In July, PCHA is highlighting the need for transparency. Our goal is to inform, educate, and empower patients and families to actively participate in data-driven shared-decision making. Julie Slicker, a member of the PCHA Medical Advisory Board and lead on the Guided Questions Tool, speaks about the importance of transparency from a provider’s perspective.
“We didn’t know until after our child was born,” “How could we predict what to ask the doctors? We had to just blindly trust in their skills,” “We were so afraid that we felt paralyzed and we didn’t know how to ask the right questions.” These are the parental anxieties that we, as providers, hope to have the power to impact. And today, with the effort of PCHA and their new Guided Questions Tool (GQT), maybe we can. But first, a story.
I will never forget the first time I had the privilege of caring for a child with congenital heart disease (CHD). It was 10 years ago, and the honor I felt being able to care for that child’s nutritional needs has never left me. As a Registered Dietitian (RD), I have had the opportunity to meet with countless other families since then. That said, every provider has a memory of one child that pulls at their heart strings.
He was a tiny infant named Joe, with a family that had no idea they were having a child with CHD and whose unexpected rush to the hospital changed their life forever. Joe’s tiny little round head, his blue lips and fingers, the fear and anxiety his family had to face, the multiple hospital admissions and the surgical interventions he had to endure will remain with me forever. I have heard so many stories over the years that started out the same way: A time that is supposed to be filled with joy and excitement quickly turned to one of stress, anxiety, and a feeling of being overwhelmed and powerless. I wanted to help to heal Joe and take away the pain and worry of his parents. I wanted to make a difference.
Together with PCHA, I feel that we’ve discovered a way to make that difference. A Guided Questions Tool (GQT) was created to facilitate relationship building and transparency between patients, families and their providers when discussing surgical interventions for infants. This tool is designed to result in data driven answers that promote discussion, leading to the balance between accurate information and reassurance. The first phase of this effort included the development of a list of “Suggested Questions” that parents could ask their providers. Parents and medical providers joined efforts and vetted the questions to identify those that reflect quality of care and outcomes. The questions were sorted into categories to address center outcome data, hospital experience and long-term outcomes. The questions were further edited by a multi-disciplinary team of providers and parents to ensure that they would meet health literacy goals and result in a transparent discussion between parents and providers. From this effort, the first true iteration of the GQT was born.
The next step is to test the GQT’s efficacy in practice. We have gathered a multidisciplinary team comprised of four CHD centers from all over the country to validate this tool via surveys for both providers and parents. We plan to initiate this phase next month.
The mere existence of PCHA, and the GQT that they have helped develop, speaks volumes about where we have come from as a discipline practicing in CHD. A nurse scientist colleague of mine who has dedicated her life’s work to improving the quality of life and developmental outcomes of children with CHD once showed me an old tattered notebook that forever changed my perspective on CHD. In this notebook she showed me the meticulous handwriting of one dedicated surgeon’s log of procedures from the 1980’s. This notebook held a list of patients with Hypoplastic Left Heart Syndrome (HLHS), one of the most severe forms of CHD. Written in front of the first 12 names was a capital letter D, denoting the passing of every single one of those infants. The nurse scientist explained the struggles in the early years of the Norwood procedure. Twelve names. Twelve families. Twelve tiny little infants with so much hope … and ultimately twelve deaths due to complications from this poorly understood physiological nightmare. Then miraculously, after twelve failures, there was a name in the book that stood alone; there was not a letter D written next to it. The thirteenth child lived. And is still living today. This story makes me remember why sometimes failure is a greater lesson than success. It is often said that it is much worse to never try at all than to suffer repeated failure. I cannot imagine the perseverance this cardiac team maintained as they pushed through so much devastating failure. However, it is due to those families and the trust they placed in the medical team that the surgeons learned what they needed to. Yes, these early families lost their infants and have experienced unimaginable pain, but I can only hope they gained solace in the fact that their infant’s death led to the life of thousands more. They changed the course of cardiac surgical history. Today our facility, Children’s Hospital of Wisconsin, proudly touts that greater than 90% of these patients survive surgery to go home with their families. In the 1980’s these babies did not make it through their first months of life, and today our expectation is that most will grow into adulthood.
So, keeping this story in mind, here we stand. We can now save the lives of thousands of individuals with CHD all over the country. Cardiac programs have been built surrounding the ideals of survival and excellent outcomes, but as far as most of us working with CHD families are concerned, it is still not enough. Survival rates are high, we have surpassed that hurdle, and now we are focusing on improving care even earlier, particularly, during the prenatal period. In order to help families navigate the difficult world of congenital heart disease, PCHA, along with other cardiac providers from across the country, have implemented the GQT for this exact reason. This tool elicits discussions among providers and families around transparency and quality of care at cardiac centers. Joe’s family, like countless others, experienced extreme stress, confusion, and anxiety. They had to blindly trust their local CHD program. Our goal with the GQT is to give families a guide to discuss important topics with their fetal cardiologists before their baby is even born. This tool offers a list of questions that inquire about outcomes at each cardiac center, as well as what parents can expect during their hospital stay. Additionally, the GQT prompts parents to ask about what the expected long term results are for their child’s particular lesion. The GQT also focuses on the type and number of procedures children may undergo, the survival rate for their diagnosis, and the type of training and experience that the providers have. This tool will empower parents to ask the right questions, and will prompt providers to anticipate these questions and become knowledgeable about the answers. Utilizing this tool will allow transparency to take place, trust to be built, and knowledge to be gained.
Providers and parents alike push aside their fears and try to maintain hope that each child with CHD will have a positive outcome and achieve the quality of life deserved. It is because of this passion that I believe the field has progressed so far in the last 30 years. As PCHA and four other sites across the country embark on this small initiative to test and validate the GQT, I cannot help but think about the particular surgeon and his team in that notebook, and how they truly changed the world of CHD forever. This tool may be a drop in the bucket in comparison, but we aim to continue raising the bar for families with CHD to help support and empower them as much as we can.
It is truly an honor and a privilege for all of us that work with CHD families to help change the world – one CHD family at a time.
Julie Slicker MS RD CSP CD CNSC with edits by Sydney Allen, MPH
Julie Slicker is currently the Quality, Outcomes and Research Manager of the Herma Heart Center at Children’s Hospital of Milwaukee in the Division of Cardiology. Julie has been at Children’s Hospital of Wisconsin since June 2006. Pediatric nutrition for infants with complex congenital heart disease is Julie’s passion, and since 2006 she has dedicated her time to caring for the nutrition of this patient population. In conjunction with patient care, Julie’s research focuses on hypoplastic left heart syndrome (HLHS) and single ventricle physiology. She pursued her Master’s Degree at the Medical College of Wisconsin in Clinical Translational Science and graduated in 2013. She is currently pursuing a degree as a nurse practitioner in order to continue her work in the cardiac ICU, caring for the patients she has come to cherish over her career thus far.
Sydney Allen is a Program Coordinator for the Herma Heart Center at the Children’s Hospital of Wisconsin, focusing on quality improvement initiatives. Many of her projects revolve around improving patient outcomes, patient satisfaction, quality of life, and optimizing clinical process flow. She obtained her Master’s in Public Health Nutrition in 2014 and when she’s not busy working on healthcare quality improvement, she enjoys recipe testing in her kitchen to find simple, delicious, and nutritious plant-based meals to share with her friends and family.