A Systems Approach to Align ICU Care with Patient Treatment Goals

This career development award will provide Jacqueline M Kruser, MD MS the opportunity to become an independent physician investigator with the training and experience necessary to improve communication and treatment decision-making for patients with critical illness. Dr. Kruser will use this award to build on her existing foundation in health services and outcomes research to achieve two near-term career development goals: (1) develop expertise in the application of systems engineering methods in healthcare, and (2) gain experience in the conduct of clinical trials of behavioral interventions. These skills will expand Dr. Kruser’s research focus beyond individual-level interventions to address complex, systems-level factors that influence treatment decision making and end-of-life care for patients with life-threatening illness, specifically in chronic critical illness. She will achieve these career objectives through a 5-year career development plan that involves structured didactic experiences, patient-oriented experiential research training, and intensive mentoring. Dr. Kruser’s career development will be mentored by Jane L Holl MD MPH, an expert in systems engineering in healthcare with over 20 years of sustained extramural funding and an outstanding record of mentorship. The co-mentors of this award are experts in clinical trials and outcomes research in critical care (Richard G Wunderink, MD), and end-of-life decision making and behavioral intervention development (Margaret Schwarze, MD MPP). Dr. Kruser’s career development will be supported by the exceptional institutional environment of Northwestern University, including 1) dedicated resources from the Division of Pulmonary and Critical Care Medicine and Department of Medicine, 2) the strong research infrastructure of the inter-professional Center for Healthcare Studies (led by Dr. Holl), and 3) established, productive collaborations between the McCormick School of Engineering and the Feinberg School of Medicine. Nearly 400,000 people in the US develop chronic critical illness each year, and most older adults with this condition will not survive beyond one year. Studies suggest that many older adults with chronic critical illness who are near the end of life receive unwanted care that does not reflect their goals, values, or preferences (goal-discordant care). Thus, the overall research objective of this award is to apply the tools of systems engineering to adapt an existing individual-level communication tool (“Best Case/Worst Case”) to reduce goal-discordant care in older adults at risk for chronic critical illness. Specific Aim 1 will identify the most impactful ICU system failures in communication and treatment decision-making through failure mode, effects, and criticality analysis. Next, Specific Aim 2 will use user-centered design engineering and simulation testing to adapt “Best Case/Worst Case” to the complex ICU system. Finally, Specific Aim 3 will test the feasibility and acceptability of the novel intervention through a two-site pilot clinical trial.