- Email: [email protected]
How care decisions are made among interdisciplinary providers caring for critically injured patients: A qualitative study
Surgery xxx (2019) 1e5
Contents lists available at ScienceDirect
Surgery journal homepage: www.elsevier.com/locate/surg
How care decisions are made among interdisciplinary providers caring for critically injured patients: A qualitative study Anne M. Stey, MD, MSca,b,*, Christopher A. Wybourn, MDb, Audrey Lyndon, PhD, RNb,c, M. Margaret Knudson, MDb, R. Adams Dudley, MD, MBAb, Pingyang Liu, PhDb, Tasce Bongiovanni, MD, MPPb, Gery W. Ryan, PhDd a
Northwestern University, Chicago, IL University of California San Francisco, San Francisco, CA NYU Rory Meyers College of Nursing, New York, NY d RAND Corporation, Santa Monica, CA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 3 November 2019 Available online xxx
Background: Injury is the leading cause of death in people under 45 years of age in the United States; however, how care decisions occur in critical injury is poorly understood. This exploratory study sought to generate hypotheses about how care decisions are made among interdisciplinary providers caring for patients who have been critically injured. Methods: This was a qualitative study conducted at two intensive care units in a level 1 trauma center in an urban, teaching, safety-net hospital. Semistructured interviews consisted of case scenarios with competing clinical priorities presented to 25 interdisciplinary providers, elucidating how decisions are approached. Responses were recorded, transcribed, and coded. Thematic analysis was conducted to discover central themes. Category formulation and sorting was done for data reduction and thematic structuring of the data. The range and central tendency of these themes are reported. Results: The central theme for how care decisions are made among interdisciplinary providers was through the distribution of shared responsibility. The distribution of shared responsibility depended on interdisciplinary communication to navigate the two subthemes of time and roles. Time had to be navigated carefully, because it was both an opportunity for data acquisition and consensus building but also a pressure to decisively progress care. Roles were distinct but interchangeable and consisted of experts, actualizers, and questioners. Conclusion: Care decisions are made in the context of shared responsibility among interdisciplinary providers. Interdisciplinary communication is a means of establishing roles and navigating time to distribute shared responsibility among interdisciplinary providers. © 2019 Elsevier Inc. All rights reserved.
Introduction Unintentional and intentional injury are the leading cause of death among people aged 1 to 44 y.1 The Committee on Trauma of the American College of Surgeons has standardized prehospital and hospital-based care and has ensured that hospitals have optimal resources to provide evidence-based trauma care. However, mortality rates in critically injured patients remain high. The critically injured patient requires care from many interdisciplinary providers because of the multiple organ systems injured as well as systemic,
Presented at the 2019 Academic Surgical Congress. * Reprint requests: Anne M. Stey, 676 N. St. Clair, Suite 650, Chicago, IL 60611. E-mail address: [email protected] (A.M. Stey). https://doi.org/10.1016/j.surg.2019.11.009 0039-6060/© 2019 Elsevier Inc. All rights reserved.
physiologic consequences of injury.2 To deliver the best team-based care, applied psychology suggests all providers must first develop shared mental models of the problem.3 Shared mental models are a communal understanding of an underlying problem (eg, a diagnosis in clinical medicine). Second, providers must maintain situational awareness for effective triage of the injuries and for prioritization of treatment.4 Situational awareness is a communal understanding of the steps in a treatment plan as well as the anticipated outcomes including what would prompt a change in the treatment plan. Shared mental models and situational awareness propose how groups of individuals with different backgrounds and experiences can find common ground for team-based decisionmaking. Shared mental models and situational awareness have been found to increase team processes and performance.5,6
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Delays in care or inappropriate care can occur if providers are unable to convey their knowledge to develop those shared mental models needed for all providers to diagnose and triage an injury.7,8 Furthermore, secondary injury can occur if prioritization of treatment occurs without full situational awareness of when to reconsider treatment plans if the patient is clinically doing worse.9 It is unknown what specific themes guide care decisions among interdisciplinary providers caring for critically injured patients; however, exploring the interdisciplinary experience of the providers of what shapes diagnosis, triage of injury, and prioritization of treatment may improve the understanding of how care decisions are made in critically injured patients. Conducting an exploratory analysis of how two competing clinical priorities would be approached by interdisciplinary providers may define how care decisions are made.10 This exploratory, qualitative study sought to generate hypotheses about how care decisions are made among interdisciplinary providers caring for critically injured patients. Methods This study was conducted at two surgical intensive care units (ICUs) in a level 1 urban trauma center, which is also a safety-net hospital. Each ICU is a state-of-the-art, 16-bed unit. One unit is focused on patients with neurologic injuries and the other unit is focused on patients with all other traumatic injuries. Both units are hybrid open units. The primary teams are most commonly the neurosurgery team and the trauma surgery team. The primary teams write most of the daily orders. The ICU team writes orders for sedation, pain medication, ventilators, and intravenous infusions. The nurse-to-patient staffing ratio is 1:2 and occasionally 1:1. There are 1 or 2 respiratory therapists per unit depending on the number of ventilated patients and 1 critical-care pharmacist for both units. The study period was from October 2017 to December 2018. Data collection Data collection consisted of semi-structured interviews with 25 interdisciplinary providers from the 2 surgical ICUs and involving 20 hours of observations of team rounds. Semi-structured interviews To ensure that the full range of experiences and perspectives were captured, a diverse sample of providers were selected purposefully and recruited to participate in the study. Interviewees included nurses (including charge nurses), respiratory therapists, pharmacists, neurosurgery and trauma surgery nurse practitioners, as well as supervising attending physicians in neurosurgery, anesthesia, neurocritical care, and trauma surgery, most of whom were double-boarded in critical care. A minimum of two individuals in each role were interviewed. All roles contributed data to the primary themes that bridged across roles. Only professionals who had completed training were included in this study. The interviews were structured around four clinical scenarios (Appendix 1). To design the scenarios, we created a conceptual model for the interdisciplinary care of a critically injured patient from arrival to the trauma bay to ICU management. This conceptual model was expanded upon iteratively after feedback from clinical providers with expertise in management of critical injury, specifically ICU nurses, respiratory therapists, trauma surgeons, neurosurgeons, anesthesiologists, and intensivists boarded in critical care. Subsequently, four clinical scenarios were developed where different nodes in the model presented competing care priorities. These competing care priorities were usually system specific, such that interdisciplinary providers specialized in a given system would have to communicate their concern and recommendations with
other interdisciplinary providers to come to a consensus on how to move forward with the individual patient’s care. The goal was to expose opportunities for divergent clinical management to the interviewees and to then understand how they perceived or witnessed resolution. Last, individuals who did not participate in the study but were representative of each provider group reviewed the scenarios and gave feedback on their content. The reviewers of the scenarios were not eligible to participate in the study. Each scenario was designed with the most salient of two competing clinical priorities common in the trauma surgery ICU population that requires interdisciplinary decision-making. The clinical scenarios included: (1) goals of oxygen saturation in a patient with traumatic brain injury and acute respiratory distress syndrome; (2) prophylaxis and treatment of venous thromboembolism in a patient with an expanding intracranial hemorrhage; (3) trial extubation versus tracheostomy in a patient with a spinal cord injury; and (4) goals of care versus heroic interventions in a young, persistently unstable patient with penetrating thoracic injury. Each clinical scenario was edited by a senior ICU nurse, senior ICU respiratory therapist, trauma nurse practitioner, neurologist, surgical intensivist, neurosurgeon, and a trauma and orthopedic surgeon. After reading each scenario, interviewees were asked four specific questions to elucidate the priorities of the providers and how competing priorities were approached. These included: (1) When you read this case, what do you prioritize in the management of this patient? (2) What do you perceive as problems in the management? (3) What (if anything) could have been done better? (4) Are there ever disagreements in regard to treatment priorities in a case like this and what are these disagreements? A single interviewer and observer conducted 25 semi-structured interviews. All interviews were recorded and transcribed.
