A. M. Stey1,2, P. Liu1, C. Wybourn1,2, T. Bongiovanni1,2, R. Menza1,2, V. Singh1,2, T. Cage1, N. Brennan2, G. Ryan3 1University of California San Francisco,San Francisco, CA, USA 2Zuckerberg San Francisco General Hospital,San Francisco, CA, USA 3RAND Health,Santa Monica, CA, USA
Introduction: The care of critically injured patients is complex and requires coordination across professionals from a wide range of disciplines including multidisciplinary staff. The aim of this study was to map out existing communication pathways and how they could be improved upon in the intensive care units.
Methods: A total of 21 semi-structured case-based interviews were performed in an open mixed neuro and surgical intensive care unit in a level 1 trauma urban academic-affiliated safety net hospital. Neurosurgery, trauma surgery team members, neurologists, intensivists, nurses, pharmacists, and respiratory therapists of diverse backgrounds and seniority were interviewed. Interviewees were presented with 4 case scenarios involved decision making around two competing priorities that would require multi-disciplinary communication to determine treatment and timing of intervention and asked to describe what they would do. The interviews responses were reviewed and range and central tendency are reported.
Results: The central tendency theme of shared responsibility among all multi-disciplinary staff was identified. There were a range of roles each provider played in the care of critically injured patients. The primary team were the actualizers of decisions and interventions. In addition to the actualizers, two other roles were identified including secondary decision makers and interveners. Secondary decision makers were often consultants whose opinions were perceived as indispensable prior to decision making or intervention. Interveners were frontline staff who were able to intervene if they felt a decision or intervention were discordant from clinical practice. There did seem to be considerable variation in the extent to which secondary decision makers and interveners could be engaged with the actualizers. A second important theme was the long communication routes among the teams. Typically, communication occurred between frontline staff between the teams and had to travel up and down hierarchies within the team prior to decision regarding treatment were implemented. When patients were gravely ill or disagreements/miscommunication through the standard pathway occurred, staff at the head of the hierarchies would reach out to their homologues directly to shorten the communication route. This seemed to resolve most disagreements due to a perception of mutual respect and perceived importance in the gesture between staff at the head of the hierarchies.
Conclusion: This study identified two themes including shared responsibility and long communication routes among teams. More research is needed to determine how communication could be improved upon both by promoting involvement of secondary decision makers and interveners as well as streamlining communication routes.