Nudging clinicians to promote serious illness communication for critically ill patients: A pragmatic cluster randomized trial

IMPORTANCE: Guidelines recommend that intensive care unit (ICU) clinicians consider prognosis and offer a comfort-focused treatment alternative to patients with limited prognoses to promote preference-sensitive treatment decisions.

OBJECTIVE: To determine whether nudging ICU clinicians to adhere to communication guidelines improves outcomes among critically ill patients at high risk of death or severe functional impairment.

DESIGN, SETTING, AND PARTICIPANTS: This 4-arm pragmatic, stepped-wedge, cluster randomized trial (conducted February 1, 2018-October 31, 2020, follow-up through April 29, 2021, and analyses December 2023-January 2024) involved 3500 encounters of adults with chronic serious illness receiving mechanical ventilation for at least 48 hours at 10 hospitals comprising 17 medical, surgical, specialty, or mixed ICUs in community, rural, and urban settings.

INTERVENTIONS: Two clinician-directed electronic health record nudge interventions were each compared with usual care alone and combined: document of 6-month functional prognosis and whether a comfort-focused treatment alternative was offered or a reason why not.

MAIN OUTCOMES AND MEASURES: The primary outcome was hospital length of stay, with death coded at the 99th percentile. Secondary end points included 22 measures of acute care utilization, end-of-life care processes, and mortality.

RESULTS: Of 3500 patient encounters among 3250 patients (mean [SD] age, 63.2 [13.5] years; 46.1% female), 3384 encounters (96.7%) had complete baseline data and were included in risk-adjusted analyses. The overall intervention document completion rate for all patients was 75.0% (n = 1714) and similar across groups. Among the 3500 encounters, observed hospital mortality was 35.7% (n = 1249), and the median observed length of stay was 8.93 days (IQR, 4.64-16.23). The median length of stay with deaths coded as the 99th percentile did not differ between any intervention and usual care groups (for length of stay, all adjusted median difference 95% CIs include 0; for hospital mortality, all adjusted risk difference [RD] 95% CIs include 0). Results were similar in sensitivity analyses with death coded as low at the fifth percentile and without ranking deaths. Compared with usual care, a higher percentage of patients were discharged to hospice in the treatment alternative group (10.9% vs 7.3%; adjusted RD, 6% [95% CI, 1%-10%]) and the combined group (8.9% vs 7.3%; adjusted RD, 6% [95% CI, 0%-12%]). The treatment alternative intervention led to earlier comfort-care orders (3.6 vs 4.5 days; adjusted hazard ratio, 1.42 [95% CI, 1.06-1.92]). The 20 other secondary end points were unaffected by the interventions.

CONCLUSIONS AND RELEVANCE: This cluster randomized clinical trial found that electronically nudging ICU clinicians to adhere to communication guidelines was feasible but did not reduce hospital length of stay.

The Donaghue Foundation

Katherine R Courtright, Jaspal Singh, Erich Dress, Brian Bayes, Michael O Harhay, Marzana Chowdhury, Yingying Lu, Kenneth M Lee, Dylan S Small, Casey Whitman, Jenny Tian, Vanessa Madden, Timothy Hetherington, Lindsay Plickert, D Matthew Sullivan, Henry L Burke, Michael B Green, Scott D Halpern