Observations A biomedical researcher with a PhD in biology observed approximately 20 hours of rounds throughout 7 days staggered over 5 months and noted interactions among interdisciplinary providers caring for critically injured patients. The observing researcher was introduced to the team as a research observer and given permission to shadow the various team members. The observer listened to team discussions during rounds and made notes without interjecting or asking questions directly to any providers. The primary tasks of the researcher were to note: (1) the number of and identity of providers during rounds; (2) which other interdisciplinary providers were mentioned (who were not in the rounds) with whom the team would need to communicate; and (3) how much time was spent discussing accessing other providers. Members of the researcher team would meet to debrief after rounding observation sessions. Approval for the interviews and observational components of this study were obtained from the Institutional Review Board of the University of California San Francisco.
Data analysis The transcriptions of the interviews were reviewed to identify content categories for systematic evaluation. Thematic analysis was conducted to discover central themes. Category formulation and sorting was done for data reduction and thematic structuring of the data. The thematic analysis was performed by two coders, and, where present, discrepancies were addressed with iterative revision to consensus, and a PhD-level anthropologist supervised development of the central theme and subthemes. The range and central tendency of these themes are reported.
A.M. Stey et al. / Surgery xxx (2019) 1e5
3
Results
Subtheme: The tension of time
The analysis yielded a central theme and two subthemes. The central theme for how care decisions are made among interdisciplinary providers caring for critically injured patients was through distribution of shared responsibility. The distribution of shared responsibility depended on interdisciplinary communication to navigate the two subthemes of time and roles. Time had to be navigated carefully, because it was both an opportunity for data acquisition and consensus building yet also a pressure to decisively progress care. Roles were distinct but interchangeable and consisted of experts, actualizers, and questioners.
Time as an opportunity Time emerged as an important theme in two ways that were in tension. First, time offered an opportunity for all interdisciplinary providers to assess the clinical scenario and to build consensus to develop shared mental models around injury diagnosis. Engaging all providers was highly valued in a context of shared responsibility even when it took time, as shown in the following statement:
Central theme: The distribution of shared responsibility
“It sometimes takes a few hours, but I think they do a really good job not making impulse decisions about large decisions and big decisions like that.”
There were two extremes in the distribution of shared responsibility. One side of the spectrum was a highly concentrated distribution of shared responsibility, where many interdisciplinary providers felt strongly that their treatment plan should be prioritized. Interviewees perceived this positively because of the high levels of engagement, as shown by the following statements:
Time was so highly valued that many providers reported that time was critical to doing their job properly and found it dangerous to be rushed, as shown in the following statement:
“I think there is an enhanced investment in our trauma patients and I think all of those people that you’ve described feel very integral and have been made to feel very important in the care of the patient and therefore hold a portion of the responsibility. ” “Everyone who works here feels like he or she is the staunchest patient advocate and they have to do itedo right by the patient.” “I think at the end of the day, everybody goes home and that’s the thing that they worry about the most: did I hurt this person?”
Time was also an opportunity that allowed teams to develop situational awareness, to anticipate changes in a patient’s course, and to reconsider the treatment plan if the patient was clinically doing worse. For example, a prolonged damage control operation may be a sign that the approach adopted by the surgical team should be reconsidered, as shown in the following statement:
When there were such high levels of engagement, shared responsibility could lead to disagreements when various teams prioritized different injuries. Strong engagement of so many providers could lead to the distribution of shared responsibility becoming too diffuse. As a result, decision-making concerning care could become stalled and fail to progress, as shown by the following statements:
Some providers delineated anticipated outcomes verbally over time that could signal a need for a change in treatment plan, thereby creating situational awareness. For example, the continued need for aggressive transfusion in a bleeding patient being managed non-operatively over the course of a shift may prompt an operation to control hemorrhage as one interviewee mentioned in the following statement:
“I’ve seen teams butt heads. [There has to be an] answer to coming to an agreement, or meeting down the middle. And I’ve seen it go on for days and there has to be some governing person to say, ‘No, this is it.’” “Trauma knows so much about one thing, neurosurgery knows so much about another thing, but when it comes to a bad, injured-in-many-systems individual, [we need to] tie everything together so that everybody’s on board from respiratory therapy all the way up to the top. “ “Our multidisciplinary approach enhances getting expertise to the bedside at the expense of sometimes having someone who’s the captain of the ship to the exclusion of others. But it leads to the risk of diffusion of responsibility.” “Responsibility could be spread too thin and lead to a lack of accountability”.
