called the PICU Chain of Survival, modeled after the AHA in which we talk about predicting bad events through recovery and rehab for our patients. Every quality improvement project is put into a bucket to say, this is where this fits; this fits in the “training” aspect of our patient’s journey to try to bring it back to the bedside.

And then collaborate. Like I said earlier, we're much more similar than we are different. And if COVID-19 has taught us anything, it is that we need to be fluid in how we share and what we do. So, spending the time to really learn from your colleagues, whether it's within your unit or within your institution or within larger collaboratives, I think it’s going to be the key for us going forward.

Jaspal Singh: Awesome. So, I heard you say (1) make things easy, (2) share the vision, like a true north, and (3) then collaborate across the disciplines, across the field, across institutions. That's excellent.

Anita, what are your key lessons?

Anita Reddy: Yeah, so I think one of the things that I've learned at the clinic is that when you're involved in local initiatives, making sure that the individuals who are involved understand the “why” behind the initiative.

Oftentimes we’ll say, “We need to do this, and we mandate it,” but we don't always share the reasoning. How is going to benefit our patients? Some tricks or tips that I would offer up to the group is when you're trying to engage a multidisciplinary, multiprofessional group, we found that nurses tend to respond better to individual patient stories and that physicians and other providers tend to respond more to data—so more hard evidence on why we should be doing certain quality and patient initiatives.

I think a corollary to this is that you should always approach these initiatives in a way that is all inclusive. Everyone who might have a role in that particular initiative should be involved in some way to get their perspectives.

Tangential to that, making sure that you're getting the bedside perspective, if you're focusing on a patient safety, patient quality issue. I would say go to the bedside, experience what your patients are going to experience, and what your caregivers are going through. Sometimes quality and patient safety initiatives are led by administrators who may not fully understand the processes at the bedside or are connected to those things.

The last thing that we've actually found is that you can also greatly affect quality and patient safety when you engage the patient themselves, when they're able, and their families. I'll provide you an example. I'll hear from patients who are able to interact with me if I tell them we're going to be removing a folio, a central line. There is some hesitancy that they don't feel well enough to get up and go to a bedside commode, or they don't want to get stuck for labs. They'd rather keep those lines and drains in.

Helping them understand that these are sources of infection, and we don't truly need them anymore, I think helps them get on the same page as us, that we can lessen the chances of them getting infection from these lines and drains.

Jaspal Singh: That's great. I heard you say, piggybacking on what Maya was saying earlier, was “know the why” and then provide an individualistic data or storytelling or whatever the audience needs to really drive that behavior or drive that change.

Experience the clinical aspect and having everyone on the team understand the clinical relevance of what decisions are being made and the reasoning for that. Then, engaging patients and families and communities, essentially, to help enlist them in the effort. I think as physicians, we’re oftentimes too physician-centric and we don't really expand our scope—is what you're getting at. I think that's very well said both of you. So, thank you.

So, this is awesome work as a whole, like body of work that just an incredibly exciting, incredibly rewarding. And then along comes COVID-19. And if you're like my institution—or other institutions—all of a sudden, a lot of work that we were working in the space suddenly gets paused or gets distracted or suddenly changes.

Tell us how the pandemic has affected your work in the space in a succinct manner. I’m asking a lot, I know it's a huge question, but if you don't mind sharing a little bit of your experience as it relates to quality and patient safety related COVID-19. How has the pandemic affected that body of work?

Anita Reddy: I think some of the things I've noticed more is that with COVID-19, we've been having trouble with, mentally, their mechanics and that patients seem to have a neurologic component to their disease. So, these patients are more sedated.

We are aiming for a degree of vent synchrony that maybe unrealistic, and so I frequently see patients who are on a large amount of sedation or are paralyzed. This then leads to a higher rate of delirium; they're on a ventilator longer. When you think about COVID-19 in general and practices that have been set up in health systems and hospitals, is that we're not allowing families to come visit if the patients are COVID-positive. This reduced family interaction.

Caregivers staying in the room and interacting with the patient is much less to reduce exposure. I think we also aren't doing as much mobility as we could be in these patients. A lot of these translate over to the non-ICU areas as well. I think a lot of these go hand-in-hand and one leads to another.

