Understanding Clinical Decision-Making of Ventilation Strategies in Acute Care: A Cognitive Engineering Approach

Abstract

Decision-making related to ventilation strategies for critically ill patients is a complex challenge faced by physicians in acute care. Common questions related to the decision-making of ventilation strategies are three-fold: (1) In whom to use non-invasive ventilation or invasive mechanical ventilation as the first line of therapy; (2) Which forms of non-invasive ventilation to use; (3) When to determine non-invasive ventilation has failed and intubation is needed. There exist gaps in studying the decision-making of ventilation strategies in the naturalistic work environment. This dissertation aims to bridge the gap by understanding and characterizing the cognitive requirements for decision-making and the cognitive challenges for tackling the complexities inherent in the work system where the decisions are made. To balance the dual goals of capturing clinicians’ knowledge, skills, and strategies as well as work system complexities, two cognitive engineering methods were selected: (1) Critical Decision Method and (2) Observations. We first used Critical Decision Method (structured multi-pass interviews) to elicit cognitive requirements needed for domain demands (e.g., how clinicians make decisions on ventilatory strategies) with opportunistic interpolation of the complexities inherent in the work systems. We identified five decision-making strategies that attending physicians use in their decision-making of ventilation therapy: (1) temporizing to allow for further clinical assessment; (2) using heuristics to simplify the problem; (3) prioritizing cues to deal with information overload and information conflicts; (4) mapping patient trajectory; (5) placing decisions in the context of resource availability. We then used observations in intensive care units (ICUs) to examine cognitive challenges related to electronic health record (EHR) use for decision-making related to respiratory support in the naturalistic setting. The results uncovered the complexities stemming from the ICU work environment. We identified three themes that represent major sequential stages related to clinical decision-making of ventilation therapy: (1) fragmented information and tasks for individual sensemaking; (2) EHR workarounds for collaborative decision-making; and (3) interruptive order entry and order execution. The results provided a comprehensive picture of the decision-making of ventilation strategies and insights for designing and implementing diagnostic clinical decision support to improve poorly supported cognition during individual sensemaking.