Office of Education

Current Funded Projects

Development of a Reliable Valid Instrument to Assess End-of-Life Communication in an Acute Care Setting. Scott Compton; Co-Investigator

Background

Over 60% of patients that are admitted through the emergency department (ED) and die in-hospital present on a known dying trajectory; that is, their underlying medical conditions predicted significant health decline and death due to known medical conditions.1 While there has been an increase in end-of-life curricula in undergraduate and graduate medical education, current guidelines do not adequately reflect the complexities of physician-family interactions that occur in actively dying patients.2 As a result, physicians do not accurately assess patient and family wishes about end-of-life care and often misinterpret the desire for life sustaining measures.3 These outcomes result in inappropriate use of medical resources and failure to comply with patient and family preferences.

Current recommendations throughout the literature require that physicians demonstrate proficiency in handling EOL care issues; however there currently does not exist an assessment tool that captures the complexities associated with EOL patient care. Available EOL assessment tools also fail to meet educational standards for curricular and performance assessment. Without these tools, robust assessment of physician performance cannot occur. Additionally, without the ability to systematically observe and assess EOL care, the capacity to effectively conduct research evaluating links between practitioner performance and patient care is limited.

Objective

The objective of this research project is to develop a content valid instrument to measure the critical care communication skills of emergency physicians in order to facilitate education and assessment of end-of-life communication skills in a time-sensitive acute care setting.

Methods

To develop a content valid end-of-life communication assessment instrument, the investigators will use the Delphi methodology with emergency medicine palliative care subject matter experts to systematically identify specific communication behaviors that are evoked by acute end-of-life care events and that are linked to relevant communication dimensions identified in the SILVER acronym: (1) Seek Information, (2) assess Life Values, (3) Empathizes, Educates family, and seeks to Extend care in a consistent manner, and (4) Responds to family members’ questions and concerns. Through a multistep review process, the Delphi method will produce a content-valid assessment instrument reflective of appropriate physician behaviors during EOL care in acute care settings.

Future Work

The investigators propose to apply a rigorous approach to develop a content valid instrument to assess end-of-life communication in a novel area: acute care. This project is an essential first step that will allow further validation of the assessment tool (i.e., establishing construct validity), ultimately producing a valid and reliable measure of physician skill in end-of-life care.

References

1. Zalenski RJ, Compton S. Death trajectories of emergency department patients and palliative care service utilization. Annals of Emergency Medicine 2004;44:222.
2. Eggly S, Penner L, Albrecht TL, et al. Discussing bad news in the outpatient oncology clinic: Rethinking current communication guidelines. Journal of Clinical Oncology 2006;24:716-9.
3. Layson RT, Adelman HM, Wallach PM, et al. Discussions about the use of life-sustaining treatments: A literature review of physicians and patients' attitudes and practices Journal of Clinical Ethics 1994;5:195-203.

Scott Compton Consultant
Agency for Healthcare Research Quality

 

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Improving patient safety through leadership and team performance in simulations

Scott Compton, PhD: Consultant
Rosemarie Fernandez, MD (Wayne State University): Principal Investigator

Background

Effective teamwork and team performance are critical to error mitigation and safety in the clinical environment. The team science literature identifies three targets for improving team performance: team design (composition), team training, and team leadership. Current efforts have focused on team training. However, challenges associated with the feasibility, sustainability, and effectiveness of these programs have been identified. Additionally, training teams as a unit, while required for effective training outcomes, is nearly impossible for ad hoc emergency teams characterized by an interdisciplinary, highly variable membership that operates under complex, dynamic and time pressured conditions. This work focuses on team leadership and team composition as two important mediators of medical emergency team performance that have not been studied nor implemented in patient safety research.

Objective

The overall objective of the proposed research is to (1) develop a novel, evidence-based leadership training program and (2) evaluate the impact of both leadership training and team member composition (unfamiliar vs. familiar teams) on medical emergency team (MET) performance using a simulation-based research platform. This will advance the patient safety mission of AHRQ by (1) providing an additional mechanism (leadership training) for improving team performance and patient safety that overcomes challenges associated with current team training programs, (2) providing a robust, diagnostic method of evaluating team performance that directly assesses evidence-based team processes (coordination, back-up behavior, etc), and (3) investigating the impact of team composition on team performance and patient safety critical behaviors.

Methods

This project builds upon previous work and is structured into three components:

Aim 1: To assess the impact of healthcare team composition (unfamiliar vs. familiar members) on medical emergency team performance.

Aim 2:a) To develop and implement a team leadership training program based on an Adaptive Learning System theoretical heuristic.

Aim 2:b) To assess the impact of team leadership training on medical emergency team performance.

Aim 3: To assess the differential impact of team leadership training on unfamiliar vs. familiar medical emergency teams.

This project uses a 2 (unfamiliar vs. familiar) X 2 (leadership training vs. control) fully crossed design to evaluate impact of leadership training and team composition (unfamiliar vs. familiar) on ad hoc medical emergency team performance. Ad hoc medical emergency teams will be comprised of emergency medical nurses and physicians from multiple hospital institutions. The primary outcome measure is team performance, assessed using a validated simulation platform (scenario + team process measures + patient care measures). These measures will collectively represent an accurate, reliable representation of both teamwork and task-work.