Jaspal Singh: That sounds great. What you're getting at is the ICU liberation. That’s actually going to be our next podcast, believe it or not—the idea of these respiratory illnesses, the sedation, agitation, delirium, analgesia, all those aspects, and immobilization. And of course, the last thing you mentioned, very importantly, which is that family engagement completely changed the direction of this work and made some major disruptions.

Maya, what are your thoughts?

Maya Dewan: I think on the pediatrics ICU side, we have met some very unique clinical challenges. So, the first being the care of adult patients. Many pediatric ICUs, ours included, have expanded our criteria for patients that we care for.

Shifting and understanding how to care for adult patients, obviously, pushes our staff and pushes our resources. Harnessing things like the POPCoRN network that's out there, which has been sharing protocols and utilizing our adult colleagues, has been huge for us.

I think other clinical challenges for us have been just new presentations—the presentation of MIS-C and how we manage it and how we treat it. It's literally looking at a new diagnosis that we're seeing in pediatric patients that we haven't seen before.

It has forced us to do more with less. So, like everybody else, we have been trying to limit our exposure to our staff, share PPE, and other resources with our adult colleagues, and try to do these new and unique things at a time with less. I think that has been our biggest struggle and that it just impacts everything else is that when that's your focus there isn't the opportunity to drive new or innovative approaches or changes to care and so feel a little stuck in moving the science and the work forward.

Jaspal Singh: You bring up a very good point. And I'm curious as to a little side that your comments made me think a little bit about is, I feel like COVID-19 has exposed all our weaknesses. The weaknesses we started with are things like the interconnectivity, the idea of making things easy—all the operations and work we put into that. I feel like that needed to be in place before that pandemic happened. Do you all feel that? Or what are your thoughts on that?

Maya Dewan: I definitely agree. I think one of the things that we're a little bit more spoiled in in pediatrics is because we care for so many rare diseases. We are very interconnected with our other pediatric colleagues across the country through various collaboratives and other such things that enabled us, for example, for MIS-C to quickly share learnings and spread them amongst the different pediatric ICUs pretty quickly.

I do think some of those infrastructures that we had in place to address other rare pediatric conditions enabled us to be more successful. But yes, I completely agree. Any weakness that you had before the stress of the system has definitely made more noticeable.

Jaspal Singh: Anita, what are your thoughts?

Anita Reddy: Yeah, absolutely. I certainly echo what Maya just said about our weaknesses being displayed pretty broadly right now. I think we have forgotten to do some of the things that we usually do in critically ill patients.

You had mentioned the ICU liberation bundle, and I would just highlight that, one example is “Why did we move away from what's been proven care for our critically ill patients?” We shouldn't forget that. We can build on top of that when we see something new, but I think that's one of the core elements that we should be undertaking when we care for these patients.

Jaspal Singh: That's great. Alright, well, that's awesome. That's a lot of information that you guys have shared with us. Any advice now that we're seeing a massive resurgence of cases in pretty much the entire country and abroad as well, with the variants and such? And now, very high acuity and high number of cases and overload. Any advice you'd give to your colleagues, like 1 or 2 things you would mention that you think, “You know what? We should consider this, this time around.”

Anita Reddy: Yeah, so I'll echo again what I had mentioned before, let's get back to the basics, but follow our ARDS management, ICU liberation bundle, getting back to some of these quality elements of, “Do we really need those lines and Foleys? Do we really need all of these labs?”

And scrutinize the literature bit more, I think. There's a lot of data that's out there on COVID-19. Some of the literature is not as high quality. So, take a deep breath. Don't always jump to the most innovative thing on the horizon. Maybe give it some time to vet out before automatically implementing treatments.

Jaspal Singh: Oh yeah, totally. I could think about all the things I wanted to do early on and reading all this stuff. I'm glad we didn't jump on all of it, but we'll see.

Maya, what are your thoughts?

Maya Dewan: I would say ask for help. I think we're now in the marathon part. This is no longer a sprint, whether it's you're at the bedside with a patient and you need more hands, ask for more hands. If you're having trouble with your academic side of your career, your professional life, balancing things at home, be prepared to ask for help and model that for everyone around you.

We all are not going to be able to accomplish everything that we were doing before, and that's okay. So, normalizing that, especially, if you work with trainees or learners to make sure that they see both your struggle and your willingness to ask for help.

