Through the Looking-Glass Door*

Abstract

In Lewis Carroll’s Alice in Wonderland sequel, Through the Looking-Glass, Alice again enters a mythical world but this time by climbing through a mirror rather than falling into the rabbit’s hole (1). Within the world, she finds a book of poetry with the words written backward so that it can only be read by holding it up to the mirror. Alice wanders through a chaotic world of Queens and characters, narrowly escaping with her life only to awaken back in her armchair, safe in her own house, unclear if the adventures were dreams or reality. Alice’s journey is not unlike those of our patients as they enter the PICU. “Why, it’s a looking-glass book, of course! And if I hold it up to a glass, the words will all go the right way again.” (1) In this issue of Pediatric Critical Care Medicine, Jones et al (2) describe the implementation of a tool to facilitate team collaboration and communication as part of a larger study with a global aim to improve outcomes for critically ill children (2). Modeled after a paper Daily Goals Checklist, daily goals are written on the patient room glass door to prompt and support shared understanding of goal-directed care (3). For patients, the Liber8 Glass Door is their own looking-glass with the information appearing backward to those inside the room. Yet, it is a guide to the chaotic world of pediatric critical care that will help the patient to survive and end up safely home through supporting ICU best practices (4). “‘You couldn’t have it if you did want it,’ the Queen said. ‘The rule is, jam to-morrow and jam yesterday-but never jam to-day.’”(1) Despite knowledge that ICU care bundles similar to PICU Liber8 bundle can hasten liberation from mechanical ventilation and the ICU while improving patient outcomes (5–7), implementation in PICUs remain variable. National guidelines recommend implementing such bundles (8), yet, significant barriers derail successful implementation and/or sustainability, even for those who want it (9). The key strength of the work by Jones et al (2) is their low cost, simple, effective, and feasible tool, which could be adapted for all care settings, coupled with the “how” of implementation (paper reference). Using a straightforward implementation strategy, Pronovost’s 4Es of engagement, education, execution, and evaluation (10), they create an implementation roadmap for any team looking to employ a similar quality improvement intervention. Most remarkably, their solution masterfully maximizes the concept of visibility to all team members, including the family. The goals are shared, standardized, and no one involved in the patient’s care could claim difficulty finding them. “The Red Queen shook her head. ‘You may call it “nonsense” if you like,’ she said, ‘but I’ve heard nonsense, compared with which that would be as sensible as a dictionary!’ (1)” Plenty of pediatric critical care colleagues will, unfortunately, discount sensible projects such as the Liber8 Glass Door, citing a lack of rigorous evaluation, privacy concerns, or believing technological solutions would be better. However, as Red Queens ourselves in pediatric critical care, we stand alongside Jones et al (2) to say that sensible science is exactly what we should be leading, presenting, publishing, and sharing as a scientific community to improve patient care today. The authors outline the limits of their work and address privacy concerns on both institutional and patient levels that would be feasible within many countries including the United States. This article joins numerous others in the pediatric critical care quality improvement and implementation science realm presenting readers with a guide for leading change. Importantly but not surprisingly, like other clinical decision support interventions (11), translating this work to the electronic health record did not improve communication or compliance. “Alice laughed. ‘There’s no use trying,’ she said: ‘one can’t believe impossible things.’ ‘I daresay you haven’t had much practice,’ said the Queen. ‘When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.’ (1)” To accomplish impossible things in pediatric critical care, we need to believe impossible things and realize sometimes it merely takes several simple things all put together to achieve the impossible. Then by utilizing a pragmatic approach based in implementation science, we can accomplish our goals. Engaging families and stakeholders, applying implementation methodology, and measuring our impact and outcomes is necessary to drive ongoing transformation. Studies like those of Jones et al (2) give us roadmaps for implementing change locally. We must also continue our larger learning health networks to examine generalizability of such interventions more broadly, and this collaborative science will allow us to accomplish as many as six impossible things before breakfast.