Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes

Abstract

Background High-quality goals of care (GOC) communication is fundamental to providing excellent critical care. Objective Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation. Methods Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19). Results All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% ( P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% ( P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% ( P < 0.05). Conclusion Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.

Interprofessional identity and motivation towards interprofessional collaboration

“…Combining online and in-person training in clinical practice can be effective. 55 A study on comparison of online versus in-person education settings related to socialisation showed equal effectiveness. 56 So far, there is no available research that compares online versus in-person education settings related to interprofessional socialisation and interprofessional identity formation.…”

“…It is possible that interprofessional identity will have a stronger association with in‐person communication compared to online communication. Combining online and in‐person training in clinical practice can be effective 55 . A study on comparison of online versus in‐person education settings related to socialisation showed equal effectiveness 56 .…”

Interprofessional Interventions to Improve Serious Illness Communication in the Intensive Care Unit: A Scoping Review

“…We speculate that interventions in interprofessional communication may be effective through a multicomponent approach, tailored to the local setting. 42 Most studies targeted physicians and nurses. More research is needed to understand the impact of communication interventions via other ICU team members, such as social work, physical therapy, occupational therapy, nutrition, speech language pathology, respiratory therapy, and chaplaincy.…”

“…We speculate that interventions in interprofessional communication may be effective through a multicomponent approach, tailored to the local setting. 42…”

Window Treatment—Bringing Art and Joy to Hospital Rooms

“…The ongoing conversations created a sense of community that transcended usual boundaries. David, whose academic work involves integrating the arts in palliative care, witnessed this phenomenon multiple times and talked to Candice and Felicia about teaming up as co-authors to disseminate this impactful idea; both readily agreed.…”