Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure

Abstract

Evidence suggests system-level norms and care processes influence individual patients' medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient's critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients' individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure.

Keywords: communication; critical care; end-of-life care; process mapping; qualitative research; shared decision making.

Figure 1.. A summary process map of intensive care delivery for adults with acute respiratory failure who require mechanical ventilation.

The current-state process has four major deliberation periods with decision points, yet these opportunities are inconsistently acted on (inconsistent steps represented with dashed lines). The blue pathways represent default processes that unfold if/when deliberation periods are bypassed.

Figure 2.. Detailed process maps of intensive care delivery for adults with acute respiratory failure who require mechanical ventilation.

Figures 2a, 2b, and 2c depict the detailed processes of care within each phase of care delivery. Squares represent key process steps; squares containing a circle represent a step during which existing information is verified (i.e., a verification step); diamonds represent decision steps; and upside-down triangles indicate system-level resources available during a process step. Dashed lines indicate that a step is performed inconsistently at the patient level. “YES” demonstrates the direction of the process if the step occurs and “NO” demonstrates the direction of the process if the step does not occur. Features of the process that may differ between intensive care units (ICU) are represented in blue. Major process events are numbered to demonstrate sequence and facilitate reference; sub-processes that arise from major process events are indicated with decimals. The term “conditional yes” refers to an agreement that a treatment is acceptable to use with specific limitations or conditions for continuation (e.g., a time-limited trial of mechanical ventilation to evaluate response to therapies or pending diagnostic/prognostic information). Abbreviations: ICU = intensive care unit; MV = mechanical ventilation

Figure 2.. Detailed process maps of intensive care delivery for adults with acute respiratory failure who require mechanical ventilation.

Figures 2a, 2b, and 2c depict the detailed processes of care within each phase of care delivery. Squares represent key process steps; squares containing a circle represent a step during which existing information is verified (i.e., a verification step); diamonds represent decision steps; and upside-down triangles indicate system-level resources available during a process step. Dashed lines indicate that a step is performed inconsistently at the patient level. “YES” demonstrates the direction of the process if the step occurs and “NO” demonstrates the direction of the process if the step does not occur. Features of the process that may differ between intensive care units (ICU) are represented in blue. Major process events are numbered to demonstrate sequence and facilitate reference; sub-processes that arise from major process events are indicated with decimals. The term “conditional yes” refers to an agreement that a treatment is acceptable to use with specific limitations or conditions for continuation (e.g., a time-limited trial of mechanical ventilation to evaluate response to therapies or pending diagnostic/prognostic information). Abbreviations: ICU = intensive care unit; MV = mechanical ventilation

Figure 2.. Detailed process maps of intensive care delivery for adults with acute respiratory failure who require mechanical ventilation.

Figures 2a, 2b, and 2c depict the detailed processes of care within each phase of care delivery. Squares represent key process steps; squares containing a circle represent a step during which existing information is verified (i.e., a verification step); diamonds represent decision steps; and upside-down triangles indicate system-level resources available during a process step. Dashed lines indicate that a step is performed inconsistently at the patient level. “YES” demonstrates the direction of the process if the step occurs and “NO” demonstrates the direction of the process if the step does not occur. Features of the process that may differ between intensive care units (ICU) are represented in blue. Major process events are numbered to demonstrate sequence and facilitate reference; sub-processes that arise from major process events are indicated with decimals. The term “conditional yes” refers to an agreement that a treatment is acceptable to use with specific limitations or conditions for continuation (e.g., a time-limited trial of mechanical ventilation to evaluate response to therapies or pending diagnostic/prognostic information). Abbreviations: ICU = intensive care unit; MV = mechanical ventilation