Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol

Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial

BACKGROUND

Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP.

METHODS

This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat.

DISCUSSION

The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.

Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis

BACKGROUND

Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized.

OBJECTIVE

Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others.

METHODS

Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings.

RESULTS

The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism.

CONCLUSIONS

Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.

Determining Goal Concordant Care in the Intensive Care Unit Using Electronic Health Records

BACKGROUND

Goal concordant care (GCC) is the alignment of care to patient values and preferences. GCC is a major outcome of communication with patients and families in serious/critical illness. Using the electronic health record (EHR) to study the provision of GCC would be pragmatic and cost-effective for research and quality improvement efforts.

RESEARCH QUESTION

Do EHRs contain information to identify GCC?

METHODS

This is a feasibility retrospective chart review performed by two independent reviewers. An existing framework containing four questions for identifying GCC was adopted. Two clinicians reviewed multi-disciplinary notes and extracted pertinent information. The primary outcomes were whether the four key questions for determining goal concordance could be answered using information in the EHR. The secondary outcome was the type of goals identified. Cohen's kappa was used to measure agreement between two reviewers.

RESULTS

Patient care was considered goal concordant in 35 (85%) of 41 patients in a random sample comprising of 36 survivors and five who died in hospital. Inter-rater agreement on identifying data to determine GCC was excellent (Kappa 0.70). Patient goals were identified in 80% of charts reviewed. Note sources informative of patient preferences, included social work (39%), hospital progress notes (29%), palliative care (20%), and physical/occupational therapy (15%). "Returning home" and "getting better/ stronger" were among the most common patient goals captured in EHR.

CONCLUSION

The EHR can be used to understand patient goals, but the information is scattered across the multi-disciplinary notes. Improving EHR and external validation will facilitate ascertainment of goal concordance as an important outcome measure.

The Practice Change and Clinical Impact of Lung-Protective Ventilation Initiated in the Emergency Department: A Secondary Analysis of Individual Patient-Level Data From Prior Clinical Trials and Cohort Studies

OBJECTIVES

Mechanically ventilated emergency department (ED) patients experience high morbidity and mortality. In a prior trial at our center, ED-based lung-protective ventilation was associated with improved care delivery and outcomes. Whether this strategy has persisted in the years after the trial remains unclear. The objective was to assess practice change and clinical outcomes associated with ED lung-protective ventilation.

DESIGN

Secondary analysis of individual patient-level data from prior clinical trials and cohort studies.

SETTING

ED and ICUs of a single academic center.

PATIENTS

Mechanically ventilated adults.

INTERVENTIONS

A lung-protective ventilator protocol used as the default approach in the ED.

MEASUREMENTS AND MAIN RESULTS

The primary ventilator-related outcome was tidal volume, and the primary clinical outcome was hospital mortality. Secondary outcomes included ventilator-, hospital-, and ICU-free days. Multivariable logistic regression, propensity score (PS)-adjustment, and multiple a priori subgroup analyses were used to evaluate outcome as a function of the intervention. A total of 1,796 patients in the preintervention period and 1,403 patients in the intervention period were included. In the intervention period, tidal volume was reduced from 8.2 mL/kg predicted body weight (PBW) (7.3-9.1) to 6.5 mL/kg PBW (6.1-7.1), and low tidal volume ventilation increased from 46.8% to 96.2% ( p < 0.01). The intervention period was associated with lower mortality (35.9% vs 19.1%), remaining significant after multivariable logistic regression analysis (adjusted odds ratio [aOR], 0.43; 95% CI, 0.35-0.53; p < 0.01). Similar results were seen after PS adjustment and in subgroups. The intervention group had more ventilator- (18.8 [10.1] vs 14.1 [11.9]; p < 0.01), hospital- (12.2 [9.6] vs 9.4 [9.5]; p < 0.01), and ICU-free days (16.6 [10.1] vs 13.1 [11.1]; p < 0.01).

CONCLUSIONS

ED lung-protective ventilation has persisted in the years since implementation and was associated with improved outcomes. These data suggest the use of ED-based lung-protective ventilation as a means to improve outcome.

Oncologist Perceptions of Algorithm-Based Nudges to Prompt Early Serious Illness Communication: A Qualitative Study

Background: Early serious illness conversations (SICs) about goals of care and prognosis improve mood, quality of life, and end-of-life care quality. Algorithm-based behavioral nudges to oncologists increase the frequency and timeliness of such conversations. However, clinicians' perspectives on such nudges are unknown. Design: Qualitative study consisting of semistructured interviews among medical oncology clinicians who participated in a stepped-wedge cluster randomized trial of Conversation Connect, an algorithm-based intervention consisting of behavioral nudges to promote early SICs in the outpatient oncology setting. Results: Of 79 eligible oncology clinicians, 56 (71%) were approached to participate in interviews and 25 (45%) accepted. Key facilitators to algorithm-based nudges included prompting documentation of conversations, peer comparisons, performance reports, and validating norms around early conversations. Barriers included cancer-specific heterogeneity in algorithm performance and the frequency and tone of text messages. Areas of improvement included utilizing different information channels, identifying patients earlier in the disease trajectory, and incorporating patient-targeted messaging that emphasizes the value of early conversations. Conclusions: Oncology clinicians identified key facilitators and barriers to Conversation Connect. These insights inform future algorithm-based supportive care interventions in oncology. Controlled trial (NCT03984773).

Electronic nudge tool technology used in the critical care and peri-anaesthetic setting: a scoping review protocol

INTRODUCTION

Electronic clinical decision support (eCDS) tools are used to assist clinical decision making. Using computer-generated algorithms with evidence-based rule sets, they alert clinicians to events that require attention. eCDS tools generating alerts using nudge principles present clinicians with evidence-based clinical treatment options to guide clinician behaviour without restricting freedom of choice. Although eCDS tools have shown beneficial outcomes, challenges exist with regard to their acceptability most likely related to implementation. Furthermore, the pace of progress in this field has allowed little time to effectively evaluate the experience of the intended user. This scoping review aims to examine the development and implementation strategies, and the impact on the end user of eCDS tools that generate alerts using nudge principles, specifically in the critical care and peri-anaesthetic setting.

METHODS AND ANALYSIS

This review will follow the Arksey and O'Malley framework. A search will be conducted of literature published in the last 15 years in MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science and SAGE databases. Citation screening and data extraction will be performed by two independent reviewers. Extracted data will include context, e-nudge tool type and design features, development, implementation strategies and associated impact on end users.

ETHICS AND DISSEMINATION

This scoping review will synthesise published literature therefore ethical approval is not required. Review findings will be published in topic relevant peer-reviewed journals and associated conferences.

Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness

BACKGROUND

Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement.

OBJECTIVE

Describe patterns of PC delivery among a large, critically ill trauma cohort.

SETTING/SUBJECTS

Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019.

METHODS

We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma.

RESULTS

Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively.

CONCLUSION

PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.