“[Some providers] will continuously resuscitate and put hundreds of units of blood into someone. Wait eif you're continuously needing to resuscitate please call me. I will sometimes make [treatment] decisions before [that continuous resuscitation] actually happens to the patient.”
Multiple interviewees noted that this diffusion of shared responsibility led to the following unaddressed clinical issues: “Where we have multiple teams involved sometimes we think somebody else is taking care of something.” “[The primary] team could be like ‘Well I thought you were going to address that.’ ‘Oh, I thought you were going to address [it].’ And then all of a sudden, ‘Well I didn't know.’”
“We rushed too soon and didn't catch all the potential hazards of his injuries, the secondary injuries”
“I’d want to know why their operation took so long. I mean, that’s concerning.”
Time as a pressure Second, time was a pressure creating a sense of urgency around diagnosis of the injury, triage, and then prioritization of treatment. Urgency was particularly strong if the injury was considered life or function-threatening, as shown in the following statements: “The patient should have a fast exam that would have gotten them to the OR sooner.” “What time the decision was made to extubate and what time he actually extubated is one of the other things we often don't prioritize in our conversations to make sure that a reintubation isn't happening late in the day or at night.” Time as pressure also enabled teams to perform their prioritization of treatment in a structured way. Time pressure seemed particularly potent when injuries were very time-sensitive such as neurologic injuries, as shown in the following statements:
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“We try to put a timeline in our head. I take all these injuries and stack them head to toe with different normal trajectories. I try to find where we should be with all our treatments.” “It depends on the time in his hospital course, but the prioritization early on toward things focusing around treatment of his acute spinal cord injury is right.” “She’s already got global ischemic damage, that’s a conversation that really needs to happen with the family [that] we may not have a lot to recover here. I’m not sure that we’re going to have time to stop the train.”
critical care physician most frequently sought to communicate with other trauma team members, interventional radiology, critical care, neurology, orthopedics, cardiology, and pharmacy. In contrast, interdisciplinary rounding team members did not always offer information during rounds, and even when questioned directly by the supervising trauma surgeon. The questions went unanswered by certain interdisciplinary rounding team members present. Critical care physicians abstained from answering questions directly posed to them by the supervising trauma surgeon 60% of the time. Pharmacists abstained from answering questions 50% of the time.
Subtheme: Distinct yet interchangeable roles
Discussion
Three distinct roles were taken by interdisciplinary providersdexperts, actualizers, and questioners. The decision-makers were usually the experts. The experts could be the senior member of the primary team or specialty consultants, indispensable for the diagnosis of injury, triage, and prioritization of treatment. The experts had to remain accessible to another key individualdthe actualizers. The actualizers were the providers who were usually in most direct contact with the patient. They put care plans into motion and often observed the first signs of a problem. When problems arose, the actualizers had to get the attention and state the problem to the expert. Some actualizers believed that experts did not always respond to their concerns, as shown in the following statement:
This was an exploratory study to generate hypotheses about how care decisions are made among interdisciplinary providers caring for critically injured patients. This study identified that care decisions made among interdisciplinary providers caring for critically injured patients occur through the distribution of shared responsibility. Interdisciplinary communication was a means of establishing roles and navigating time to distribute shared responsibility among providers; however, team members often withheld comments during rounds. Managing critically ill patients with injuries involving multiple organ systems requires the development of a shared mental model around diagnosis and triage of injury and then prioritizing treatments to create situational awareness. Developing shared mental models and situational awareness is achieved through effective interdisciplinary communication, but this communication did not always occur even when given the opportunity, as shown in the following statement: “People who communicate well, [take time to] explain why and what we’re looking for. Let’s do it this way and if we don’t see this resolved, then we’ll back up and maybe try your way…But when [people don’t communicate] well, discussion sends people seething and we don’t actually get an answer to questions.” The stress of the environment and/or the communication styles of various individuals may prevent the effective communication needed to develop shared mental models around the diagnosis and triage of injury. Different styles of communication can also limit appropriate prioritization of treatment if there is an inability to create situational awareness that should anticipate changes in trajectory. Ineffective interdisciplinary communication may result in roles and time being navigated ineffectively, and the distribution of shared responsibility may be too thin such that care suffers, as shown in the following statement: “Occasionally, the shot-caller gets flustered and they just run to the safe zonedthe OR. There has to be a point guard or that one person in the room to handle the energy level and the emotion. I’ve seen moments where that person’s emotions were wild and just careless. That grabs up everybody else and they all start missing details.” However, the high-stress environment of resuscitation of the critically injured patient is when effective interdisciplinary communication that establishes roles and navigates time to distribute shared responsibility among providers could offer the greatest opportunity to improve patient outcomes, as shown in the following statement: “The two extremes of shared responsibility are where the communication actually is the most important because [either] somebody could fall through the cracks if nobody’s taking actual responsibility or there’s too much tension and you actually don’t know what the best decision is. The observational component of this study documented variable participation of individuals in observed rounds and suggested that, even when given opportunities for interdisciplinary communication, not all members of the interdisciplinary team participate. If interdisciplinary communication does not occur, then time and roles are not navigated effectively, and shared responsibility is not
“At all levels, there are providers that I feel very comfortable expressing concerns to and then there are others that I either feel brushed off by or maybe I wouldn't take as many concerns to them because I think that they’ll be mean about it.” The third role identified were questioners or providers who would interject if they believed that a decision or intervention was discordant from ideal or conventional clinical practice. Being a questioner is difficult, because she or he would have to question the decision made by other providers. As one interviewee put it, “It is never easy to say, ‘Hey boss no.’” Providers felt comfortable being questioners if they had established relationships, as shown in the following statement: “We have all worked together, we’re a small team, and because we have a solid group, who’s worked together for quite a while…there’s respect at that level.” Conversely, younger or newer people may have found it more difficult to question, as shown in the following statement: “Not everyone feels comfortable speaking up if they don’t agree with something, especially some of the younger, newer people. They will talk among themselves instead. That happens a lot.” The roles were interchangeable. Some supervising physicians perceived themselves as the experts, the nurse practitioners as the actualizers, and the nurses as the questioners. Some nurse practitioners perceived themselves as the actualizers, the specialty consultants as the experts, and the primary supervising physicians as the questioners. There was a perception that all providers should be able to be the questioners in the context of shared responsibility, as shown in the following statement: “People who are new to our environment or have a personality that is not as forward will struggle a little bit because you have to be willing to stand toe to toe with these people that you very much respect.” Observed interdisciplinary participation on rounds During trauma rounds, a supervising trauma surgeon, nurse practitioners, trainee physicians, pharmacists, bedside nurses, and a
