6.6 Patient Safety, Teamwork & Family-Centered Care

6.6 Patient Safety, Teamwork & Family-Centered Care

Patient Safety & Detection of Non-Accidental Trauma (NAT)

Pediatric respiratory therapists regularly assess children presenting with acute traumatic injuries, respiratory failure, or altered mental status. Recognizing non-accidental trauma (physical child abuse) is a critical life-saving clinical competency.

Table 6.6.1: Findings Concerning for Non-Accidental Trauma (NAT)

Legal Responsibilities: Mandatory Reporting

• Healthcare professionals are generally mandated reporters, but the statutory wording, threshold, timing, and recipient vary by jurisdiction. Know the law and facility pathway where you practice.
• Threshold: A reasonable suspicion or equivalent statutory threshold—not diagnostic certainty—is generally sufficient to trigger a report.
• Procedure: Protect the child, treat urgent illness, document objective findings and the history, and follow jurisdictional law and facility policy for a prompt report to the designated authority. Do not delay a required report while seeking proof or confronting caregivers. Reporting, immunity, notification, consent for imaging, and emergency exceptions vary by jurisdiction; involve the child-protection and legal teams without implying that every test is automatically authorized.

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Infection Control & Critical Care Prevention Bundles

Healthcare-associated infections (HAIs) in the NICU and PICU dramatically increase length of stay, ventilator days, and mortality. Evidence-based care bundles standardize clinical practice to eliminate preventable infections.

1. Central Line-Associated Bloodstream Infection (CLABSI) Bundle

• Maximal Sterile Barrier Precautions: Full-body sterile drape, cap, mask, sterile gown, and sterile gloves during central venous line (or UVC) insertion.
• Skin antisepsis: Use the neonatal central-line protocol and product labeling. Chlorhexidine-alcohol can injure very preterm skin, while iodine exposure can affect thyroid function; agent, concentration, contact time, removal, and drying require gestation- and product-specific precautions. Sterile saline alone is not an antiseptic.
• Optimal Site Selection: Avoid femoral vein in older pediatric patients due to higher contamination risk.
• Daily Line Necessity Review: Prompt removal of catheters as soon as they are no longer clinically required.

2. Pediatric Ventilator-Associated Event (VAE / VAP) Bundle

• Positioning: Use an age-, disease-, skin-, aspiration-, and device-appropriate position. Head elevation, reverse Trendelenburg, and prone positioning are not interchangeable universal requirements; prone infants need continuous hospital monitoring.
• Oral care: Follow the age-specific unit bundle. Chlorhexidine oral products are not routine for every pediatric age group.
• Circuit and suction: Avoid unnecessary circuit breaks and scheduled changes; replace visibly soiled or malfunctioning components. Drain condensate away from the patient using infection-control precautions.
• Liberation and sedation: Assess sedation and extubation readiness daily, but use protocolized titration rather than an automatic interruption in patients at risk of withdrawal, airway loss, hemodynamic instability, or ventilator dyssynchrony.

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Interdisciplinary Ethics & High-Reliability Communication

High-reliability healthcare teams prevent clinical errors through standardized communication frameworks and ethical decision-making.

1. Structured Communication: SBAR

• S — Situation: State the immediate problem, patient name, and current location.
• B — Background: Relevant clinical context, gestational age, admitting diagnosis, ventilator settings.
• A — Assessment: Current clinical findings, vital signs, blood gas results, physical examination.
• R — Recommendation: Specific, actionable requests ("I recommend increasing PIP by 3 cmH2O and obtaining a STAT chest radiograph").

2. Closed-Loop Communication

Critical orders and resuscitation parameters must be confirmed using closed-loop messaging:

1. Sender clearly states the order: "Administer 0.64 mL of epinephrine 0.1 mg/mL via the UVC now."
2. Receiver repeats the order verbatim: "Administering 0.64 mL of epinephrine 0.1 mg/mL via the UVC."
3. Sender confirms accuracy: "That is correct."
4. Receiver announces completion: "0.64 mL of epinephrine given and flushed with 3 mL normal saline."

3. Crisis Resource Management (CRM) & The Two-Challenge Rule

To maintain psychological safety and overcome hierarchical barriers, clinical teams utilize the Two-Challenge Rule: If a clinician observes a safety hazard or incorrect order (e.g., wrong medication dose or inappropriate ventilator setting), they are empowered and obligated to respectfully state their concern at least twice. If unaddressed, they immediately escalate through the clinical chain of command.

