Themes, subthemes and illustrative quotations identified through qualitative analysis
| Theme; subtheme | Illustrative quotation |
|---|---|
| Theme 1: Infrastructure to enable effective triage implementation | |
| Administrative logistics of implementation | |
| Processes | Who’s our administrator on call? How does this interact with our electronic medical record? Who’s on our [triage] committee? How often does it meet? Who’s chairing it? … It’s all of those kinds of things that I think would be challenging. (HA-7) |
| Human resources | I think the plans required pretty extensive resources to be able to implement, particularly in terms of [human resources] and also administrative support. … And so, I think there was a lot of need to depend on a very small number of people who are already likely going to be overtaxed with clinical responsibilities. (P-10) |
| Project manager | All those logistic things have actually been handled by a project manager at the regional level. I have a ton of respect for that person and faith that we would figure it out because we have that knowledge translation skill set available to us. (HA-1) |
| Information technology processes | Our electronic medical record team was very impressive because they, in a week, got things organized, got our STMR all put into a document online, had an order put in so that [it was] similar to our advanced directives category status, you could just put STMR level I, II, III, colour code it, bring the reports over. (P-2) |
| Real-time bed map | My concern was always that if we have 1 bed and 2 patients [whose condition is deteriorating], how do we communicate as an organization that we only have 1 bed? Because I’ve got 3 different intensive care units plus 3 to 4 different spaces for critical care. So, how do we … communicate if there is a bed, yes or no? How do we then communicate to all of the various stakeholders involved? (HA-3) |
| Readiness to implement ESoC | |
| Ready | We would be very well prepared to enact [the ESoC] in [health region] and the hospitals that are affiliated with that. I mean, we put so much work and time into understanding the tool, doing various case scenarios, role plays, problem solving, troubleshooting, information packages are out, resources about goals of care, advanced care planning. I think we would do very well. (P-1) |
| Not ready | I think there was a little bit of variability between the hospitals within the subregion [in] their levels of preparedness. … I’d estimate it varied between 60% ready versus 90% ready. The smaller hospitals with the level 2 critical care unit or hospitals without critical care units at all with … [fewer] resources … they weren’t quite as ready and probably needed some more time and support. But the larger hospitals … were around that sort of 90% threshold, that with a little bit of notice … they would’ve been able to … be ready for ESoC [implementation]. (P-10) |
| Applicability of ESoC to smaller institutions | There [are] other hospitals where the physician is not even in-house. So, how would something like [ESoC implementation] look in communities that don’t have a tertiary care structure, and how would those inequities across the different health care settings be addressed, both for supporting the health care providers but also ensuring that patients in those settings were not disadvantaged or vice versa? (P-3) |
| Simulations | I think we need to do a better job of educating and simulating and having people truly prepared. And I think you can only do that through the simulation. (P-10) |
| Provincial leadership | We weren’t clear on what was coming out from … the province, what could be shared, what was not being shared. So, even when we were included, it was late in the day or not in the right way. And we certainly weren’t able to have safe conversations with a reasonable size of people about [ethical] questions. And that all would’ve been easier if the document had been released publicly. (HA-10) |
| Theme 2: Social, medical and political supports for effective triage implementation | |
| Leadership | What helped us was getting a triage physician leader … who was trustworthy and trusted, less hierarchical, and allowed opportunities in our simulations for expression of uncertainty or a very inclusive conversation about how to resolve uncertainty. (HA-10) |
| Education on ESoC | Given the uncertainty of whether or not [the ESoC protocol] would be enacted, [we assumed] giving [staff] the information … would immediately likely cause them to have that moral distress. We chose not to fully educate people on it. (HA-4) |
| Interregional collaboration | It was nice to be able to have material that other [regions] had already tried. Because there’s so much potential duplication of effort, and, in a moment like this, that’s going to be really problematic. (P-9) |
| Intraregional collaboration | I think I would hate to be a lone hospital trying to do this on our own and not having the support of the hospitals in our region. (HA-4) |
| Psychosocial impact on staff | I think nurses, personal support workers, anybody who isn’t a physician has a much higher risk of being treated like absolute crap by patients and family members. So, in all honesty, the moral distress, the risk factor for that, educated guess, is higher than it would be even for the people filling out something like the [STMR] tool. (P-1) |