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distributed appropriately. Addressing this problem will require not only creating opportunities for communication but will also determine what pushes individuals to participate meaningfully in communication and be heard so that the entire team benefits from different perspectives. The entire function of the interdisciplinary team is undermined when the exchange of information does not occur, because other team members may assume incorrectly that all attendees participated fully, just because they were physically present. Effective teamwork relies on individuals feeling responsibility and being able to act decisively to voice their observations and expertise.11 Nonetheless, a clear definition of individual roles is an important component of high-functioning teams.12,13 Effective interdisciplinary communication may be the best means to ensure that both of these criteria are fulfilled. Indeed, data support the concept that effective interdisciplinary communication improves outcomes.14 However, interdisciplinary communication may be limited by the climate of teamwork and psychologic safety.15 The abstention from participation in interdisciplinary rounds with one of the primary rounding teams in the ICU was dramatic and may have been subject to time constraints and the boundaries of the hierarchy in the format of structured rounds.16 Other known barriers to interdisciplinary communication are interruptions17 and stressful situations that narrow an individual’s attention span and limit the receipt of potentially important information.18 Promoting interdisciplinary communication requires not only creating opportunities for communication but encouraging individuals to participate meaningfully during those opportunities. This study has several limitations. First, the Hawthorne effect (ie, the alternation of behavior by participants attributable to their awareness of being observed) is a potential limitation, because the teams were cognizant that study staff were observing rounds for research purposes. This awareness may have altered the rounding practice/behaviors of the team, thereby leading them, to deviate from their normal routine; however, the teams appeared to acclimate quickly to the presence of the observer. Second, although a variety of interdisciplinary providers were interviewed, the full range of providers caring for critically injured patients was not captured, such as speech, occupational, physical therapists, dieticians, and orthopedic surgeons. Third, the person conducting the interviews was a provider who had worked closely clinically with many interviewees. The relationship may have framed the responses, thereby limiting the scope of the data. Fourth, seeking participation of a minimum of two per role may not have been enough to elaborate all possible themes. Nevertheless, there was consistence of themes across all roles, and the observation of central themes likely still holds. Another limitation of this study is that trainees were not included as study participants. This study focused on how decisions are made among fully trained, interdisciplinary providers. Although trainees in a teaching hospital are absolutely a critical component of the care teams, the ability of trainees to make decisions, particularly when there are competing priorities, may be highly variable. The ability of a trainee to incorporate information, act on it, and communicate may vary greatly by individual, by level, and by time of day.19 A dedicated follow-up study to understand the influence of trainees on inter-team dynamics and communication is planned. In conclusion, care decisions for critically injured patients are made in the context of shared responsibility. Interdisciplinary communication establishes roles and navigates time to distribute shared responsibility among providers. Despite the interviewees suggesting that interprofessional communication is critical for navigating the time and the roles to distribute shared responsibility, the observational component of this study
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demonstrated that, in practice, interprofessional communication does not always occur even when there is the opportunity for such communication. The high-stakes task of caring for critically injured patients may be an opportunity where defining and promoting effective, interdisciplinary communication could improve patient outcomes after injury. Funding/Support None of the authors have any funding sources to report. Conflict of interest/Disclosure None of the authors have any conflicts of interest to disclose. Supplementary materials Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/j.surg.2019. 11.009. References 1. Centers for Disease Control and Prevention. National Center for Health Statistics Z-force data files Web site. https://www.cdc.gov/growthcharts/zscore.htm. Accessed February 4, 2019. 2. Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Shackford SR, Eastman AB. The significance of critical care errors in causing preventable death in trauma patients in a trauma system. J Trauma. 1991;31:813e818; discussion 818e819. 3. Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/ mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013;41(9 Suppl 1):S116eS127. 4. Fackler JC, Watts C, Grome A, Miller T, Crandall B, Pronovost P. Critical care physician cognitive task analysis: an exploratory study. Crit Care. 2009;13:R33. 5. Edwards BD, Day EA, Arthur W, Bell ST. Relationships among team ability composition, team mental models, and team performance. J Appl Psychol. 2006;91:727e736. 6. Mathieu JE, Heffner TS, Goodwin GF, Salas E, Cannon-Bowers JA. The influence of shared mental models on team process and performance. J Appl Psychol. 2000;85:273e283. 7. Ferguson EJ, Brown M. Concurrent case review and retrospective review using the matrix method are complementary methods for tracking and improving timeliness of care in a level I trauma center. Am Surg. 2016;82:319e324. 8. Girard E, Jegousso Q, Boussat B, et al. Preventable deaths in a French regional trauma system: a six-year analysis of severe trauma mortality. J Visc Surg. 2019;156:10e16. 9. Sharwood LN, Stanford R, Middleton JW, et al. Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol. BMJ Open. 2017;7:e012377. 10. Weldon SM, Korkiakangas T, Bezemer J, Kneebone R. Communication in the operating theatre. Br J Surg. 2013;100:1677e1688. 11. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85ei90. 12. Southwick F. Who was caring for Mary? Ann Intern Med. 1993;118:146e148. 13. Southwick FS, Spear SJ. Commentary: “Who was caring for Mary?” revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement. Acad Med. 2009;84:1648e1650. 14. Rangachari P, Rissing P, Wagner P, et al. A baseline study of communication networks related to evidence-based infection prevention practices in an intensive care unit. Qual Manag Health Care. 2010;19:330e348. 15. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105:877e884. 16. Shoham DA, Harris JK, Mundt M, McGaghie W. A network model of communication in an interprofessional team of healthcare professionals: a crosssectional study of a burn unit. J Interprof Care. 2016;30:661e667. 17. Alvarez G, Coiera E. Interdisciplinary communication: an uncharted source of medical error? J Crit Care. 2006;21:236e242; discussion 242. 18. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745e749. 19. Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210:17e22.
