Putting ICU triage guidelines into practice: A simulation study using observations and interviews.

BACKGROUND: The COVID-19 pandemic has prompted many countries to formulate guidelines on how to deal with a worst-case scenario in which the number of patients needing intensive care unit (ICU) care exceeds the number of available beds. This study aims to explore the experiences of triage teams when triaging fictitious patients with the Dutch triage guidelines. It provides an overview of the factors that influence decision-making when performing ICU triage with triage guidelines. METHODS: Eight triage teams from four hospitals were given files of fictitious patients needing intensive care and instructed to triage these patients. Sessions were observed and audio-recorded. Four focus group interviews with triage team members were held to reflect on the sessions and the Dutch guidelines. The results were analyzed by inductive content analysis. RESULTS: The Dutch triage guidelines were the main basis for making triage decisions. However, some teams also allowed their own considerations (outside of the guidelines) to play a role when making triage decisions, for example to help avoid using non-medical criteria such as prioritization based on age group. Group processes also played a role in decision-making: triage choices can be influenced by the triagists' opinion on the guidelines and the carefulness with which they are applied. Intensivists, being most experienced in prognostication of critical illness, often had the most decisive role during triage sessions. CONCLUSIONS: Using the Dutch triage guidelines is feasible, but there were some inconsistencies in prioritization between teams that may be undesirable. ICU triage guideline writers should consider which aspects of their criteria might, when applied in practice, lead to inconsistencies or ethically questionable prioritization of patients. Practical training of triage team members in applying the guidelines, including explanation of the rationale underlying the triage criteria, might improve the willingness and ability of triage teams to follow the guidelines closely.

Learning shared decision-making in clinical practice.

OBJECTIVE: To explore how shared decision-making (SDM) is learned in clinical practice according to professionals and patients. METHODS: Focus group and individual interviews with interns (n = 9), residents (n = 12), senior physicians (n = 13), and (former) patients and relatives (n = 13) in fertility care and intensive care. RESULTS: Patients and professionals identified barriers and drivers for SDM related to patient, caregiver, and context. Participants agreed: the nuances of SDM are learned in practice, not during undergraduate medical education. Through observing and copying from other professionals, interns and residents describe building their personal "repertoire" of SDM skills, knowledge, and attitude. Professionals indicated it was helpful to see many different examples - both good and bad - of physicians in action. CONCLUSION: Learning SDM is a complicated task for both students and professionals in healthcare. Relevant factors are the involvement of patients, the role of informal learning processes and role models, and the importance of reflective practice. PRACTICE IMPLICATIONS: Learning SDM in practice requires 1) measures to lessen pressures on a meso and macro level that hinder SDM in practice, 2) inventive and precise training and education and paying explicit attention to informal learning processes in clinical practice and learning through role models.