| Psychosocial support | We have the resilience team. We have the ethics team. We have social workers that will help. We have physicians who are experts … in STMR [assessment] but also in those difficult conversations like rules of care that are available to other physicians. We have — as an administrator, I’m available through the region because I have a very good understanding of the process, but also, within the organization, I would support anybody on call. (HA-5) |
| Time to process ESoC | If we don’t give [staff] time to process it and we just make them do it, I think the risk of traumatization and posttraumatic stress from having to implement something that they haven’t had time to digest is going to be really profound. … I think it runs a real risk of traumatizing people who have to make those decisions without understanding why they’re making those decisions or understanding some of the … ethics behind it. (P-3) |
| Palliative care | I think since day 1, I was a big proponent of the abandonment issue and making sure patients were not abandoned. And then appropriate palliative care was done. And I know we worked on a palliative care order set … Making sure that the patients were not abandoned, and they were getting appropriate symptom management. (HA-6) |
| Liability protection | I’m not very concerned about ending up in court 2 years from now over this, personally, as an individual. However, many people in my region and subregion have articulated that as a concern or even a complete impediment for starting to use the ESoC. And so, as an administrator or a leader, it’s a concern, but as a professional, it’s not. (P-5) |
| Theme 3: Moral dimensions of triage implementation | |
| Ethical concerns | I don’t have ethical qualms about the ESoC. I have qualms about not implementing it in a timely manner. I have qualms about our risk threshold … getting higher … in terms of how much we’re expected to surge. And … we’ve become blind to the fact that people will die as we build this capacity. And we have blindness to the people we’re invisibly triaging. (HA-1) |
| Moral distress | [ESoC implementation] would have put physicians in a position of practising in a way that they have never practised before in their careers and is in direct conflict with their standard medical ethics. And I think that would’ve caused significant distress. … There would’ve been posttraumatic stress for sure. Burnout. People leaving the profession. … I just think it would’ve been disastrous, to be honest with you. (HA-8) |
| Conscientious objection | A big concern I have is that some providers may refuse to [triage], which would lead … to inconsistency of implementation. (P-5) |
| Withdrawal of care | |
| Moral distress | I absolutely do not believe [ESoC implementation] could be done without [withdrawal of care]. That would be morally distressing to the front-line staff, the physicians and the staff, having a patient in a bed who will not survive because the family doesn’t want to turn them off the ventilator. And yet we’re turning away other people who do have a chance of survival. (HA-5) |
| Liability concerns | I actually think [physicians] have a lot of backing for the ESoC. Now, withdrawal of treatment is a whole other ballgame, and that would require an executive order. But the ESoC — I feel like physicians are well covered. It’s us, as administrators, who, I think, are more at risk. (HA-1) |
| Appeals process | There was this ongoing discussion around appeals processes for patients who would be denied critical care. … I think there was a big divide around that piece because it makes sense from a procedural point of view, but it’s hard to imagine how that could ever work in practice. (HA-7) |
| Theme 4: Communication of triage results | |
| STMR communications among staff | We were doing a lot of [communication regarding care provision among staff] via teams. And … one of the things that’s really essential to this process is very rapidly trusting the other people on your team and being able to have frank conversations and raise concerns. And the greatest barrier was actually not knowing each other in advance and building that kind of environment of trust right away when we’re remote from one another. (HA-10) |
| Communications with deprioritized patient’s family | It’s going to be awful to just have to go and tell [the deprioritized patient’s family] and say, “We’re not … [providing your family member with a ventilator or other critical care].” … I do think I have the skill set to have that conversation. I don’t want to have that conversation. (P-3) |
| Nonphysician staff’s being abandoned | That physician does not want to have that bad-news conversation alone with the patient. They want the social worker with them, the bedside nurse with them. And then, guess what? The physician walks away, but who is left taking care of that patient, who now feels abandoned? It’s that nurse, that social worker and that family. (HA-1) |
Note: ESoC = Emergency Standard of Care, HA = hospital administrator, P = physician, STMR = short-term mortality risk.