Contents lists available at ScienceDirect
Surgery journal homepage: www.elsevier.com/locate/surg
How care decisions are made among interdisciplinary providers caring for critically injured patients: A qualitative study Anne M. Stey, MD, MSca,b,*, Christopher A. Wybourn, MDb, Audrey Lyndon, PhD, RNb,c, M. Margaret Knudson, MDb, R. Adams Dudley, MD, MBAb, Pingyang Liu, PhDb, Tasce Bongiovanni, MD, MPPb, Gery W. Ryan, PhDd a
Northwestern University, Chicago, IL University of California San Francisco, San Francisco, CA NYU Rory Meyers College of Nursing, New York, NY d RAND Corporation, Santa Monica, CA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 3 November 2019 Available online xxx
Background: Injury is the leading cause of death in people under 45 years of age in the United States; however, how care decisions occur in critical injury is poorly understood. This exploratory study sought to generate hypotheses about how care decisions are made among interdisciplinary providers caring for patients who have been critically injured. Methods: This was a qualitative study conducted at two intensive care units in a level 1 trauma center in an urban, teaching, safety-net hospital. Semistructured interviews consisted of case scenarios with competing clinical priorities presented to 25 interdisciplinary providers, elucidating how decisions are approached. Responses were recorded, transcribed, and coded. Thematic analysis was conducted to discover central themes. Category formulation and sorting was done for data reduction and thematic structuring of the data. The range and central tendency of these themes are reported. Results: The central theme for how care decisions are made among interdisciplinary providers was through the distribution of shared responsibility. The distribution of shared responsibility depended on interdisciplinary communication to navigate the two subthemes of time and roles. Time had to be navigated carefully, because it was both an opportunity for data acquisition and consensus building but also a pressure to decisively progress care. Roles were distinct but interchangeable and consisted of experts, actualizers, and questioners. Conclusion: Care decisions are made in the context of shared responsibility among interdisciplinary providers. Interdisciplinary communication is a means of establishing roles and navigating time to distribute shared responsibility among interdisciplinary providers. © 2019 Elsevier Inc. All rights reserved.
Introduction Unintentional and intentional injury are the leading cause of death among people aged 1 to 44 y.1 The Committee on Trauma of the American College of Surgeons has standardized prehospital and hospital-based care and has ensured that hospitals have optimal resources to provide evidence-based trauma care. However, mortality rates in critically injured patients remain high. The critically injured patient requires care from many interdisciplinary providers because of the multiple organ systems injured as well as systemic,
Presented at the 2019 Academic Surgical Congress. * Reprint requests: Anne M. Stey, 676 N. St. Clair, Suite 650, Chicago, IL 60611. E-mail address: [email protected] (A.M. Stey). https://doi.org/10.1016/j.surg.2019.11.009 0039-6060/© 2019 Elsevier Inc. All rights reserved.
physiologic consequences of injury.2 To deliver the best team-based care, applied psychology suggests all providers must first develop shared mental models of the problem.3 Shared mental models are a communal understanding of an underlying problem (eg, a diagnosis in clinical medicine). Second, providers must maintain situational awareness for effective triage of the injuries and for prioritization of treatment.4 Situational awareness is a communal understanding of the steps in a treatment plan as well as the anticipated outcomes including what would prompt a change in the treatment plan. Shared mental models and situational awareness propose how groups of individuals with different backgrounds and experiences can find common ground for team-based decisionmaking. Shared mental models and situational awareness have been found to increase team processes and performance.5,6
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Delays in care or inappropriate care can occur if providers are unable to convey their knowledge to develop those shared mental models needed for all providers to diagnose and triage an injury.7,8 Furthermore, secondary injury can occur if prioritization of treatment occurs without full situational awareness of when to reconsider treatment plans if the patient is clinically doing worse.9 It is unknown what specific themes guide care decisions among interdisciplinary providers caring for critically injured patients; however, exploring the interdisciplinary experience of the providers of what shapes diagnosis, triage of injury, and prioritization of treatment may improve the understanding of how care decisions are made in critically injured patients. Conducting an exploratory analysis of how two competing clinical priorities would be approached by interdisciplinary providers may define how care decisions are made.10 This exploratory, qualitative study sought to generate hypotheses about how care decisions are made among interdisciplinary providers caring for critically injured patients. Methods This study was conducted at two surgical intensive care units (ICUs) in a level 1 urban trauma center, which is also a safety-net hospital. Each ICU is a state-of-the-art, 16-bed unit. One unit is focused on patients with neurologic injuries and the other unit is focused on patients with all other traumatic injuries. Both units are hybrid open units. The primary teams are most commonly the neurosurgery team and the trauma surgery team. The primary teams write most of the daily orders. The ICU team writes orders for sedation, pain medication, ventilators, and intravenous infusions. The nurse-to-patient staffing ratio is 1:2 and occasionally 1:1. There are 1 or 2 respiratory therapists per unit depending on the number of ventilated patients and 1 critical-care pharmacist for both units. The study period was from October 2017 to December 2018. Data collection Data collection consisted of semi-structured interviews with 25 interdisciplinary providers from the 2 surgical ICUs and involving 20 hours of observations of team rounds. Semi-structured interviews To ensure that the full range of experiences and perspectives were captured, a diverse sample of providers were selected purposefully and recruited to participate in the study. Interviewees included nurses (including charge nurses), respiratory therapists, pharmacists, neurosurgery and trauma surgery nurse practitioners, as well as supervising attending physicians in neurosurgery, anesthesia, neurocritical care, and trauma surgery, most of whom were double-boarded in critical care. A minimum of two individuals in each role were interviewed. All roles contributed data to the primary themes that bridged across roles. Only professionals who had completed training were included in this study. The interviews were structured around four clinical scenarios (Appendix 1). To design the scenarios, we created a conceptual model for the interdisciplinary care of a critically injured patient from arrival to the trauma bay to ICU management. This conceptual model was expanded upon iteratively after feedback from clinical providers with expertise in management of critical injury, specifically ICU nurses, respiratory therapists, trauma surgeons, neurosurgeons, anesthesiologists, and intensivists boarded in critical care. Subsequently, four clinical scenarios were developed where different nodes in the model presented competing care priorities. These competing care priorities were usually system specific, such that interdisciplinary providers specialized in a given system would have to communicate their concern and recommendations with
other interdisciplinary providers to come to a consensus on how to move forward with the individual patient’s care. The goal was to expose opportunities for divergent clinical management to the interviewees and to then understand how they perceived or witnessed resolution. Last, individuals who did not participate in the study but were representative of each provider group reviewed the scenarios and gave feedback on their content. The reviewers of the scenarios were not eligible to participate in the study. Each scenario was designed with the most salient of two competing clinical priorities common in the trauma surgery ICU population that requires interdisciplinary decision-making. The clinical scenarios included: (1) goals of oxygen saturation in a patient with traumatic brain injury and acute respiratory distress syndrome; (2) prophylaxis and treatment of venous thromboembolism in a patient with an expanding intracranial hemorrhage; (3) trial extubation versus tracheostomy in a patient with a spinal cord injury; and (4) goals of care versus heroic interventions in a young, persistently unstable patient with penetrating thoracic injury. Each clinical scenario was edited by a senior ICU nurse, senior ICU respiratory therapist, trauma nurse practitioner, neurologist, surgical intensivist, neurosurgeon, and a trauma and orthopedic surgeon. After reading each scenario, interviewees were asked four specific questions to elucidate the priorities of the providers and how competing priorities were approached. These included: (1) When you read this case, what do you prioritize in the management of this patient? (2) What do you perceive as problems in the management? (3) What (if anything) could have been done better? (4) Are there ever disagreements in regard to treatment priorities in a case like this and what are these disagreements? A single interviewer and observer conducted 25 semi-structured interviews. All interviews were recorded and transcribed.
