A functional perspective for Intensive Care Unit modelling

Ransolin, Natália; Wachs, Priscila; Bueno, Wagner Pietrobelli

doi:10.1590/0103-6513.20220081

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Sumário

Research Article • Prod. 33 • 2023 • https://doi.org/10.1590/0103-6513.20220081 copy

A functional perspective for Intensive Care Unit modelling

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Paper aims

This study demonstrates the complexity of the patient flow from admission to discharge of an adult Intensive Care Unit (ICU) through the application of the Functional Resonance Analysis Method (FRAM).

Originality

This paper shows the daily functioning of the patient flow, shedding light on the high levels of interdependence and variabilities in Complex Sociotechnical Systems.

Research method

The research was developed according to the four steps for FRAM analysis. Sources of evidence involved empirical data collection in a leading teaching public hospital in Brazil.

Main findings

There were identified 34 functions performed mainly by caregivers and support staff. Five instantiations were described to illustrate the functional resonance scenarios caused by the variability propagation across the functions.

Implications for theory and practice

Limitations of this study and suggestions for future research are pointed out. The resulting model is a basis for context understanding for ongoing and following studies.

Keywords
Complexity; Healthcare; Services; Resilience; FRAM

Paper	Aim of the study or study contribution	FRAM´s contribution
Sujan et al. (2022) Sujan, M., Bilbro, N., Ross, A., Earl, L., Ibrahim, M., Bond-Smith, G., Ghaferi, A., Pickup, L., & McCulloch, P. (2022). Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. Applied Ergonomics, 98, 103608. http://dx.doi.org/10.1016/j.apergo.2021.103608. PMid:34655965. http://dx.doi.org/10.1016/j.apergo.2021....	“to demonstrate how FRAM can be used to explore the adaptations and priority decisions (“trade-offs”) clinical staff make in order to manage acute post-operative deterioration in emergency surgery patient”	modeled the response to a deteriorating patient after a surgery. Recommendations to improve organizational resilience were made.
Arcuri et al. (2022) Arcuri, R., Bellas, H. C., Ferreira, D. S., Bulhões, B., Vidal, M. C. R., Carvalho, P. V. R., Jatobá, A., & Hollnagel, E. (2022). On the brink of disruption: applying Resilience Engineering to anticipate system performance under crisis. Applied Ergonomics, 99, 103632. http://dx.doi.org/10.1016/j.apergo.2021.103632. PMid:34740073. http://dx.doi.org/10.1016/j.apergo.2021....	“analyses of the pandemic’s effects in the access of riverine communities to the prehospital emergency healthcare system in the Brazilian Upper Amazon River region”	modeled the mobile emergency care system at the studied area, which provided data about possible variations and disruptions in atypical situations.
van Dijk et al. (2022) van Dijk, L. M., van Eikenhorst, L., & Wagner, C. (2022). Daily practice performance (Work-as-Done) compared to guidelines (Work-as-Imagined) of medication reconciliation at discharge: outcomes of a FRAM study. Safety Science, 155, 105871. http://dx.doi.org/10.1016/j.ssci.2022.105871. http://dx.doi.org/10.1016/j.ssci.2022.10...	“to gain more understanding (MR) of the low compliance of healthcare professionals with medication reconciliation standards by comparing national guidelines and hospital protocols for MR during discharge and in daily clinical practice”	to visualize MR during discharge, comparing work-as-imagined (FRAM modeled based on documents) and work-as-done (interviews about daily routine).
Slater et al. (2022) Slater, D., Hollnagel, E., MacKinnon, R., Sujan, M., Carson-Stevens, A., Ross, A., & Bowie, P. (2022). A systems analysis of the COVID-19 pandemic response in the United Kingdom-Part 1-The overall context. Safety Science, 146, 105525. http://dx.doi.org/10.1016/j.ssci.2021.105525. PMid:34658531. http://dx.doi.org/10.1016/j.ssci.2021.10...	to provide a macro system description of the COVID-19 pandemic response in the United Kingdom	“to describe the way in which the overall national pandemic response and management functions were deployed in the current UK COVID-19 response”.
Salehi et al. (2021b) Salehi, V., Smith, D., Veitch, B., & Hanson, N. (2021b). A dynamic version of the FRAM for capturing variability in complex operations. MethodsX, 8, 101333. http://dx.doi.org/10.1016/j.mex.2021.101333. PMid:34430239. http://dx.doi.org/10.1016/j.mex.2021.101...	method article, focused on presenting dynamic FRAM-based tool.	to support specialists and practitioners of complex operations to make decisions in complicated situations.
Furniss et al. (2020) Furniss, D., Nelson, D., Habli, I., White, S., Elliott, M., Reynolds, N., & Sujan, M. (2020). Using FRAM to explore sources of performance variability in intravenous infusion administration in ICU: A non-normative approach to systems contradictions. Applied Ergonomics, 86, 103113. http://dx.doi.org/10.1016/j.apergo.2020.103113. PMid:32342897. http://dx.doi.org/10.1016/j.apergo.2020....	“to explore sources of performance variability in intravenous infusion administration in intensive care unit”	to identify and analyze the variability in intravenous medication and how to manage the trade-offs and create safety.
Kaya et al. (2019) Kaya, G. K., Ovali, H. F., & Ozturk, F. (2019). Using the functional resonance analysis method on the drug administration process to assess performance variability. Safety Science, 118, 835-840. http://dx.doi.org/10.1016/j.ssci.2019.06.020. http://dx.doi.org/10.1016/j.ssci.2019.06...	to understand performance variability and how variability influences the system in terms of both success and failure. The study focused on the drug administration process in a neonatal intensive care units.	argues that FRAM can support the four potential analyses: responde, monitor, anticipate and learn.
McNab et al. (2018) McNab, D., Freestone, J., Black, C., Carson-Stevens, A., & Bowie, P. (2018). Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method. BMC Medicine, 16(1), 174. http://dx.doi.org/10.1186/s12916-018-1164-x. PMid:30305088. http://dx.doi.org/10.1186/s12916-018-116...	“to explore and better understand how acutely ill patients who may have sepsis are currently identified and managed”	FRAM model was used in a workshop to discuss intervention improvement on a systems approach.
Wachs & Saurin (2018) Wachs, P., & Saurin, T. A. (2018). Modelling interactions between procedures and resilience skills. Applied Ergonomics, 68, 328-337. http://dx.doi.org/10.1016/j.apergo.2017.12.013. PMid:29409652. http://dx.doi.org/10.1016/j.apergo.2017....	research questions: “how can procedures and the development of RSs be jointly analysed? What are the interactions between RSs and procedures?”	the study was conducted through the preparation and administration of intravenous medications in an emergency department. The FRAM was the fifth step of the proposed framework, focusing on the everyday work modelling.

