Time-limited trials in the ICU: a mixed-methods sequential explanatory study of intensivists at two academic centres

Elizabeth M Viglianti; Jennifer N Ervin; Chad A Newton; Jacqueline M Kruser; Theodore J Iwashyna; Thomas S Valley

doi:10.1136/bmjopen-2021-059325

Time-limited trials in the ICU: a mixed-methods sequential explanatory study of intensivists at two academic centres

BMJ Open. 2022 Apr 4;12(4):e059325. doi: 10.1136/bmjopen-2021-059325.

Authors

Elizabeth M Viglianti^{1

2}, Jennifer N Ervin³, Chad A Newton⁴, Jacqueline M Kruser⁵, Theodore J Iwashyna^{6

7

8}, Thomas S Valley^{6

9}

Affiliations

¹ Department of Internal Medicine Division of Pulmonary Critical Care, University of Michigan, Ann Arbor, Michigan, USA eviglian@med.umich.edu.
² Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.
³ Office of Health Affairs, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA.
⁴ Department of Internal Medicine Division of Pulmonary and Critical Care, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
⁵ Department of Medicine Division of Allergy, Pulmonary and Critical Care, University of Wisconsin-Madison, Madison, Wisconsin, USA.
⁶ Department of Internal Medicine Division of Pulmonary Critical Care, University of Michigan, Ann Arbor, Michigan, USA.
⁷ Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA.
⁸ Institute of Social Research, Ann Arbor, MI, USA.
⁹ Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA.

Abstract

Objective: To understand intensivist perceptions of the appropriateness of time-limited trials (TLTs)-a strategy to align life-sustaining care with patient goals and values in the midst of clinical uncertainty.

Design: We conducted a mixed-methods sequential explanatory study of intensive care unit (ICU) intensivists regarding appropriateness of utilising TLTs in three vignettes centred on invasive mechanical ventilation (IMV); continuous renal replacement therapy (CRRT); and heated high-flow nasal cannula (HHFNC). Semistructured interviews were conducted using the Tailored Implementation of Chronic Diseases framework. Data were analysed using thematic and matrix analysis.

Setting: Two academic medical centres in the USA participated in the randomised surveys and one centre participated in the semistructured interviews.

Participants: Pulmonary and critical care intensivists and fellows.

Primary and secondary outcomes: To understand intensivists perceptions of the appropriateness in using TLTs.

Results: Of 115 physicians surveyed, 71 initiated the survey and 44 completed the entire survey with a response rate of 38% (N=44/115) and a completion rate of 62% (N=44/71). While 35% (N=23/66) of intensivists had never heard of a TLT, of the intensivists who had heard of a TLT, 77% (N=33/43) had participated in one. In response to the vignettes, appropriateness of using a TLT varied (IMV: 74% (N=46/62); CRRT 78% (N=49/63); HHFNC 92% (N=56/61) as did the durations of the TLT. Semistructured interviews with 11 intensivists revealed having clarity about patient goals and clinical endpoints facilitated successful TLTs while lack of an evidenced-based framework was a barrier.

Conclusion: More than half of the physicians who responded had conducted or participated in a TLT. To increase the use of TLTs in the ICU, clinicians desire a more robust, evidence-based framework on how to conduct TLTs.

Keywords: Adult intensive & critical care; MEDICAL ETHICS; Protocols & guidelines; Quality in health care.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Clinical Decision-Making*
Critical Care
Humans
Intensive Care Units*
Surveys and Questionnaires
Uncertainty

Abstract

Publication types

MeSH terms

Grants and funding