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Andersen SK, Yang Y, Kross EK, Haas B, Geagea A, May TL, Hart J, Bagshaw SM, Dzeng E, Fischhoff B, White DB. Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study. Chest 2024; 166:107-117. [PMID: 38365177 PMCID: PMC11251076 DOI: 10.1016/j.chest.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process. RESEARCH QUESTION How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process? STUDY DESIGN AND METHODS We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description. RESULTS We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members. INTERPRETATION Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
| | - Yanran Yang
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anna Geagea
- Division of Critical Care Medicine, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Teresa L May
- Department of Pulmonary and Critical Care, Maine Medical Center, Portland, ME
| | - Joanna Hart
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Gencturk M, Laleci Erturkmen GB, Akpinar AE, Pournik O, Ahmad B, Arvanitis TN, Schmidt-Barzynski W, Robbins T, Alcantud Corcoles R, Abizanda P. Transforming evidence-based clinical guidelines into implementable clinical decision support services: the CAREPATH study for multimorbidity management. Front Med (Lausanne) 2024; 11:1386689. [PMID: 38860204 PMCID: PMC11163046 DOI: 10.3389/fmed.2024.1386689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/13/2024] [Indexed: 06/12/2024] Open
Abstract
Introduction The CAREPATH Project aims to develop a patient-centered integrated care platform tailored to older adults with multimorbidity, including mild cognitive impairment (MCI) or mild dementia. Our goal is to empower multidisciplinary care teams to craft personalized holistic care plans while adhering to evidence-based guidelines. This necessitates the creation of clear specifications for clinical decision support (CDS) services, consolidating guidance from multiple evidence-based clinical guidelines. Thus, a co-creation approach involving both clinical and technical experts is essential. Methods This paper outlines a robust methodology for generating implementable specifications for CDS services to automate clinical guidelines. We have established a co-creation framework to facilitate collaborative exploration of clinical guidelines between clinical experts and software engineers. We have proposed an open, repeatable, and traceable method for translating evidence-based guideline narratives into implementable specifications of CDS services. Our approach, based on international standards such as CDS-Hooks and HL7 FHIR, enhances interoperability and potential adoption of CDS services across diverse healthcare systems. Results This methodology has been followed to create implementable specifications for 65 CDS services, automating CAREPATH consensus guideline consolidating guidance from 25 selected evidence-based guidelines. A total of 296 CDS rules have been formally defined, with input parameters defined as clinical concepts bound to FHIR resources and international code systems. Outputs include 346 well-defined CDS Cards, offering clear guidance for care plan activities and goal suggestions. These specifications have led to the implementation of 65 CDS services integrated into the CAREPATH Adaptive Integrated Care Platform. Discussion Our methodology offers a systematic, replicable process for generating CDS specifications, ensuring consistency and reliability across implementation. By fostering collaboration between clinical expertise and technical proficiency, we enhance the quality and relevance of generated specifications. Clear traceability enables stakeholders to track the development process and ensure adherence to guideline recommendations.
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Affiliation(s)
- Mert Gencturk
- SRDC Software Research & Development and Consultancy Corporation, Ankara, Türkiye
| | | | - A. Emre Akpinar
- SRDC Software Research & Development and Consultancy Corporation, Ankara, Türkiye
- Department of Computer Engineering, Middle East Technical University, Ankara, Türkiye
| | - Omid Pournik
- Department of Electronic, Electrical and Systems Engineering, School of Engineering, University of Birmingham, Birmingham, United Kingdom
| | - Bilal Ahmad
- Department of Electronic, Electrical and Systems Engineering, School of Engineering, University of Birmingham, Birmingham, United Kingdom
| | - Theodoros N. Arvanitis
- Department of Electronic, Electrical and Systems Engineering, School of Engineering, University of Birmingham, Birmingham, United Kingdom
- Digital & Data Driven Research Unit, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | | | - Tim Robbins
- Digital & Data Driven Research Unit, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Ruben Alcantud Corcoles
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Pedro Abizanda
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina de Albacete, Universidad de Castilla-La Mancha, Albacete, Spain
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Verhoeven A, Marres H, van de Loo E, Lalleman P. Board talk: How members of executive hospital boards influence the positioning of nursing in crisis through talk. Nurs Inq 2024; 31:e12618. [PMID: 38047295 DOI: 10.1111/nin.12618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/11/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
Talk by members of executive hospital boards influences the organizational positioning of nurses. Talk is a relational leadership practice. Using a qualitative-interpretive design we organized focus group meetings wherein members of executive hospital boards (7), nurses (14), physicians (7), and managers (6), from 15 Dutch hospitals, discussed the organizational positioning of nursing during COVID crisis. We found that members of executive hospital boards consider the positioning of nursing in crisis a task of nurses themselves and not as a collective, interdependent, and/or specific board responsibility. Furthermore, members of executive hospital boards talk about the nursing profession as (1) more practical than strategic, (2) ambiguous in positioning, and (3) distinctive from the medical profession. Such talk seemingly contrasts with the notion of interdependence that highlights how actors depend on each other in interaction. Interdependence is central to collaboration in hospital crises. In this paper, therefore, we depart from the members of executive hospital boards as leader and "positioner," and focus on talk-as a discursive leadership practice-to illuminate leadership and governance in hospitals in crisis, as social, interdependent processes.
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Affiliation(s)
- Arjan Verhoeven
- Radboudumc, Otorhinolaryngology, Head and Neck Surgery, Nijmegen, The Netherlands
| | - Henri Marres
- Radboudumc, Otorhinolaryngology, Head and Neck Surgery, Nijmegen, The Netherlands
| | | | - Pieterbas Lalleman
- Fontys University of Applied Sciences, Eindhoven, Noord-Brabant, The Netherlands
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