Observations A biomedical researcher with a PhD in biology observed approximately 20 hours of rounds throughout 7 days staggered over 5 months and noted interactions among interdisciplinary providers caring for critically injured patients. The observing researcher was introduced to the team as a research observer and given permission to shadow the various team members. The observer listened to team discussions during rounds and made notes without interjecting or asking questions directly to any providers. The primary tasks of the researcher were to note: (1) the number of and identity of providers during rounds; (2) which other interdisciplinary providers were mentioned (who were not in the rounds) with whom the team would need to communicate; and (3) how much time was spent discussing accessing other providers. Members of the researcher team would meet to debrief after rounding observation sessions. Approval for the interviews and observational components of this study were obtained from the Institutional Review Board of the University of California San Francisco.
Data analysis The transcriptions of the interviews were reviewed to identify content categories for systematic evaluation. Thematic analysis was conducted to discover central themes. Category formulation and sorting was done for data reduction and thematic structuring of the data. The thematic analysis was performed by two coders, and, where present, discrepancies were addressed with iterative revision to consensus, and a PhD-level anthropologist supervised development of the central theme and subthemes. The range and central tendency of these themes are reported.
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Results
Subtheme: The tension of time
The analysis yielded a central theme and two subthemes. The central theme for how care decisions are made among interdisciplinary providers caring for critically injured patients was through distribution of shared responsibility. The distribution of shared responsibility depended on interdisciplinary communication to navigate the two subthemes of time and roles. Time had to be navigated carefully, because it was both an opportunity for data acquisition and consensus building yet also a pressure to decisively progress care. Roles were distinct but interchangeable and consisted of experts, actualizers, and questioners.
Time as an opportunity Time emerged as an important theme in two ways that were in tension. First, time offered an opportunity for all interdisciplinary providers to assess the clinical scenario and to build consensus to develop shared mental models around injury diagnosis. Engaging all providers was highly valued in a context of shared responsibility even when it took time, as shown in the following statement:
Central theme: The distribution of shared responsibility
“It sometimes takes a few hours, but I think they do a really good job not making impulse decisions about large decisions and big decisions like that.”
There were two extremes in the distribution of shared responsibility. One side of the spectrum was a highly concentrated distribution of shared responsibility, where many interdisciplinary providers felt strongly that their treatment plan should be prioritized. Interviewees perceived this positively because of the high levels of engagement, as shown by the following statements:
Time was so highly valued that many providers reported that time was critical to doing their job properly and found it dangerous to be rushed, as shown in the following statement:
“I think there is an enhanced investment in our trauma patients and I think all of those people that you’ve described feel very integral and have been made to feel very important in the care of the patient and therefore hold a portion of the responsibility. ” “Everyone who works here feels like he or she is the staunchest patient advocate and they have to do itedo right by the patient.” “I think at the end of the day, everybody goes home and that’s the thing that they worry about the most: did I hurt this person?”
Time was also an opportunity that allowed teams to develop situational awareness, to anticipate changes in a patient’s course, and to reconsider the treatment plan if the patient was clinically doing worse. For example, a prolonged damage control operation may be a sign that the approach adopted by the surgical team should be reconsidered, as shown in the following statement:
When there were such high levels of engagement, shared responsibility could lead to disagreements when various teams prioritized different injuries. Strong engagement of so many providers could lead to the distribution of shared responsibility becoming too diffuse. As a result, decision-making concerning care could become stalled and fail to progress, as shown by the following statements:
Some providers delineated anticipated outcomes verbally over time that could signal a need for a change in treatment plan, thereby creating situational awareness. For example, the continued need for aggressive transfusion in a bleeding patient being managed non-operatively over the course of a shift may prompt an operation to control hemorrhage as one interviewee mentioned in the following statement:
“I’ve seen teams butt heads. [There has to be an] answer to coming to an agreement, or meeting down the middle. And I’ve seen it go on for days and there has to be some governing person to say, ‘No, this is it.’” “Trauma knows so much about one thing, neurosurgery knows so much about another thing, but when it comes to a bad, injured-in-many-systems individual, [we need to] tie everything together so that everybody’s on board from respiratory therapy all the way up to the top. “ “Our multidisciplinary approach enhances getting expertise to the bedside at the expense of sometimes having someone who’s the captain of the ship to the exclusion of others. But it leads to the risk of diffusion of responsibility.” “Responsibility could be spread too thin and lead to a lack of accountability”.
