探索适应情境的决策辅助工具和在线培训对重症监护室老年患者共同决策护理目标的影响:一项混合方法研究

Ariane Plaisance, Julien Turgeon, Lucas Gomes Souza, France Légaré, Stéphane Turcotte, Nathalie Germain, Tommy Jean, Maude Dionne, Félix Antoine Fortier, Patrick Plante, Diane Tapp, Véronique Gélinas, Emmanuelle Bélanger, Mark H Ebell, Christian Chabot, Tom van de Belt, Alexis F Turgeon, Patrick M Archambault
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引用次数: 0

摘要

目的:探讨在重症监护病房中,适应情境的决策辅助工具和关于护理目标共同决策(SDM)的在线培训对重症监护医生让老年患者参与护理目标共同决策(SDM)的程度和护理目标讨论(GCD)质量的影响。方法:这是在加拿大魁北克省莱维斯市一家重症监护病房进行的一项前后三阶段混合方法实施研究。我们遵循了 StaRI 和 COREQ 报告指南。我们招募了年龄≥ 65 岁的患者及其主治重症监护医师。我们分三个阶段对 GCD 进行了录像:第一阶段:无决策辅助工具的 GCD;第二阶段:有护理目标决策辅助工具但无在线培训的 GCD;第三阶段:有护理目标决策辅助工具但有 SDM 在线培训的 GCD。所有 GCD 录音均逐字记录。我们通过 OPTION 量表衡量了重症监护医师在有关护理目标的 SDM 中的患者参与程度,并使用 "沟通、护理计划和文档审核"(ACCEPT)指标评估了 GCD 的质量。此外,还对会诊记录进行了定性专题分析。结果:在 359 名符合条件的患者中,研究对象包括 21 名患者(71% 为男性;年龄中位数为 77 岁;57% 没有高中文凭)和 5 名重症监护医师(80% 为男性;年龄中位数为 35 岁)。尽管完成了在线培训,但在记录的会诊中从未使用过决策辅助工具。由于每个阶段的样本量较小,我们没有对每个研究阶段的结果进行统计学意义比较测试。每个阶段的 OPTION 和 ACCEPT 分数都很低,但医生确实参与了 GCD。我们发现,讨论后医疗记录中记录的 76% 的护理目标与患者在观察记录中表达的偏好一致。一些患者对 GCD 表示困惑。重症监护医生在引导 GCD 时发现的障碍包括医生的态度、在重症监护病房的需求下开展 GCD 所面临的挑战、误解以及缺乏培训。促进因素包括以患者为中心的方法、清晰的辅助决策以及患者的积极态度。在今后的工作中,必须对支持医生进行GCD的环境、促进患者在进入重症监护病房前更早和更高质量地进行GCD的环境以及鼓励在重症监护中进行有意义的SDM的环境进行评估,以此作为重症监护病房GCD取得成功的途径:结论:除了辅助性的在线培训模块外,我们还创建了一个适应具体情况的护理目标决策辅助工具。所有参与培训的医生都完成了在线培训,但并未观察到重症监护病房 GCD 期间患者参与 SDM 的程度有所提高,也未观察到辅助决策工具的使用情况。我们发现了一些沟通障碍,需要加以探讨,以改善重症监护病房 GCD。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Exploring the impact of a context-adapted decision aid and online training about shared decision making about goals of care with elderly patients in the intensive care unit: a mixed-methods study
Purpose: To explore the impact of a context-adapted decision aid and an online training about shared decision-making (SDM) about goals of care on the level of involvement of elderly patients by intensivists in SDM about goals of care and quality of goals of care discussions (GCD) in an intensive care unit. Methods: This was a three-phase before-after mixed-methods implementation study conducted in an ICU in Lévis, Quebec, Canada. We followed the StaRI and COREQ reporting guidelines. We recruited patients aged ≥ 65 and their attending intensivists. We video-recorded GCD in three phases: Phase I: GCD without a decision aid; Phase II: GCD with a decision aid about goals of care but no online training; and Phase III: GCD with both a decision aid about goals of care following online training about SDM. All GCD recordings were transcribed verbatim. We measured the level of patient engagement by intensivists in SDM about goals of care through the OPTION scale and evaluated GCD quality using the Audit of Communication, Care Planning, and Documentation (ACCEPT) indicators. A qualitative thematic analysis of the encounters transcriptions was also performed. Results: Out of 359 eligible patients, the study included 21 patients (71% males; median age, 77 years; 57% without high school diploma) and 5 intensivists (80% male; median age, 35). Despite completing online training, the decision aid was never used in recorded encounters. We did not perform any tests of statistical significance to compare results in each study phase because of small sample sizes over each phase. OPTION and ACCEPT scores were low in each phase, but physicians did engage in GCD. We found that 76% of the goals of care recorded in medical records after the discussion were consistent with preferences expressed by patients during recorded observations. Several patients expressed confusion about GCD. Barriers identified by intensivists leading GCD include physician attitudes, challenges to performing GCD along with the demands of the intensive care unit, misunderstandings, and lack of training. Facilitators include a patient-centered approach, a clear decision aid, and positive patient attitudes. In future work, an environment that supports physicians in performing GCD, promotes earlier and higher quality patient GCD before admission to the intensive care unit, and encourages meaningful SDM in critical care must be assessed as pathways to successful intensive care unit GCD. Conclusion: A context-adapted decision aid about goals of care was created in addition to a complementary online training module. The online training was completed by all participating physicians but no increased involvement of patients in SDM during intensive care unit GCD was observed, and use of the decision aid was also not observed. We found several communication barriers that will need to be explored to improve intensive care unit GCD.
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