Investigating Why Clinicians Deviate from Standards of Care: Liberating Patients from Mechanical Ventilation in the ICU

Abstract

Clinical practice guidelines, care pathways, and protocols are designed to support evidence-based practices for clinicians; however, their adoption remains a challenge. We set out to investigate why clinicians deviate from the "Wake Up and Breathe" protocol, an evidence-based guideline for liberating patients from mechanical ventilation in the intensive care unit (ICU). We conducted over 40 hours of direct observations of live clinical workflows, 17 interviews with frontline care providers, and 4 co-design workshops at three different medical intensive care units. Our findings indicate that unlike prior literature suggests, disagreement with the protocol is not a substantial barrier to adoption. Instead, the uncertainty surrounding the application of the protocol for individual patients leads clinicians to deprioritize adoption in favor of tasks where they have high certainty. Reflecting on these insights, we identify opportunities for technical systems to help clinicians in effectively executing the protocol and discuss future directions for HCI research to support the integration of protocols into clinical practice in complex, team-based healthcare settings.

Clinical Decision Support Opportunities among Clinicians Caring for People Receiving Invasive Mechanical Ventilation: A Cross-sectional Survey

“…Because of this complexity and uncertainty, there is significant variation in care delivery and outcomes for people receiving IMV with large inequities between rural and urban hospitals (Balas et al, 2022; Harlan et al, 2024; Kalhan et al, 2006; Mikkelsen et al, 2008; Qadir et al, 2021). By reducing unwarranted variation in care patterns, an artificial intelligence (AI) clinical decision support system (CDSS) could ameliorate uncertainty in these complex decisions (Chen et al, 2022; Gandhi et al, 2023) support personalized treatment recommendations,(Shah et al, 2021; Yildirim et al, 2024a), and overcome known barriers to optimal IMV care (Dexter and Schleyer, 2022; Fitzpatrick and Ellingsen, 2013; Yildirim et al, 2024b). Previously developed IMV CDSSs have focused on only one or a handful treatment decisions, and none provides suggestions for more than five ventilator settings simultaneously (Tehrani and Roum, 2008).…”