“[Some providers] will continuously resuscitate and put hundreds of units of blood into someone. Wait eif you're continuously needing to resuscitate please call me. I will sometimes make [treatment] decisions before [that continuous resuscitation] actually happens to the patient.”
Multiple interviewees noted that this diffusion of shared responsibility led to the following unaddressed clinical issues: “Where we have multiple teams involved sometimes we think somebody else is taking care of something.” “[The primary] team could be like ‘Well I thought you were going to address that.’ ‘Oh, I thought you were going to address [it].’ And then all of a sudden, ‘Well I didn't know.’”
“We rushed too soon and didn't catch all the potential hazards of his injuries, the secondary injuries”
“I’d want to know why their operation took so long. I mean, that’s concerning.”
Time as a pressure Second, time was a pressure creating a sense of urgency around diagnosis of the injury, triage, and then prioritization of treatment. Urgency was particularly strong if the injury was considered life or function-threatening, as shown in the following statements: “The patient should have a fast exam that would have gotten them to the OR sooner.” “What time the decision was made to extubate and what time he actually extubated is one of the other things we often don't prioritize in our conversations to make sure that a reintubation isn't happening late in the day or at night.” Time as pressure also enabled teams to perform their prioritization of treatment in a structured way. Time pressure seemed particularly potent when injuries were very time-sensitive such as neurologic injuries, as shown in the following statements:
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“We try to put a timeline in our head. I take all these injuries and stack them head to toe with different normal trajectories. I try to find where we should be with all our treatments.” “It depends on the time in his hospital course, but the prioritization early on toward things focusing around treatment of his acute spinal cord injury is right.” “She’s already got global ischemic damage, that’s a conversation that really needs to happen with the family [that] we may not have a lot to recover here. I’m not sure that we’re going to have time to stop the train.”
critical care physician most frequently sought to communicate with other trauma team members, interventional radiology, critical care, neurology, orthopedics, cardiology, and pharmacy. In contrast, interdisciplinary rounding team members did not always offer information during rounds, and even when questioned directly by the supervising trauma surgeon. The questions went unanswered by certain interdisciplinary rounding team members present. Critical care physicians abstained from answering questions directly posed to them by the supervising trauma surgeon 60% of the time. Pharmacists abstained from answering questions 50% of the time.
Subtheme: Distinct yet interchangeable roles
Discussion
Three distinct roles were taken by interdisciplinary providersdexperts, actualizers, and questioners. The decision-makers were usually the experts. The experts could be the senior member of the primary team or specialty consultants, indispensable for the diagnosis of injury, triage, and prioritization of treatment. The experts had to remain accessible to another key individualdthe actualizers. The actualizers were the providers who were usually in most direct contact with the patient. They put care plans into motion and often observed the first signs of a problem. When problems arose, the actualizers had to get the attention and state the problem to the expert. Some actualizers believed that experts did not always respond to their concerns, as shown in the following statement:
This was an exploratory study to generate hypotheses about how care decisions are made among interdisciplinary providers caring for critically injured patients. This study identified that care decisions made among interdisciplinary providers caring for critically injured patients occur through the distribution of shared responsibility. Interdisciplinary communication was a means of establishing roles and navigating time to distribute shared responsibility among providers; however, team members often withheld comments during rounds. Managing critically ill patients with injuries involving multiple organ systems requires the development of a shared mental model around diagnosis and triage of injury and then prioritizing treatments to create situational awareness. Developing shared mental models and situational awareness is achieved through effective interdisciplinary communication, but this communication did not always occur even when given the opportunity, as shown in the following statement: “People who communicate well, [take time to] explain why and what we’re looking for. Let’s do it this way and if we don’t see this resolved, then we’ll back up and maybe try your way…But when [people don’t communicate] well, discussion sends people seething and we don’t actually get an answer to questions.” The stress of the environment and/or the communication styles of various individuals may prevent the effective communication needed to develop shared mental models around the diagnosis and triage of injury. Different styles of communication can also limit appropriate prioritization of treatment if there is an inability to create situational awareness that should anticipate changes in trajectory. Ineffective interdisciplinary communication may result in roles and time being navigated ineffectively, and the distribution of shared responsibility may be too thin such that care suffers, as shown in the following statement: “Occasionally, the shot-caller gets flustered and they just run to the safe zonedthe OR. There has to be a point guard or that one person in the room to handle the energy level and the emotion. I’ve seen moments where that person’s emotions were wild and just careless. That grabs up everybody else and they all start missing details.” However, the high-stress environment of resuscitation of the critically injured patient is when effective interdisciplinary communication that establishes roles and navigates time to distribute shared responsibility among providers could offer the greatest opportunity to improve patient outcomes, as shown in the following statement: “The two extremes of shared responsibility are where the communication actually is the most important because [either] somebody could fall through the cracks if nobody’s taking actual responsibility or there’s too much tension and you actually don’t know what the best decision is. The observational component of this study documented variable participation of individuals in observed rounds and suggested that, even when given opportunities for interdisciplinary communication, not all members of the interdisciplinary team participate. If interdisciplinary communication does not occur, then time and roles are not navigated effectively, and shared responsibility is not
“At all levels, there are providers that I feel very comfortable expressing concerns to and then there are others that I either feel brushed off by or maybe I wouldn't take as many concerns to them because I think that they’ll be mean about it.” The third role identified were questioners or providers who would interject if they believed that a decision or intervention was discordant from ideal or conventional clinical practice. Being a questioner is difficult, because she or he would have to question the decision made by other providers. As one interviewee put it, “It is never easy to say, ‘Hey boss no.’” Providers felt comfortable being questioners if they had established relationships, as shown in the following statement: “We have all worked together, we’re a small team, and because we have a solid group, who’s worked together for quite a while…there’s respect at that level.” Conversely, younger or newer people may have found it more difficult to question, as shown in the following statement: “Not everyone feels comfortable speaking up if they don’t agree with something, especially some of the younger, newer people. They will talk among themselves instead. That happens a lot.” The roles were interchangeable. Some supervising physicians perceived themselves as the experts, the nurse practitioners as the actualizers, and the nurses as the questioners. Some nurse practitioners perceived themselves as the actualizers, the specialty consultants as the experts, and the primary supervising physicians as the questioners. There was a perception that all providers should be able to be the questioners in the context of shared responsibility, as shown in the following statement: “People who are new to our environment or have a personality that is not as forward will struggle a little bit because you have to be willing to stand toe to toe with these people that you very much respect.” Observed interdisciplinary participation on rounds During trauma rounds, a supervising trauma surgeon, nurse practitioners, trainee physicians, pharmacists, bedside nurses, and a
