Phases-of-illness paradigm: better communication, better outcomes

Communication failures are a significant contributor to medical errors that harm patients. Critical care delivery is a complex system of inter-professional work that is distributed across time, space, and multiple disciplines. Because health-care education and delivery remain siloed by profession, we lack a shared framework within which we discuss and subsequently optimize patient care. Furthermore, our disparate professional perspectives and interests often interfere with our ability to effectively prioritize individual care. It is important, therefore, to develop a cognitively shared framework for understanding a patient's severity of illness and plan of care across multiple, traditionally poorly communicating disciplines. We suggest that the 'phases-of-illness paradigm' will facilitate communication about critically ill patients and create a shared mental model for interdisciplinary patient care. In so doing, this paradigm may reduce communication errors, complications, and costs while improving resource utilization and trainee education. Additional research applications are feasible.


1
Brooke Army Medical Center, 3851 Roger Brooke Dr., Fort Sam Houston, TX 78234-6200, USA Full list of author information is available at the end of the article illness and apply supportive therapies according to patient-oriented goals and care team objectives ( Figure 1, Table 1). In each 'phase' , patients have similar severities of illness, goals of care, and treatment objectives. Within this framework, checklists help identify the patient's severity of illness and priorities of care. Patients may move forward (rightward) or backward (leftward) through acute illness, stabilization, weaning, and recovery phases. Patients transitioned to palliative care would exit this model into a palliative care 'phase' that is distinct because it is blind to a patient's severity of illness. Most clinicians implicitly utilize a similar model to help them recognize a patient's condition and to target a care plan. POIP explicitly states these goals and objectives so that all team members may recognize and share them.
Th e POIP has the advantages of several key quality improvement tools, including clinical pathways, bundles of care, and checklists. Each of these tools has been demonstrated to reduce complications, reduce cost, and improve outcomes [7][8][9]. Common to each of these tools is the notion of shared responsibility and objective assessments of care quality. Once the entire care team recognizes a patient's severity of illness, it can share the responsibility of ensuring that the care plan is optimized to achieve explicitly stated goals by reviewing checklists (a type of cognitive aid). Any member of the team can identify areas for improvement, and the team may quantify successful care by its achievement of goals. Sharing the responsibility of goal attainment for supportive care across the care team reduces individual cognitive load, thus freeing cognition for other, poten tially more important functions, such as making an accurate diagnosis, optimizing a treatment strategy, providing valuable family support, or attending another patient.

Application
A patient's progress through the ICU can be thought of as a continuum in which movement may occur both forward and backward. A 'phase of illness' is a distinct period along the continuum in which patients with similar characteristics may be grouped or stratifi ed. In each phase, patients' severity of illness and the healthcare teams' goals of care are similar for all the patients in that phase (Table 1). For example, we describe the most acute or sickest stratum as the 'acute' phase. During this phase, we prioritize life-saving therapies and eff ective organ support. Th us, a patient's phase determines our goal priorities. Within each phase, it is simple to create phase-specifi c checklists for your institution that help ensure adherence to local protocols, best practices, clinical guidelines, or specifi c care bundles. Similarly, order sets may be written to facilitate patient-driven standardization of supportive care elements, such as types of monitoring, frequency and type of laboratory assessment, sedation strategies, modes of mechanical ventilation, and physical therapy interventions ( Figure 1).
Although this framework off ers a shared mental model of patient care to the interdisciplinary team, not all team members interact with it in the same way. Th e experienced provider, for example, conceptualizes patient movement through phases intuitively. Th is intuition is best expressed by a provider changing goals of care for a patient. Th e advantage of the POIP for the inexperienced health-care provider is the ability to categorize patients according to criteria and to have a roadmap for recovery. Often, the inexperienced provider gets 'stuck' providing the same level of care to a patient and is unable to recognize when to transition goals. For this provider, it is useful to ask, 'What needs to be done to move to the next phase?' If the patient meets certain criteria, such as 'no longer in shock' , the inexperienced provider may be more comfortable advancing the patient from an acute illness phase to a stabilization phase and then can utilize the goals within the stabilization phase to establish a plan of care.
For both experienced and inexperienced health-care providers, adding an additional 'pause' phase (which we call a 'pause cloud') is also useful. A pause occurs when a clinician recognizes a potential change in patient condition that requires additional monitoring or investigation. It occurs when a patient who was previously advancing in his or her care -tolerating weaning, diuresing, demonstrating improved mental status, and so on -'pauses' in this progress for unclear reasons. In this event, the team recognizes that the change may or may not be signifi cant but that it requires additional evaluation. A pause may be brief (for example, awaiting a lab result) or may be more prolonged ('let's not walk the patient today; he looks like he may be getting sicker'). Th e key, however, is that the patient has not gotten worse and remains within his or her current phase. If, during this heightened period of observation, the patient's condition deteriorates, the goals of care change, and the patient regresses to a diff erent phase of illness that better refl ects his severity of illness. Conversely, if his condition does not worsen during the pause, he continues to progress forward through the continuum of care.

