Presentation
HE12 - Mapping “Time-Limited Trials” in the ICU: From Work-as-Imagined to Work-as-Done
SessionPoster Session 1
DescriptionBackground: In intensive care units (ICUs), critically ill patients often receive prolonged life-sustaining therapies without clearly defined milestones. This uncertainty can lead to prolonged life-sustaining therapy near end of life that doesn’t align with patients’ priorities, emotional distress for families, and burnout among healthcare providers. To address these challenges, time-limited trials (TLTs) are being used to provide a more explicit plan of care. TLTs are structured, collaborative plans between the clinical team and the patient or the patient’s surrogate decision maker, setting a defined timeframe for life-sustaining therapies (e.g. trial of mechanical ventilator for week). After this period, the patient's response to therapy will inform decisions on whether to continue life-sustaining therapies or shift the focus to comfort-based care.
While TLTs are designed to provide structure and clarity, current evidence suggests they are often implemented incompletely and face systematic barriers, which can undermine their intended benefits and may lead to unintended harm. At present, a significant gap exists in our understanding of when and why the TLT process tends to fall short, including which critical steps in the longitudinal process of a TLT are missed or incompletely performed. Addressing this gap is crucial for the design of interventions to support the optimal use of TLTs. Human factors and systems engineering principles are increasingly being applied in the ICU environment to improve complex care processes. In this study, we utilize the systems engineering approach to process mapping to identify and characterize vulnerabilities in the current TLT process.
Method: Our analysis was guided by a Delphi study, which established expert consensus on the essential elements required in any time-limited trial. From this study, we developed a 16-step process map, referred to as the "TLT Work As Imagined" process map, outlining the experts’ view of an ideal TLT process. To understand how TLT processes and discussions are currently occurring in ICUs, we conducted focused ethnography of patients undergoing a TLT in 5 hospitals across the US. Collected data included direct observations, electronic health record (EHR) notes, audio-recorded family meetings, and interviews with both clinicians and family members. For the current study we analyzed data from 3 hospitals.
Prior to coding, we developed a deductive codebook based on the 16-step “Work-as-Imagined” process map. Additionally, criteria were established to categorize each of the sixteen steps as fully completed, partially completed, or absent. We then applied a directed content analysis to the ethnographic data, with two independent coders using the codebook to systematically assess the implementation of each step in the TLT process. After this initial stage of coding, the coders engaged in a reconciliation process to compare their findings, resolve discrepancies, and build consensus.
Results: Among the 10 cases analyzed, only 1 case had 100% of the eligible essential steps fully executed, while two cases had less than 30% of the steps completed. Four cases had more than 75% of the steps executed, and eight cases had more than 50%. Across the 16 essential steps of a TLT, dissemination of plans was partially completed or absent in 80% of the cases. The discussion of patient goals, therapies, potential end-of-trial decisions, and documentation of the TLT plan were partially completed or absent in 50% of the cases. Additionally, consent for TLT participation was partially completed or absent in 40% of the cases, and clinical criteria were partially completed defined in 30% of the cases. Notably, three cases involved attending physician rotation during the time-limited trial. While one transition went smoothly, the other two interrupted the trial. In one case, the new attending switched to standard ICU care, and in another, there were issues regarding when the TLT was initiated and its intended duration.
Conclusions: We found that using the Work-As-Imagined Process Map to deductively identify steps in the work-as-done is a valuable approach for coding the dataset. The process map helps to identify intended TLT steps. Our findings build on the general observation that time-limited trials are often incomplete by showing exactly where they tend to fail as a longitudinal process. This work goes beyond previous studies by detailing when failures occur—whether during considering, planning, support, or the reassessment phase—and which specific steps are incompletely performed. We found that when TLT planning steps are suboptimal, subsequent phases of care were impacted. Moreover, dissemination and documentation of TLT plans emerged as key issues, with many plans either not being properly communicated or inadequately recorded. This becomes particularly critical during staff rotations, as new team members, unaware of the plan, may default to standard ICU care, potentially compromising the patient's goals. Future research should look into what are barriers to completion of TLT steps.
While TLTs are designed to provide structure and clarity, current evidence suggests they are often implemented incompletely and face systematic barriers, which can undermine their intended benefits and may lead to unintended harm. At present, a significant gap exists in our understanding of when and why the TLT process tends to fall short, including which critical steps in the longitudinal process of a TLT are missed or incompletely performed. Addressing this gap is crucial for the design of interventions to support the optimal use of TLTs. Human factors and systems engineering principles are increasingly being applied in the ICU environment to improve complex care processes. In this study, we utilize the systems engineering approach to process mapping to identify and characterize vulnerabilities in the current TLT process.
Method: Our analysis was guided by a Delphi study, which established expert consensus on the essential elements required in any time-limited trial. From this study, we developed a 16-step process map, referred to as the "TLT Work As Imagined" process map, outlining the experts’ view of an ideal TLT process. To understand how TLT processes and discussions are currently occurring in ICUs, we conducted focused ethnography of patients undergoing a TLT in 5 hospitals across the US. Collected data included direct observations, electronic health record (EHR) notes, audio-recorded family meetings, and interviews with both clinicians and family members. For the current study we analyzed data from 3 hospitals.
Prior to coding, we developed a deductive codebook based on the 16-step “Work-as-Imagined” process map. Additionally, criteria were established to categorize each of the sixteen steps as fully completed, partially completed, or absent. We then applied a directed content analysis to the ethnographic data, with two independent coders using the codebook to systematically assess the implementation of each step in the TLT process. After this initial stage of coding, the coders engaged in a reconciliation process to compare their findings, resolve discrepancies, and build consensus.
Results: Among the 10 cases analyzed, only 1 case had 100% of the eligible essential steps fully executed, while two cases had less than 30% of the steps completed. Four cases had more than 75% of the steps executed, and eight cases had more than 50%. Across the 16 essential steps of a TLT, dissemination of plans was partially completed or absent in 80% of the cases. The discussion of patient goals, therapies, potential end-of-trial decisions, and documentation of the TLT plan were partially completed or absent in 50% of the cases. Additionally, consent for TLT participation was partially completed or absent in 40% of the cases, and clinical criteria were partially completed defined in 30% of the cases. Notably, three cases involved attending physician rotation during the time-limited trial. While one transition went smoothly, the other two interrupted the trial. In one case, the new attending switched to standard ICU care, and in another, there were issues regarding when the TLT was initiated and its intended duration.
Conclusions: We found that using the Work-As-Imagined Process Map to deductively identify steps in the work-as-done is a valuable approach for coding the dataset. The process map helps to identify intended TLT steps. Our findings build on the general observation that time-limited trials are often incomplete by showing exactly where they tend to fail as a longitudinal process. This work goes beyond previous studies by detailing when failures occur—whether during considering, planning, support, or the reassessment phase—and which specific steps are incompletely performed. We found that when TLT planning steps are suboptimal, subsequent phases of care were impacted. Moreover, dissemination and documentation of TLT plans emerged as key issues, with many plans either not being properly communicated or inadequately recorded. This becomes particularly critical during staff rotations, as new team members, unaware of the plan, may default to standard ICU care, potentially compromising the patient's goals. Future research should look into what are barriers to completion of TLT steps.
Authors
Event Type
Poster Presentation
TimeMonday, March 314:45pm - 6:15pm EDT
LocationFrontenac Foyer
Digital Health (DH)
Simulation and Education (SE)
Hospital Environments (HE)
Medical and Drug Delivery Devices (MDD)
Patient Safety and Research Initiatives (PS)