"We're Not Ready, But I Don't Think You're Ever Ready." Clinician Perspectives on Implementation of Crisis Standards of Care.
"We're Not Ready, But I Don't Think You're Ever Ready." Clinician Perspectives on Implementation of Crisis Standards of Care.
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DOI：
10.1080/23294515.2020.1759731
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发表时间：
2020-07
影响因子：
--
通讯作者：
Gong MN
中科院分区：
文献类型：
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作者：
Chuang E;Cuartas PA;Powell T;Gong MN
2019冠状病毒病大流行凸显了卫生保健系统的脆弱性。医院面临越来越大的生命维持资源短缺的风险，如机械呼吸支持的呼吸机，就像意大利截至2020年3月的情况一样。美国国家医学院（National Academy of Medicine）提供了关于危机护理标准的指导，要求将稀缺的医疗资源重新分配给在极端情况下受益最大的人。鉴于这将需要背离床边临床医生通常的受托责任，我们确定并绘制了利益相关者使用实施科学框架实施指南的潜在障碍。制定了一项协议，以实施在危机情况下对呼吸机进行分类的国家和州指南。2018年7月至9月，对某城市学术医疗中心三家急症护理医院的临床医生进行了焦点小组和关键信息提供者访谈。呼吸治疗师、重症监护医师、护理领导和姑息治疗跨学科团队参加了焦点小组。对紧急管理、呼吸治疗和急救医学方面的关键信息提供者进行了访谈。研究人员向受试者展示了该协议，并通过半结构化的访谈指南引出了他们的想法。使用基于理论领域框架的编码策略对来自抄本和笔记的数据进行分类。与会者预计，实施这一方案将挑战他们作为临床医生的角色和身份，包括他们对患者的信托义务和决策自主权。尽管如此，许多参与者承认需要这样一个方案来规范护理，最大限度地减少偏见，并减轻对临床医生个人的潜在后果。与会者确定了在分诊决定中考虑患者生活质量的问题，这是灾难分诊中一个重要的、尚未解决的伦理问题。临床医生对角色和义务转换的不适可能会对危机护理标准的实施造成障碍。
The COVID-19 pandemic has highlighted health care systems’ vulnerabilities. Hospitals face increasing risk of periods of scarcity of life-sustaining resources such as ventilators for mechanical respiratory support, as has been the case in Italy as of March, 2020. The National Academy of Medicine has provided guidance on crisis standards of care, which call for the reallocation of scarce medical resources to those who will benefit most during extreme situations. Given that this will require a departure from the usual fiduciary duty of the bedside clinician, we determined and mapped potential barriers to the implementation of the guidelines from stakeholders using an implementation science framework. A protocol was created to operationalize national and state guidelines for triaging ventilators during crisis conditions. Focus groups and key informant interviews were conducted from July-September 2018 with clinicians at three acute care hospitals of an urban academic medical center. Respiratory therapists, intensivists, nursing leadership and the palliative care interdisciplinary team participated in focus groups. Key informant interviews were conducted with emergency management, respiratory therapy and emergency medicine. Subjects were presented the protocol and their reflections were elicited using a semi-structured interview guide. Data from transcripts and notes were categorized using a coding strategy based on the Theoretical Domains Framework. Participants anticipated that implementing this protocol would challenge their roles and identities as clinicians including both their fiduciary duty to the patient and their decision-making autonomy. Despite this, many participants acknowledged the need for such a protocol to standardize care and minimize bias as well as to mitigate potential consequences for individual clinicians. Participants identified the question of considering patient quality of life in triage decisions as an important and unresolved ethical issue in disaster triage. Clinicians’ discomfort with shifting roles and obligations could pose implementation barriers for crisis standards of care.