Analysis Categories	Description	Data Collection Instruments
Analysis Categories	Description	Observation	Document Analysis	General Interview	Focal Group	Refinement Interview
Functions	Necessary activities for patient care in ICU.	X	X	X		X
Agents	Who/what performs the function (Human, Technology or Organization).	X	X	X		X
Aspects	Input, Output, Control, Precondition, Time, Resource. Each function has, at least, one input and one output.	X	X	X	X	X
Variabilities	The output of each function is precise and finishes on time. If not, it has variability.	X		X	X	X
Improvement Opportunities	Improvement opportunities to reduce the variability of the function or to support the worker (team) to cope with the variability.	X		X	X	X

GROUP	FUNCTIONS	DESCRIPTION	OUTPUTS	VARIABILITY
GROUP	FUNCTIONS	DESCRIPTION	OUTPUTS	T	P	C
CARE HANDOVER (ADMISSION)	REQUEST EXPERT ASSESSMENT ON PATIENT ADMISSION TO ICU	An ICU bed is requested by activating the RRT (Rapid Response Team) to assess whether the patient is considered critical to be admitted in the ICU, using pre-defined criteria.	RRT ACTIVATED; PATIENT SIGNALIZED (IF MULTIDRUG-RES. BACTERIA)	X		1
	ASSIGN BED TO PATIENT	The RRT receives the bed request, and if the patient meets the recommended criteria for ICU admission, the bed is allocated according to prioritization. The secretary proceeds with the electronic health recording of the patient's admission to the ICU.	PATIENT BED ALLOCATED; CARE HANDOVER PERFORMED; ELECTRONIC HEALTH RECORD COMPLETED	X		1
	TRANSPORT PATIENT TO ICU	Transport of the patient from the unit of origin to the ICU, under the supervision of the responsible team at the moment.	PATIENT'S ARRIVAL IN THE ICU	X	X	2
	ACCOMMODATE PATIENT ON BED	In the ICU, accommodation of the patient in the allocated bed.	PATIENT ACCOMMODATED ON THE BED	X	X	2
PATIENT ASSESSMENT (1st)	ASSESS CONDITION OF TARGET ORGANS	The first patient assessment is carried out mainly by professionals from the medical, nursing, physiotherapy, and nutrition teams. In the ICU, the patient's needs are related to the dysfunctions of one or more target organs: heart, lung, kidney, their combinations, and the advanced therapies offered to them: hemodynamics, ventilatory support, hemodialysis, etc. Most of the time, the patient arrives with little or no condition to communicate (sleepy, intubated), and the ICU team receives information from the RRT, verbally, during the care handover, and from the patient's medical health record.	TARGET ORGANS DYSFUNCTION EVALUATION PERFORMED; CONSULTING REQUESTED; EXAMINATION REQUESTED; ADVANCED THERAPY(S) REQUESTED	X	X	2
PATIENT ASSESSMENT (2nd)	COMMUNICATE WITH FAMILY MEMBER	Team communication with the patient's relatives and/or companions upon admission and throughout their stay. It covers the behavior guidelines in an ICU and on specific patient care. It also aims to investigate the clinical aspects of patient diagnosis.	COMMUNICATION WITH FAMILY MEMBERS PERFORMED		X	1
	ASSESS (SPEECH THERAPY)	When requested by the medical team, an assessment is performed by the speech therapist.	DIAGNOSIS BY THE SPECIALIST PERFORMED	X	X	2
	ASSESS (NUTRITIONIST)	When requested by the medical team, an evaluation is performed by the nutritionist.	DIAGNOSIS BY THE SPECIALIST PERFORMED; PATIENT ORIENTED ON EATING OR FASTING	X	X	2
	ASSESS (PHYSIOTHERAPY)	When requested by the medical team, an evaluation is performed by the physiotherapist.	DIAGNOSIS BY THE SPECIALIST PERFORMED	X	X	2
	ASSESS (CONSULTANT DOCTOR)	When requested by the medical team, an evaluation is performed by the consultant doctor.	DIAGNOSIS BY THE SPECIALIST PERFORMED		X	1
	ASSESS (CLINICAL PHARMACY)	Evaluation of the medical prescription by the clinical pharmacist when drugs are reviewed concerning the patient's conditions.	MEDICAL PRESCRIPTION REVISED	X	X	2
PATIENT ASSESSMENT AND CARE	CARRY OUT CARE PROCEDURE	Care procedures typically performed in the patient's bay, such as catheter insertion, etc.	CARE PROCEDURE UNDERTAKEN	X	X	2
	CARRY OUT ADVANCED THERAPIES	After assessing the dysfunctions of the patient's target organs and/or reassessments over the length of the patient's stay in the ICU, life support is offered through advanced therapies, such as Hemodialysis, Extracorporeal Membrane Oxygenation (ECMO), Mechanical ventilation, among others.	ADVANCED THERAPIES PERFORMED	X	X	2
