Map out the complex ICU environment and highlight pain points around care delivery for patients undergoing mechanical ventilation.
Create, prototype, and test novel interventions to improve communication and care delivery.
Chronic critical illness (CCI) is a syndrome affecting nearly 400,000 individuals per year in the United States. It results in long-term dependence on life-sustaining treatments, and the most recognized subtype is persistent respiratory failure requiring prolonged mechanical ventilation.
Approximately 1 in 3 Americans over age 65 is admitted to an intensive care unit (ICU) right before death. Interventions given to patients with CCI, such as mechanical ventilation, are life-sustaining yet invasive. Studies suggest a growing discrepancy between the wishes and care preferences of older adults and the actual medical treatments received near the end of life.
The ICU nurses station at Northwestern Memorial Hospital
I worked with one other intern and a small team of doctors to address problems of care delivery in the ICU. Our primary advisor on the project was Dr. Jacky Kruser, a doctor of pulmonology and critical care medicine, as well as an attending physician in the Northwestern Memorial Hospital ICU.
Dr. Kruser and her team have done extensive academic research on various problems of care delivery in the ICU, and using her background, the team was able to identify several areas of opportunity to guide our initial research and interviews. I also conducted a literature review of several dozen journal articles to add to the context of the knowledge gaps that we hoped to address.
Research and Interviews
My partner and I conducted numerous interviews to refine our understanding of the problems and develop insights. We interviewed fifteen individuals with ICU experience. These subjects were either ICU care professionals or family members whose loved ones had ICU experiences. Some relevant quotations are included below:
“Anything that can be done to stop the momentum and get the team to bring it up in a systematic way could be helpful . . . Something that forces people to be more thoughtful about it.” - Attending physician
“It’s hard to discern just from reading notes [what the status is]. I think right now it’s hard to give the families updates . . . with the fellows rotating and the attendings rotating, it’s hard when there’s not a consistent care team.” - Social worker
Images from virtual observation of the ICU floor
Due to visitor limitations in place during the COVID-19 pandemic, we were not able to conduct our planned in-context observation on the ICU floor, but instead, we virtually observed the care team's morning rounds. All of these research opportunities allowed us to achieve a comprehensive look at the stakeholders in the environment and uncover opportunities for improvement. The primary insights that guided the design work for my thesis project are outlined below:
Lack of Coordination
ICU care teams often experience a frustrating lack of coordination when delivering treatment and also communicating with patients and families. The complex nature of the ICU environment presents significant logistical challenges to implement precise coordination, iterative evaluation, and reflection.
Barriers to Communication
Non-physician team members (like nurses and social workers) desire a better understanding of the clinical course so they can better bridge the communication between families and physicians, however their support is hindered by a lack of up-to-date knowledge on the trajectory of the patient’s care. This leaves families feeling lost and confused, and creates a perceived lack of transparency.
Synthesis and Brainstorming
An important feature of my project is improving the implementation of time-limited trials, which are a common practice in most medical ICUs. A time-limited trial (TLT) is the use of medical therapies for life support—such as mechanical ventilation or dialysis—over a defined period of time to evaluate improvement or deterioration according to agreed-upon clinical outcomes.
However, a standardized process for using time-limited trials in a critical care setting currently does not exist. Physicians may believe that they are providing an approximation of this process, but in the current state of the ICU, these trials are used informally and usually in narrow circumstances.
I conducted multiple rounds of brainstorming and preliminary concept sketching, keeping in mind the insights and opportunities I had learned from the research. Through discussions with my team and ICU professionals, I decided to move forward with creating a digital tool to aid in care planning and collaboration, with a focus on use in the context of time-limited trials. Some of my outputs from this phase are pictured below.
Early-phase sketching and examples of my ideas
Although my internship work for the hospital team included sketches and brainstorming for a variety of tools, both physical and digital, I went into my thesis project with the intent to focus exclusively on a digital format. This would allow me to quickly and easily make prototypes, as well as facilitate simple testing in a remote way as necessitated by the current situation of COVID-19. I also felt that digital tools offered more flexibility and usefulness in a modern ICU setting.