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distributed appropriately. Addressing this problem will require not only creating opportunities for communication but will also determine what pushes individuals to participate meaningfully in communication and be heard so that the entire team benefits from different perspectives. The entire function of the interdisciplinary team is undermined when the exchange of information does not occur, because other team members may assume incorrectly that all attendees participated fully, just because they were physically present. Effective teamwork relies on individuals feeling responsibility and being able to act decisively to voice their observations and expertise.11 Nonetheless, a clear definition of individual roles is an important component of high-functioning teams.12,13 Effective interdisciplinary communication may be the best means to ensure that both of these criteria are fulfilled. Indeed, data support the concept that effective interdisciplinary communication improves outcomes.14 However, interdisciplinary communication may be limited by the climate of teamwork and psychologic safety.15 The abstention from participation in interdisciplinary rounds with one of the primary rounding teams in the ICU was dramatic and may have been subject to time constraints and the boundaries of the hierarchy in the format of structured rounds.16 Other known barriers to interdisciplinary communication are interruptions17 and stressful situations that narrow an individual’s attention span and limit the receipt of potentially important information.18 Promoting interdisciplinary communication requires not only creating opportunities for communication but encouraging individuals to participate meaningfully during those opportunities. This study has several limitations. First, the Hawthorne effect (ie, the alternation of behavior by participants attributable to their awareness of being observed) is a potential limitation, because the teams were cognizant that study staff were observing rounds for research purposes. This awareness may have altered the rounding practice/behaviors of the team, thereby leading them, to deviate from their normal routine; however, the teams appeared to acclimate quickly to the presence of the observer. Second, although a variety of interdisciplinary providers were interviewed, the full range of providers caring for critically injured patients was not captured, such as speech, occupational, physical therapists, dieticians, and orthopedic surgeons. Third, the person conducting the interviews was a provider who had worked closely clinically with many interviewees. The relationship may have framed the responses, thereby limiting the scope of the data. Fourth, seeking participation of a minimum of two per role may not have been enough to elaborate all possible themes. Nevertheless, there was consistence of themes across all roles, and the observation of central themes likely still holds. Another limitation of this study is that trainees were not included as study participants. This study focused on how decisions are made among fully trained, interdisciplinary providers. Although trainees in a teaching hospital are absolutely a critical component of the care teams, the ability of trainees to make decisions, particularly when there are competing priorities, may be highly variable. The ability of a trainee to incorporate information, act on it, and communicate may vary greatly by individual, by level, and by time of day.19 A dedicated follow-up study to understand the influence of trainees on inter-team dynamics and communication is planned. In conclusion, care decisions for critically injured patients are made in the context of shared responsibility. Interdisciplinary communication establishes roles and navigates time to distribute shared responsibility among providers. Despite the interviewees suggesting that interprofessional communication is critical for navigating the time and the roles to distribute shared responsibility, the observational component of this study
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demonstrated that, in practice, interprofessional communication does not always occur even when there is the opportunity for such communication. The high-stakes task of caring for critically injured patients may be an opportunity where defining and promoting effective, interdisciplinary communication could improve patient outcomes after injury. Funding/Support None of the authors have any funding sources to report. Conflict of interest/Disclosure None of the authors have any conflicts of interest to disclose. Supplementary materials Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/j.surg.2019. 11.009. References 1. Centers for Disease Control and Prevention. National Center for Health Statistics Z-force data files Web site. https://www.cdc.gov/growthcharts/zscore.htm. Accessed February 4, 2019. 2. Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Shackford SR, Eastman AB. The significance of critical care errors in causing preventable death in trauma patients in a trauma system. J Trauma. 1991;31:813e818; discussion 818e819. 3. Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/ mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013;41(9 Suppl 1):S116eS127. 4. Fackler JC, Watts C, Grome A, Miller T, Crandall B, Pronovost P. Critical care physician cognitive task analysis: an exploratory study. Crit Care. 2009;13:R33. 5. Edwards BD, Day EA, Arthur W, Bell ST. Relationships among team ability composition, team mental models, and team performance. J Appl Psychol. 2006;91:727e736. 6. Mathieu JE, Heffner TS, Goodwin GF, Salas E, Cannon-Bowers JA. The influence of shared mental models on team process and performance. J Appl Psychol. 2000;85:273e283. 7. Ferguson EJ, Brown M. Concurrent case review and retrospective review using the matrix method are complementary methods for tracking and improving timeliness of care in a level I trauma center. Am Surg. 2016;82:319e324. 8. Girard E, Jegousso Q, Boussat B, et al. Preventable deaths in a French regional trauma system: a six-year analysis of severe trauma mortality. J Visc Surg. 2019;156:10e16. 9. Sharwood LN, Stanford R, Middleton JW, et al. Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol. BMJ Open. 2017;7:e012377. 10. Weldon SM, Korkiakangas T, Bezemer J, Kneebone R. Communication in the operating theatre. Br J Surg. 2013;100:1677e1688. 11. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85ei90. 12. Southwick F. Who was caring for Mary? Ann Intern Med. 1993;118:146e148. 13. Southwick FS, Spear SJ. Commentary: “Who was caring for Mary?” revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement. Acad Med. 2009;84:1648e1650. 14. Rangachari P, Rissing P, Wagner P, et al. A baseline study of communication networks related to evidence-based infection prevention practices in an intensive care unit. Qual Manag Health Care. 2010;19:330e348. 15. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105:877e884. 16. Shoham DA, Harris JK, Mundt M, McGaghie W. A network model of communication in an interprofessional team of healthcare professionals: a crosssectional study of a burn unit. J Interprof Care. 2016;30:661e667. 17. Alvarez G, Coiera E. Interdisciplinary communication: an uncharted source of medical error? J Crit Care. 2006;21:236e242; discussion 242. 18. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745e749. 19. Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210:17e22.