431 - Pediatric Intensive Care Unit Approaches to Conflict Handling (PATCH): Results of Unit Leadership Surveys

Poster Number: 431
Publication Number: 431.1751

Background: Conflict between patient families and clinical teams in pediatric intensive care units (PICUs) is common and associated with worse patient safety, family satisfaction, and team well-being. Data demonstrate disparities in conflict management. PICU conflict management is underexplored, with no studies describing existing approaches.

Objective: To describe existing approaches to PICU team-family conflict.

Design/Methods: In this prospective, multi-site, mixed methods analysis of PICU leadership surveys, approved by the local IRB, we used purposive and snowball sampling. We emailed closed survey invitations to 98 medical directors and 22 nursing directors. Survey design, distribution, and reporting adhered to CHERRIES checklist. Descriptive statistics and bivariate analyses were performed. A two-tailed p-value < 0.05 defined significance. Qualitative analysis applied a modified grounded theory constructivist approach.

Results: Response rate was 57% (68/120), with a wide range of respondent and institution characteristics (Table 1). Frequent conflict sources were: poor communication (51%), coping problems (31%), difficulty comprehending prognosis (20%), care plan disagreements (20%), and life-sustaining therapy (17%). Frequent interventions were: social work (97%), patient-family relations (56%), behavior contracts (32%), security (19%), and ethics (8%).

65% reported having conflict management policies. 23% reported tracking outcomes. 38% track behavior contract use. 18% track disparities in use. 98% have a diversity, equity, and inclusion (DEI) office; 5% involve them in conflicts systematically. Those at institutions tracking behavior contracts were more likely to involve ethics in conflicts (p=0.04).

For the cases, respondents at larger PICUs were more likely to have specific policies (p < 0.05). Respondent initial approaches varied across the cases (Table 2). Respondents were more likely to limit family decision-making when family deviated from standard of care, requesting less medical intervention (case 4); respondents were more likely to support family decisions when family requested interventions deemed as "futile" by the team (case 1). Table 3 summarizes key themes from qualitative analysis.

Conclusion(s): PICU conflict management varied across respondents and across conflict types, suggesting that systematic, generalizable, and consistent approaches to conflict that are specific to different conflict types may be worthwhile. Learning from key issues identified by leaders in applying existing strategies may help development of standardized interventions to reduce conflict and improve interventions.