4. Pediatric Ethical Principles & End-of-Life Care

• Best-interests standard: Parents or guardians usually make decisions for children, integrating benefits, burdens, prognosis, the child's developing preferences, family values, and applicable law. Adolescents may have meaningful assent or, in some jurisdictions, legal decision rights.
• Limits of surrogacy: When refusal creates imminent serious harm, activate ethics, safeguarding, risk-management, and legal pathways. Emergency treatment and court authorization depend on urgency and jurisdiction; do not present a court order as the only possible immediate pathway.
• Palliative Extubation: When mechanical ventilation merely prolongs the dying process in fatal conditions, compassionate extubation to comfort care is ethically appropriate, accompanied by aggressive analgesia and multidisciplinary palliative support.

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NPS Exam Traps Callout Box: Transport, Safety & Ethics

[!WARNING] NPS Exam Trap 1: Boyle's Law and the Untreated Pneumothorax Trapped pleural gas can expand as ambient pressure falls. Before fixed-wing transport, involve transport medical control, assess whether drainage is required, plan cabin altitude or pressurization, and ensure immediate decompression capability. Observation or oxygen alone is not an adequate plan for a pneumothorax judged at risk of expansion; not every tiny pneumothorax automatically follows the same procedure.

NPS Exam Trap 2: Calculating Cylinder Duration Without Subtracting Safe Residual Subtract the reserve pressure supplied in the vignette or service policy before applying the correct cylinder factor and total gas consumption. If an exam item states a 200-psig reserve, use 200 psig; do not assume that value when another reserve is specified.

NPS Exam Trap 3: Hesitating on Mandated Abuse Reporting Findings highly concerning for abuse require immediate patient safety, objective documentation, treatment, and a report through the jurisdiction's mandated pathway. Do not investigate by confronting caregivers or postpone a required report until every alternative diagnosis is excluded. The receiving agency and exact reporting route depend on local law and policy.

NPS Exam Trap 4: Chlorhexidine Burns in Micro-Preterms Antiseptic choice in extremely preterm skin is protocol- and product-specific. Chlorhexidine-alcohol can cause chemical injury, while povidone-iodine has neonatal thyroid and skin risks. Follow the NICU line-insertion policy for concentration, contact time, drying, removal, and monitoring rather than substituting one agent universally.

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Emergency Preparedness: Pandemic, Disaster & Mass-Casualty Events

Respiratory therapists sit at the center of hospital emergency preparedness because respiratory failure drives both surge demand and equipment scarcity. The NPS content outline lists preparation for pandemic, disaster, or mass-casualty events under patient-care protocols, with two explicit components: triage procedures and equipment and supply management.

1. Pediatric Mass-Casualty Triage: START vs. JumpSTART

Adult field triage (START - Simple Triage And Rapid Treatment) misclassifies children, because a respiratory rate of 40 breaths/min is alarming in an adult and unremarkable in a toddler, and because pediatric arrest is usually respiratory rather than primarily cardiac. JumpSTART is the pediatric adaptation, applied to casualties who appear to be roughly 1 to 8 years old; older children who look like adults are triaged with START.

• Why the five rescue breaths exist: JumpSTART gives an apneic child who still has a palpable pulse a brief ventilation trial before any black tag is assigned, because reversing hypoxic apnea often restores spontaneous breathing in a child. Applying the adult rule unchanged would tag a salvageable child as deceased.
• The non-ambulatory infant: A child who is not walking because of developmental stage rather than injury is carried out and evaluated during secondary triage. "Not walking" is never read as an injury finding in a pre-ambulatory infant.

2. Equipment & Supply Management During Surge

• Size-stratified pediatric cache: Maintain counted stock of ventilator circuits, cuffed and uncuffed tubes, laryngoscope blades, supraglottic airways, resuscitation bags with appropriate volumes, and interfaces spanning neonatal through adolescent sizes. Adult-only inventory is the classic pediatric-surge failure.
• Oxygen supply, not cylinder count: Bulk liquid-oxygen capacity, vaporizer throughput, and terminal-unit flow limits determine how many high-flow patients a unit can support at once. High-flow nasal cannula and open delivery systems consume disproportionate supply during respiratory pandemics.
• Honest ventilator accounting: Surge inventories mix full-featured ICU ventilators, transport and anesthesia machines, and stockpile units with limited neonatal capability. Confirm that a surge ventilator can actually deliver the small tidal volumes, pressure control, and PEEP the population requires before counting it as pediatric capacity.
• Competency is capacity: Cross-trained staff must be checked off on the specific devices in the cache. A machine nobody at the bedside can operate is not capacity.
• Pandemic-specific planning: Filter placement, closed suction, aerosol-generating-procedure policy, negative-pressure room allocation, and PPE burn rate must be planned alongside device counts.
• Scarce-resource allocation: Allocation follows a pre-declared institutional and jurisdictional framework with a designated triage authority, deliberately separated from the bedside clinician's duty to the individual patient.