Jaspal Singh: That's fantastic advice. That's a great segue to our final question. This podcast series is based on critical care women leaders, and I started this partly because watching my wife go through this last struggle with academics and clinical work.

So, I’m curious from your perspective, from critical care, what are some of personal challenges in this pandemic that you and others are facing, both professionally and at home, especially related to your roles and your home life?

Maya Dewan: I think I feel what lots of people feel. I don't think this is a woman-specific question; I think this is all of us. The bucket is empty, and it's impossible to refill.

We have 5 children. So, between the 5 kids at home, the funded research, and the clinical work, the bucket is empty. The things that I love to do—I love travel. I love theatre. I love arts. I love going out to eat—none of those things are currently available to refill the bucket. So, finding other ways to bring joy, I think, is what we've been trying to do. I am very open and willing to ask for help.

Like I said, I don't necessarily feel like that's necessarily unique to women, but we often will bear the brunt of the changes, the caregiving, and then the emotional support. My door is often knocked on by others, especially trainees, to come and chat, and that's what I'm here for. But that emotional load can be a lot as well.

Jaspal Singh: Wow. Thank you for taking that on and for doing all you're doing. Anita, what are your thoughts?

Anita Reddy: Yeah, I very much agree with what Maya said. I think there is a degree of burnout, especially given we’re 10 to 11 months into this. The physical exhaustion, as we are all being called in to do more clinical time, even though we have other duties as well. That mental exhaustion—and when I say the mental exhaustion, it's taking care of these patients. They're still critically ill. Watching, unfortunately, a lot of them pass away without family at the bedside. We're the replacement for that as they're passing away, and not being able to care for all the people that you want to, given our hospitals and our ICUs are so full.

We are a huge referral center. I can't bring in patients who we would normally be able to. I know people that we can help. So, there's this mental struggle that we can't do everything, and that's hard.

I would say that early on in the pandemic, when we didn't know a lot about how COVID-19 it is being transmitted, how infective it was, there was a lot of fear, I think, in caregivers who work in a medical setting. “Well, I don't want to pass it on to my family,” and “School isn't in session, so we don’t have anyone to care for our children.”

I only have one daughter. Because we didn’t have family nearby, we were actually going to send our daughter to Texas to be taken care of by her grandparents. We had no idea how long that was going to be. Eventually, I said I can't handle this. I can't handle sending her away. So, we found an alternative.

I think these are all things that just weigh on you, as Maya said. As the woman in the family, we do have to take the burden of a lot of the things that happen at home. But I would say that, in a time where we're not able to enjoy some of the other things that we would normally be doing—and I have similar things that gratify me, like what Maya said: eating out, traveling especially—we’re not able to do that.

But I did find that our family was able to connect more, even though we were home, and we were able to enjoy the outdoors more. We would go outside almost every day when the weather was okay. If we were to find a silver lining, I think having more personal interactions with family when otherwise it might have been busy with other types of activities where we’re not relating to each other as well.

Jaspal Singh: Oh yeah, I think that's great advice. I mean, I can definitely say that I've enjoyed spending time with my family as well, which traveling and doing other things are a lot of distractions, or just simply shuttling them from place to place can be really exhausting.

I don't have 5 children, like Maya. We have 3; five is a lot. That's awesome.

So, let's recap. You both talked about important lessons, such as making things easy in the quality patient safety world, have a shared vision, collaborate, know the why of why we're doing certain things, communicate the clinical reasoning behind a lot of things, and then engage patient safety.

And you also give us a lot of important lessons about the Choosing Wisely campaign, how we're very similar in adults and pediatrics, how we think about the pandemic and how we responded, and how we're going to respond this time.

Really dive deep in the literature, dive deep into the understanding of the data, be more scientific, be more methodical, and be more of a stronger patient advocate, even when there's challenges around. Lastly, of course, taking care of ourselves, making sure that we are responsive for ourselves, our teammates, and others, and reaching out if there's any concerns.

I want to just thank you both today for taking the time. This is, again, Jaspal Singh for Consultant360. You're listening to Women Leaders in Critical Care. Dr Maya Dewan from the University of Cincinnati and Dr Anita Reddy from Cleveland Clinic.

I just want to thank you both for joining us today.