	CARRY OUT PHYSIO/ RESPIRATORY THERAPY	If prescribed, perform motor and/or chest physiotherapy.	PHYSIOTHERAPY PERFORMED	X	X	2
	DEVELOP PRESCRIPTION	Medical prescription: registration of patient clinical decision-making in the electronic health record.	PRESCRIPTION DEVELOPED; CONSULTING REQUESTED; PATIENT ORIENTED ON EATING OR FASTING;EXAMINATION REQUESTED;ADVANCED THERAPIES REQUESTED		X	1
	DEVELOP PRESCRIPTION	Nursing prescription: patient care, after assessment of their needs.			X	1
	SET ADMINISTRATIVE TIME OF DRUGS	Determine time slots for drug administration, according to the medical prescription.	TIME SETTED FOR DRUG ADMINISTRATION	X		1
	DISPENSE DRUGS	In possession of the drug’s schedule, request it at the Satellite Pharmacy and distribute them on each patient's bed.	DRUGS DISPENSED	X		1
	PREPARE DRUGS	At the nursing station, preparation of the drug to be administered to the patient.	DRUG PREPARED	X		1
	ADMINISTER DRUGS	Administering the drug prepared to the patient.	MEDICATED PATIENT	X		1
	FEED PATIENT	Offer the diet to the patient, according to recommendations such as food consistency and drug interactions.	PATIENT FED		X	1
	TRANSPORT PATIENT TO EXAM OUT OF ICU	Transport the patient for examinations in the Hospital's Radiology unit. In this case, the Radiology team accompanies the transport.	EXAMINATION PERFORMED	X	X	2
	CARRY OUT EXAM ON THE BEDSIDE	X-ray tests or blood collection for laboratory tests on the patient in bed.	EXAMINATION PERFORMED	X		1
	SEND SAMPLES FOR ANALYSIS	Sending the exams for laboratory analysis.	SAMPLE SENT	X	X	2
	RECEIVE EXAM ANALYSIS	Receipt of clinical reports by the laboratory or imaging by Radiology.	CLINICAL REPORT RECEIVED	X		1
	DAILY BED CLEANING	Daily cleaning of physical spaces in all ICU rooms, including the patient's bay.	PATIENT BAY SANITIZED		X	1
CARE ASSISTANCE	PROVIDE REGULAR CARE	Constant care assistance, monitoring, (re)assessing, and intervention on the patient, promoting greater quality in the care offered, 24/day, during their stay in the ICU. This function exerts a control aspect in other functions related to direct patient care.	PATIENT ASSISTED;PATIENT ASSESSMENT PERFORMED	X		1
	CARRY OUT ROUND	A multidisciplinary round is held around the patient, when the daily plan is defined, based on the exchange of information between professionals and, often, with the patient/family member.	DAILY PLAN PREPARED;PATIENT PRE-DISCHARGE CONDITION IDENTIFIED		X	1
	UPDATE PATIENT CHART	Registering in the electronic health record all care decisions and interventions made on the patient and their response to treatments.	PATIENT CHART UPDATED	X	X	2
CARE HANDOVER (DISCHARGE)	CONFIRM PATIENT DISCHARGE	After the Pre-discharge notice (i.e., the patient can be discharged within 24 hours), the responsible physician confirms discharge.	PATIENT DISCHARGE OF ICU CONFIRMED;PATIENT DISCHARGE PLATE VISIBLE	X		1
	TRANSPORT PATIENT TO WARDS	After confirmation of ICU discharge and availability of the bed in the hospital ward, the patient is transported to the new bed.	PATIENT TRANSPORTED TO HOSPITAL WARD		X	1
	RELEASE BAY (REMOVE EQUIP, ACCESS. AND BELONGINGS)	After the patient leaves the ICU, they remove equipment and accessories used by the patient in the bay to clean and deliver their belongings.	PATIENT BAY RELEASED FOR TERMINAL CLEANING		X	1
	TERMINAL CLEANING (PATIENT BAY)	Cleaning the bay (bed, furniture, curtains, floor, ceiling, etc.) upon patient discharge and leaving. At the end of cleaning and supervision, the bay must be in its default configuration to receive a new patient.	PATIENT'S BAY CLEANED	X	X	2
	SUPERVISION TERMINAL CLEANING	After terminal cleaning, the supervision team checks, according to protocols and bioluminescence test, whether the environment is properly clean.	CLEANING SUPERVISION PERFORMED	X		1
	REPORT BED RELEASE/AVAILABILITY	Once the supervision accepts the terminal cleaning, the secretary is informed that the patient bed is free for future demands. The secretary inserts this information into the hospital system.	PATIENT BED RELEASED		X	1