I used Figma to create all of the digital prototypes for this project. There were three total phases of prototyping. The first stage was to make simple wireframes, and then move on to low-fidelity, black-and-white screens, followed by a round of mid-fidelity prototypes. Each phase was followed by a round of user testing and synthesis that informed the next iteration of the concept.
Excerpts from the low and mid-fidelity prototypes, showing progression of the care planning tool
The final stage of the project was the refinement of the prototype through user testing. We conducted four different rounds of testing with three users to iterate, improve, and strengthen our concept as we moved from low to high-fidelity prototypes.
Initial testing focused on validation of the core concept, as well as understanding user expectations of the content, layout, and organization of the screens and the general information that we should make available. Later testing moved into the ability of users to perform specific tasks with confidence, as well as honing the look and feel of the screens and the transitions between them.
A key change that resulted from user testing was the adoption of "before meeting" and "after meeting" phases of the tool. This replaced a previous focus on real-time information capture in the middle of a family meeting. Doctors told me that this method would be the most useful and fit most comfortably in their daily flow of tasks.
Excerpts from the final prototype, showing the welcome page and one of the information capture pages
I named the final concept Unifi, with the tagline "Care Planning Companion." The tool is a standalone application that is primarily used by the doctors, but it generates helpful content for families as well. The tool operated in two phases. The first one is before a family meeting takes place, when the doctors told us they would be interested in using a tool to help guide these conversations.
The second phase occurs after a family meeting. A care team member can print or email a summary of the meeting for family members. This lasting artifact of the meeting helps keep both the family and the care team aware of what was discussed, and also specifies a time for the next meeting so it doesn't get forgotten when the care team changes. You can see the pre-meeting guide and the family meeting summary examples below.
The final concept was well-received by my test users across a number of clinical roles, from physicians to nurses, as well as therapists. They praised the tool's ability to apply consistency and transparency to the care planning process. The physical artifacts that Unifi generated also were a focus of positive comments. I have included some of the clinician feedback below:
“I like the consistency this would provide, as well as the tangible artifact for families.” - Attending physician
“I think the whole thing brings so much transparency to the team and to the patients and families. Families can feel that they are involved and they are not totally lost.” - Respiratory therapist
I have identified a number of next steps for the Unifi concept before it can be fully labeled as a successful ICU intervention. With the concept as a suitable fidelity, the first step would be testing in real environments to see if it leads to better patient outcomes, higher family satisfaction, and improved feelings of collaboration on teams.
Other areas of future work would include finding ways to integrate easily with electronic health records, and even expanding the application of this tool outside the implementation of time-limited trials. This is an ongoing area of research at Northwestern and other institutions, and I am hopeful that the ICU researchers I partnered with for my internship and thesis will continue to develop this concept in the future.
The final deliverable for my master's thesis project was a 10-minute presentation on the topic and my solution, as well as a brief Q&A session. To convey the narrative of my Unifi tool, I drew my own storyboards and characters to illustrate various steps of the process. The resulting visual aids allowed me to explain necessary concepts to an audience who was unfamiliar with the ICU environment.
After compiling my visual resources, writing a compelling narrative, and practicing with my mentor, I was able to complete my slides ahead of schedule. I delivered this presentation live to my professors, a group of class mentors, and my classmates. The research team at Northwestern hospital also viewed the presentation and remarked positively on my content and delivery.
The thesis professors also complimented my work, in particular, how I was able to distill a complex topic down to an easy-to-understand journey. After the presentation, my project was selected for inclusion in a Northwestern online publication.
Patient and physician characters from my storyboards
Slide excerpts from my final thesis presentation
My Key Learnings
Watch Your Language: One thing that came up over and over again in interviews and testing was the importance of language. It became clear that using family-focused language was crucial to a successful design, and I leaned especially on social workers to help me flag confusing terms and achieve the clarity that I needed. The design was much stronger as a result of this attention to the words I used.
The Need to Adapt: We could have never foreseen a global pandemic when this project began, but it quickly changed many things about my planned approach. Most crucially, conducting in-context research was much more of a challenge. I learned to adapt to a fast-changing situation and still was able to obtain quality insights through the creative use of technology to allow for remote observation and different kinds of interview techniques.