Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU.
This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer (MDT) scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised (MDS-R), were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p = 0.015), a statistically significant increase in both code status changes DNR (11 % control, 28 % PEACE, p = 0.013), and in-hospital death (9 % control, 25 % PEACE, p = 0.015), with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients.
Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA. lwocial@iuhealth.org.|Indiana University School of Nursing, Indianapolis, IN, USA. lwocial@iuhealth.org.
Lucia
L
Wocial
Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA.|Riley Hospital for Children, Indianapolis, IN, USA.
Veda
V
Ackerman
Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA.|Riley Hospital for Children, Indianapolis, IN, USA.
Brian
B
Leland
Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA.|Riley Hospital for Children, Indianapolis, IN, USA.|Children's Health Services Research Unit, Indiana University School of Medicine, Indianapolis, IN, USA.
Brian
B
Benneyworth
Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA.|Riley Hospital for Children, Indianapolis, IN, USA.
Vinit
V
Patel
Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA.|Riley Hospital for Children, Indianapolis, IN, USA.
Yan
Y
Tong
Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA.|Riley Hospital for Children, Indianapolis, IN, USA.
Mara
M
Nitu
D000328:Adult; D003142:Communication; D005260:Female; D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000941:ethics*; D007400:Interprofessional Relations; D007902:Length of Stay; D008020:Life Support Care / Q000941:ethics; D008297:Male; D008875:Middle Aged; D011594:Psychometrics / Q000295:instrumentation / Q000379:methods; D012720:Severity of Illness Index; D013315:Stress, Psychological / Q000523:psychology*; D056164:Teaching Rounds / Q000379:methods; D019564:Unnecessary Procedures / Q000941:ethics*; D000078329:Workforce
Clinical ethics; Ethics intervention; ICU length of stay; Moral distress; Pediatrics