Strengths and weaknesses
Th e complexities of critical care are beyond the capacity of one provider or a single professional group to deliver optimal patient care [10]. Th e emergence of the multidisciplinary care team as an optimal model for care delivery is well supported by the literature [11]. Unfortunately, the shared responsibilities of patient care require frequent negotiations between team members in order to deliver optimal care. In our current culture, most disciplines approach disagreement by using positional bargaining strategies to direct patient care:

Objectives:
Frequent assessment to direct optimization of resuscitation.
Organize evaluations consistently so as not to overwhelm bedside nursing. According to the theory of principled negotiation, objective measures are needed to determine how well a course of action satisfi es the interests of the parties involved in the negotiation [12]. Th e POIP provides these objective measures by establishing patient goals. To aid these negotiations, goals need to be identifi ed as patientcentric needs that may be addressed through multiple possible solutions; objectives are the diff erent solutions that the health-care team may take, and tasks are the responsibilities of individuals in the team required to achieve an objective ( Table 2). Using the POIP to facilitate principled negotiation, the negotiation in the previous scenario for a patient in the recovery phase might become the following: Provider 1: 'I want the patient to have 2 units of blood. ' Provider 2: 'What goal will that help us achieve?' Provider 1: 'I think it will help him achieve his physical therapy goals today because he failed them yesterday. '

Consider
While POIP provides a framework for the health-care team to better communicate, it may also facilitate communication with patients and family members. Patients and their families have diffi culty understanding the direction of their progress through the ICU, and the health-care team often has diffi culty explaining it to them. A framework that groups severity of illness and care goals helps families to understand where in the continuum of care they are and where they need to go to get better. It helps them to focus on goals of care, less on how to achieve them, and thus facilitates the shared decision-making model [13]. Finally, the POIP provides transparency to our discussions with a patient or family by giving them a visual depiction of how they move through critical illness.
Th e future applications of a phase-based paradigm in the ICU are robust. In particular, administrative and research benefi ts may be signifi cant. Currently, extensive resources are spent understanding and managing patient throughput in a hospital and matching resources, particularly human resources (most notably nursing), to patient needs. After adopting a phase-based paradigm, supervising bed managers could check the status of an ICU and rapidly determine potential changes in capacity. If a ten-bed ICU has fi ve patients in the acute phase of illness, it is unlikely that these patients will leave the ICU in the next 24 to 48 hours unless they die. If there are three 'recovery' phase patients in the remaining beds, the managers' time and eff orts may be placed on determining what resources are needed to facilitate those patients' transfer out of the ICU. Th e remaining patients would require little attention from the bed manager. Furthermore, the resource manager may better match staffi ng to patient needs. It is likely that a patient in the acute illness phase will need more one-to-one nursing than a patient in the recovery phase.
Future research applications of the POIP will need to focus on how it aff ects patient care. Because the POIP stratifi es patients according to clinical condition, studies of ICU populations could prospectively stratify patients because therapies of interest may be more or less eff ective at a particular time during a patient's ICU course (for example, red blood cell transfusions). Research questions specifi c to this paradigm must also be answered: does the POIP improve communication and thus reduce errors F igure 1. The phases-of-illness paradigm. Patients enter the ICU environment for one of two reasons: resuscitation (organ support, including respiratory failure, shock states, acute liver failure, and so on) or ICU monitoring. Patients who need resuscitation are in shock and need aggressively titrated and carefully monitored care. Patients who need monitoring are typically 'stable' , but need a higher level of observation than is available elsewhere in the hospital: hourly checks or interventions, invasive monitors, and so on. Movement through the continuum of phases is fl uid, timeless, and directionless. A patient getting better will move to the right and a patient getting worse to the left. Since a severity of illness may describe any type of patient, and supportive care goals (Table 1) apply to all patients with a certain severity of illness, additional 'disease-specifi c' protocols may also apply to a patient. Phase specifi c protocols or checks in this table are examples only: these objectives and do-confi rm type checks must be adapted to fi t a local environment and culture. The 'pause cloud' is an 'in-between' phase during which it is unclear what 'direction' a patient is moving (that is, could be getting better or worse). Typically, monitoring may increase, decrease, or stay the same as the patient's current phase. Sometimes this phase may be a brief 'check' (check another set of labs, check an imaging study, check cultures, and so on). Sometimes it may be more prolonged (for example, during traumatic brain injury (TBI) when intracranial pressure (ICP) management is ongoing but unchanging). ABG, arterial blood gas; AC mode, pressure or volume assist control mode of ventilation; AKI, acute kidney injury; ALI, acute lung injury; APRV, airway pressure release ventilation; ARDS, acute respiratory distress syndrome; BiPAP, bi-level pressure consisting of inspiratory and expiratory positive airway pressure; CBC, complete blood count; CIN, contrast-induced nephropathy; CPAP, continuous positive airway pressure; CRP, C-reactive protein; DSH, daily sedation holiday; DVT, deep vein thrombosus; ECMO, extracorporeal membrane oxygenation; GI, gastrointestinal; HFOV, high frequency oscillatory ventilation; IBW, ideal body weight; ICP, intracranial pressure; IVC, inferior vena cava; LFT, liver functions test; NPO, noting per os (nothing to eat by mouth); PE, pulmonary embolism; PEEP, positive end expiratory pressure; Pplat, plateau pressure; PRN, as needed; PS, pressure support; PT/PTT, prothrombin time/partial thromboplastin time; P-V loop, pressure volume loop; SBT, spontaneous breathing trial; ScvO2/SvO2, central vein oxygen saturation/mixed venous oxygen saturation; SpO2, peripheral oxygen saturation; TBI, traumatic brain injury; TEG, thromboelastogram; TPN, total parenteral nutrition; TTE, transthoracic echocardiogram; UUN, urine urea nitrogen; VILI, ventilator induced lung injury.

