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

Figures & data

Table 1. Demographics and characteristics of study participants.

Demographic/characteristic	Participants (N = 70)
Age, years, n (%)
20–30	15 (21.4)
31–40	27 (38.6)
41–50	14 (20.0)
51–60	6 (8.6)
61–70	3 (4.3)
> 70	5 (7.1)
Female, n (%)	46 (65.7)
Race, n (%)
White or Caucasian	57 (81.4)
Black or African American	6 (8.6)
Asian	3 (4.3)
Hispanic/Latinx	1 (1.4)
Other^a	3 (4.3)
Ethnicity, n (%)
Not Hispanic/Latinx	64 (91.4)
Hispanic/Latinx	5 (7.1)
Other^a	1 (1.4)
Process Stakeholder Role, n (%)
Attending Physician^b	17 (24.3)
Clinical Nurse or Unit Nursing Leadership^b	14 (20.0)
Surrogate^c	9 (12.9)
Critical Care Fellow	7 (10.0)
Chaplain^b	5 (7.1)
Occupational Therapist	4 (5.7)
Advanced Practice Provider^b^,d	3 (4.3)
Physical Therapist	3 (4.3)
Respiratory Therapist	3 (4.3)
Social Worker^b	3 (4.3)
Patient Survivor	2 (2.9)
Palliative Care Team Member, n (%)^e	13 (22)
Site 1 Team Member, n (%)^e	41 (69)
Years since completion of professional training, median (IQR); n = 52^e^,f	6.0 (4.0-12.0)
Years of experience in study site ICU, median (IQR); n = 57^e^,g	4.0 (2.0-6.0)
Total years of experience in an ICU setting, median (IQR); n = 56^e^,g	5.0 (3.5-9.0)

^aOther includes “other race” or “other ethnicity”, missing, or declined to answer.

^bBoth ICU and palliative care team members participated from this professional background.

^cThe relationship of surrogates to the patient included spouses (3), cousins (3), adult children (2), and parent (1).

^dNurse Practitioner or Physician Assistant.

^eCharacteristic applies only to clinician participants; n = 59.

^fA total of 7 participants had not completed training.

^gTotal respondents less than 59 due to incomplete responses.

Abbreviations: ICU = intensive care unit; IQR = interquartile range.

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–c 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

Table 2. Key inconsistencies in the process of deliberation about life-sustaining treatments for patients with acute respiratory failure.

Central Theme	Exemplary Participant Quotes
Critical periods to deliberate about life-sustaining treatment are bypassed because the opportunity is not recognized or acted on	Surrogate: I didn’t want it to sound like I was giving up on him, or that I didn’t trust their ability to cure him. I just didn’t feel like me bringing it up—me bringing it up was not the right thing. ICU Team Member^a: we can also be better at raising these concerns. […] we are talking on the back end of, like, ‘Are-are you serious? We’re going to intubate this person again?’ […] we talk about it, but we don’t bring these concerns up.
Clinician-level variation leads to inconsistent actions during critical periods to deliberate	ICU Team Member: I feel like if you have a strong nurse, that’s like “no. You’re going to go talk to the family about this, because this is getting out of hand.” I think if you have a strong fellow as well […]. ICU Team Member: there are people that I will not raise concerns to. And there people that I [pause] feel comfortable […]. It’s hard to, kind of, um, voice those concerns and those frustrations, sometimes.
Regular rotation of ICU clinicians leads to avoidance or repetition of deliberation steps	ICU Nurse: we will drop the ball in a way and say, “Well, I’m only on for the weekend, so I don’t want to get involved. I’m only here for one shift. I don’t want to get involved.” ICU Team Member: one day, a physician might have a discussion with the family that ends with the family thinking that no additional interventions are acceptable, and that starts this process of consulting palliative and maybe moving toward end-of-life. And then while all that’s happening, the next day, the next care team has the same exact conversation with the family, but decides with the family that additional interventions are acceptable, and then that leads us back into that cycle.

^aTo preserve participant confidentiality, professional roles with 5 or fewer study participants were grouped as “ICU Team Member” to label direct quotes in table and manuscript text.

Abbreviations: ICU = intensive care unit.