Over the past 2 decades, hospitals have been increasingly called on to provide stabilization and treatment of pediatric patients with mental health symptoms. At least 1 in 10 hospitalized children >3 years has both a medical and a psychiatric condition,1 and the population of hospitalized patients with significant psychiatric morbidity is growing.2 Patients who have conditions affecting both their mental and physical health are in need of integrated medical and psychiatric treatments, and hospitals report challenges ensuring teams are prepared to care for these patients.3 In this month’s Hospital Pediatrics, Ibeziako et al4 provide a new window into understanding the characteristics of patients with eating disorders and somatoform disorders with an eye toward advancing the quality of their inpatient care.
In this single-center, retrospective cohort study of 250 patients, Ibeziako et al4 found that patients hospitalized for eating disorders and somatoform disorders shared similar demographic characteristics, stressors, and coping styles. Nevertheless, a number of their medical and psychiatric symptoms and treatments differed. Eating disorder patients had higher rates of depression, suicidal ideation, and self-injury and required more laboratory testing, whereas somatoform disorder patients had greater fragmentation of their care, more neurologic evaluation, more specialty consults, and higher rates of learning disabilities. The reported findings highlight the value of a team approach to providing hospital care to patients with eating disorders and somatoform disorders. Efforts to use data like those reported by Ibeziako et al4 to improve pediatric hospital care depend on collaboration between professionals with different expertise in high-functioning teams.
Fostering strong team cohesion and collaboration is particularly important in teams caring for patients with medical and psychiatric comorbidities. Symptoms and behaviors that may occur in patients with psychiatric conditions, such as agitation, aggression, or splitting behaviors, can lead to compassion fatigue and burnout among clinicians. High-functioning teams can weather such challenges and promote good patient outcomes by promoting flexibility and resilience among clinical staff. The Institute of Medicine espouses 5 principles as pillars of team-based healthcare: shared goals, clear roles, mutual trust, effective communication, and measureable processes and outcomes.5 Ensuring that clinical teams focus on these team processes will increase the likelihood of good patient outcomes, as well as reducing burnout and improving retention of clinical team members.
Alignment between patients, families, and clinicians from different disciplines rests on a foundation of shared goals for the patient’s treatment plan. These goals need to be carefully and repeatedly shared with shifting team members to ensure that there is a shared mental model for the treatment plan. Providing opportunities for patients and families to communicate their priorities and placing those priorities at the center of a team’s clinical care can help the team retain a common focus. Regular team meetings that include patients and families, which might take the form of patient- and family-centered rounds, family meetings, or team case conferences, can help shape team members’ understandings of those goals. Beyond individual patients’ treatment goals, clinical teams may also benefit from developing a shared set of guiding management principles. For example, agreement within a team about the timeline for workup of physical symptoms in a new patient with a suspected somatoform disorder can help guide later conversations about the timing of a specialty consult or a specific imaging test.
Outlining clear roles for each team member can help teams take full advantage of diverse clinical knowledge and skills. In high-resource healthcare systems, team members may have overlapping responsibilities and be challenged to avoid duplication of tasks or inconsistent messages. For example, is it the responsibility of the neurologist, the psychiatrist, or the adolescent medicine specialist to address a patient’s frequent emergency department visits? If several professionals share a responsibility, how will new information be communicated? Conversely, other teams may find that some roles are unfilled. For example, teams may find themselves asking who can provide psychological support to a parent or develop rules about patients’ use of social media. High functioning team members understand each other’s roles in patient care and are able to monitor each other’s work so that colleagues can provide prompts or step in to complete any important, uncompleted tasks. Honest, open, ongoing discussion about each team member’s preparedness to achieve various goals may help teams identify creative strategies to address specific needs. In the many regions reporting lack of availability of enough mental health clinicians to meet patients’ needs,6 such conversations may identify areas where other professionals can ease the demands on mental health clinicians’ time.
Mutual trust is essential to a team’s ability to support each other in the complicated patient care tasks. Departing team members need to trust that their colleagues will maintain therapeutic boundaries in their absence. Trust also allows expression of diverging opinions about how to achieve patient goals. Community-building activities, like team meals, celebration of milestones and goals accomplished, or off-campus social events, can provide opportunities for individuals to find common ground and develop mutually supportive relationships. Such relationships can help teams communicate clearly and achieve shared goals while remaining resilient to burnout, compassion fatigue, and splitting behaviors.
Effective communication involves informal and structured group interactions, individual conversations, and various forms of written and digital communication. Teams can create safe spaces to collectively solve problems by encouraging curiosity about other team members’ positions and humility about what any one individual brings to the solution. Norms of inclusive communication with active listening by all team members should be clearly modeled and reinforced. Team leaders may be called on to reorient attitudes and behaviors when team members do not demonstrate respect for others’ contributions. A primary goal of effective communication is accurate information transfer, and teams may benefit from establishing practice guidelines for communication in various forums. For example, establishing a shared understanding for what level of detail is expected during rounds or for who is responsible for documenting the outcome of a patient conversation can help avoid frustration and misunderstandings. Such shared understanding can also help achieve other objectives of team communication, like reinforcing trust relationships.
Establishing a set of measurable processes and outcomes can help teams evaluate progress toward achieving shared goals and making practice changes when needed. Metrics that can help teams measure progress may include patient health outcomes, patient care processes, safety measures, value outcomes, or patient and family experience. For patients with medical and psychiatric comorbidity, connecting metrics to both mental health and physical health can help promote integration of disciplines. Routine evaluation of progress toward specific measures can reinforce other pillars of effective team collaboration by maintaining a group’s focus on a shared goal or providing a target for the outcome of effective communication. Demonstrating measurable progress toward meeting mutually agreed-on goals can promote patient and professional satisfaction.
As hospital teams strive to improve outcomes for patients with medical and psychiatric comorbidity, attention to team dynamics can help professionals and patients achieve appropriate, high-value care. By collaborating to develop a set of shared management principles, clinicians from different disciplines can maximize the value of their knowledge and skillset. Effective collaboration within multidisciplinary teams is key to improving hospital care and helping a vulnerable population of patients achieve better mental and physical health.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Doupnik was supported by Ruth L. Kirschstein National Research Service Award institutional training grant T32-HP010026-11. Dr Walter was supported by the Cambia Foundation Sojourns Scholar Leadership Program. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2016-0080.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
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- Copyright © 2016 by the American Academy of Pediatrics