Table 1. Example of the phases-of-illness paradigm phase criteria and supportive care goals
Phase 1 -Acute (6 to 24 hours; few patients)

Criteria
Presence of shock SBP <90 after fl uid bolus An elevated lactate (>2 to 4) Decreased SvO2 or ScvO 2 (<70% or <65%) Active resuscitation: medications, drips, and therapies are rapidly added and/or changed Rapid fl uid/blood product and improve patient safety? Will use of this paradigm improve patient outcomes? Can use of this paradigm decrease costs? Can this paradigm be used as a predictive model for patient outcomes? Th ere are several potential concerns when adopting the POIP. First, there are always patients who do not fi t well into any model. When a patient's phase is unclear or there is disagreement about a patient's phase, we recommend focusing on the goals of care, not the phase criteria. In general, focusing on the goals will help determine whether a patient is 'sicker' or 'less sick' and can better defi ne the patient's current phase. If phase determination still proves challenging, it is simple to make a choice and pursue phase goals that make the most sense for the patient. In this case, a group's conservative or aggressive biases often dictate the phase choice. Th e key is to make a decision so that all team members can understand a patient's status and then move forward with care. Second, the model's transparency with respect to patient severity of illness may lead some members of the team, particularly family members, to lose hope. For example, a spouse may feel fear or hopelessness when his wife, who was doing very well in a recovery phase, moves to a resuscitation phase. It is important to recognize that although this paradigm defi nes a desired trajectory through the ICU, it should not be used to predict patient outcome. A phase only describes a patient's current condition so that the entire team, including the family and the patient, may better understand expectations and therefore have a better framework for communication and planning. While establishing and maintaining a trajectory through this model is the goal, falling back to prior phases does not prohibit reaching the fi nal goal of recovery.
Th ird, it is vital for an institution to closely examine the model and adapt it, particularly the phase-based checklists and order sets, to the local environment. Phase criteria and goals that may fi t well for one ICU may not fi t well for another (Table 3).

Conclusion
Overall, we believe that the POIP will enhance the ability of the entire multidisciplinary health-care team to more eff ectively recognize a patient's changing condition, establish a patient-driven care plan, and communicate with each other about patient care. Establishing daily goals for patients according to their condition and delivering specifi c treatments according to this condition in a patient-centric model will decrease time and money spent in the ICU. Additional improvements in resource utilization and research applications are also possible. Ultimately, aligning a patient's condition with specifi c goals and therefore treatments in a phase-based paradigm will help all health-care providers choose the most appropriate therapies to facilitate a patient's recovery.