Functions ressonation	Instantiations
Transport patient to ICU > accommodate patient on bed > assess conditions of target organs	Transporting the patient to the ICU is a highly unstable event due to the patient's health conditions and limited inventory along the way. In addition, waiting for the elevator and possible complications in the patient's condition may affect the patient's accommodation in bed, interfering with the diagnosis of the first assessment.
Communicate with family member> carry out round patient > assess (speech therapy) /assess (nutritionist) /assess (physiotherapy) /assess (clinical pharmacy) > update patient chart >develop prescription	The patient information contained in the clinical record often lacks the history brought by the family, which may be absent in clinical decision-making situations. In addition, multidisciplinary rounds should ideally bring together family members and at least one representative of the multidisciplinary team, which is often not feasible. Added to this is the potential delay in the consultancy evolution by the multidisciplinary team in the system due to the limited supply of computers. Finally, communication via the system is insufficient, requiring professionals to rework to ensure that the medical team has accessed the prescribed guidelines.
	Frequent miscommunications accumulate until the diagnosis and prescription of patient care.
Develop prescription > carry out exam on the bedside > transport patient to exam out of ICU> provide regular care	The lack of management in the distribution of the schedule for requesting and scheduling exams to patients overloads the routine of nursing technicians in the ICU and Radiology. They must accompany the patient throughout the course and examination. Also, transporting the patient for examination is an event of high instability due to the patient's health conditions and limited inventory along the way. In Radiology, the patient must be switched to a metal-free stretcher to access the CT room. These factors delay the care of other patients or leave them unattended in the ICU.
Set administrative time of drugs > dispense drugs > prepare drugs > administer drugs	The lack of a shift in time to schedule drugs to patients hampers the prescription schedule, requiring a routine for all employees. This situation overloads both the pharmacy space and nursing stations as well as the respective teams. In addition, the nursing technician must review the prescription items with the drug. Drug preparation and admission is a high percentage of technician time, and such bottlenecks and delays in drug dispensing and preparation can spill over into patient administration.
Confirm patient discharge > release bay > terminal cleaning (patient bay) > supervision terminal cleaning > report bed release/availability > assign bed to patient	Information is presented below.

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