Applying Journey Mapping and Human-Centered Design to Improve Critical Care Delivery for Patients with Acute Respiratory Failure

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Golden, Patrick G. Lyons, Allison Young, Scott Warner, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6874775/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted 10 You are reading this latest preprint version Abstract Background Acute respiratory failure is a common cause for hospitalization and intensive care unit (ICU) admission. Prior literature has found that hospital factors unrelated to patients’ illness severity or clinical needs contribute to substantial variability in ICU admission rates across hospitals. Overuse of the ICU for patients unlikely to benefit from critical care is inefficient, contributes to rising costs, and may cause harm. As part of efforts to improve the value of critical care, we utilized human-centered design to create a prototype, system-level intervention designed to optimize ICU utilization for patients hospitalized with acute respiratory failure. Methods We created a multidisciplinary taskforce and conducted four meetings over a 5-month period in 2022 at a VA medical center. We used journey mapping to depict the care continuum of acute respiratory failure patients and identify facilitators/barriers to high-value care; next, we integrated qualitative methods using rapid team-based analysis with human-centered design to develop a system-level intervention to guide triage decisions and tailor care-delivery processes. Results Our taskforce was comprised of ten participants (including nurses/physicians/respiratory therapists) with clinical and leadership roles in the emergency department, medical/surgical wards, and ICU. We created a service blueprint map and leveraged it to identify themes influencing ICU utilization among patients with acute respiratory failure, including: 1) hospital organization and care processes (e.g., lack of established ICU admission criteria); 2) available resources outside the ICU (e.g., staffing/bed shortages); and 3) staff interactions (e.g., lack of communication/coordination between clinicians/departments). Informed by these results, the taskforce designed a prototype intervention with four components: a) create explicit ICU admission criteria; b) assign levels of care based on patients’ needs; c) geographically cohort patients with shared needs outside the ICU; and d) re-engineer rapid-response teams to proactively assess/follow patients outside the ICU. Conclusions We combined qualitative and human-centered design methodologies, in concert with creation of a service blueprint map, to develop a prototype intervention designed to improve the value of care for patients with acute respiratory failure. Our methods serve as a model to address complex problems within the inpatient healthcare delivery system. Future work includes pilot-testing the intervention for feasibility/acceptability. human-centered design triage intensive care units qualitative research respiratory insufficiency Figures Figure 1 Figure 2 Figure 3 Introduction Acute respiratory failure is one of the most common reasons for hospitalization and intensive care unit (ICU) admission. 1 Although acute respiratory failure can be associated with high morbidity and mortality, many patients with this syndrome are not critically ill and do not require ICU-level care. 2 Hospitals vary widely in how ICU admitting decisions are made for these patients, and little evidence exists to guide such decisions. 3 Because ICU beds are a limited and costly resource, ICU admission for patients who are not critically ill can create waste and inefficiencies within the healthcare delivery system, while simultaneously exposing patients to unnecessary and potentially harmful invasive monitoring and treatments. 2 , 4 A key goal of optimizing critical care delivery and healthcare resource utilization is to identify and admit patients to the ICU who will truly benefit from such resource-intensive care. 4 , 5 However, prior literature has found that hospital factors (e.g., hospital culture, practice patterns) unrelated to patients’ illness severity or clinical needs contribute significantly to variability ICU admission for patient. 6 These findings are of great policy relevance, as they suggest that comparable patients may be treated differently based on their location of treatment. 6 They also highlight existing opportunity to improve the quality and efficiency of our critical care delivery system through the development of hospital-level interventions that guide ICU admitting decisions for patients with acute respiratory failure in a way that is tailored to different risk groups and sensitive to different health systems. 6 , 7 While recent studies have attempted to quantify the benefits of ICU admission for patients with acute respiratory failure, 5 , 8 , 9 little is known about how to design or implement hospital-level interventions to guide triage of patients in the emergency department. Therefore, we sought to utilize human-centered design – a research and innovation framework in which the needs, behaviors, and experiences of end users drive product or service design and implementation – to develop a hospital-level intervention that guides ICU utilization with the goal of improving efficiency and quality of care for patients presenting to the emergency department with acute respiratory failure. Here, we describe using qualitative methods to evaluate clinicians’ perspectives and using journey mapping to identify specific barriers and facilitators to efficient, high-quality care across the continuum of inpatient care. We then utilize these qualitative findings to inform the development of a hospital-level intervention designed to guide the triage of patients with acute respiratory failure throughout the acute care setting using human-centered methodology. Methods Study Design Human-centered design is a systematic method to optimize the design of products or interventions using an iterative approach, taking into account the contexts of use, local environment, user characteristic, and workflow. 10 Of note, it places strong emphasis on developing empathy for the end user to enable targeting the most relevant problem and prioritizing feasible, acceptable solutions. 11 For this study, we utilized a previously described methodological framework for design that includes four distinct phases: (1) Pre-design, in which feedback is sought from users about their experience of using products and systems, and sensitizing to the problem to be addressed in the design process; (2) Generative, in which ideas, insights, and concepts are tested and refined with users in preparation for the development of prototype interventions; (3) Evaluative, in which prototypes are further developed and their effects and effectiveness tested with end-users; and (4) Post-design, which examines how users experience the design in practice in order to iterate in future design cycles based on identified needs and use patterns (Fig. 1). 10 , 12 Herein, we report the Pre-design and Generative phases of this human-centered design framework, including qualitative data collected through design workshops with a multidisciplinary taskforce comprised of clinicians and hospital administrators. As a first step in the human-centered design process, we created a journey map depicting the current-state triage processes for patients presenting to the emergency department with acute respiratory failure. Journey mapping – an emerging concept that has evolved out of the service design field – is increasingly being applied in healthcare to visually map the care continuum and identify efficiencies and inefficiencies in care processes. 13 – 15 For this study, we chose to create a service blueprint map, a specific form of journey map that describes a service experience from a systems view, typically in a chronological format. 13 In contrast to a patient journey map – which focuses on what patients experience when they experience clinical care – a service blueprint map goes deeper to illustrate the clinicians’ actions and organizational processes that may or may not be visible to the patient. Service blueprint maps typically contain several categories that illustrate the main components of the service being mapped out and how they may (or may not) interact with each other. 16 , 17 Notably, with its focus on healthcare delivery rather than the patient experience, a service blueprint map represents the perspectives and experiences of clinical and administrative stakeholders, allowing for illustration of critical timepoints in patients’ movement through the acute care setting through an organizational lens. Setting and Participants This study was conducted at a Veterans Affairs hospital located in the United States. The hospital is high complexity with a combined 24-bed medical/surgical/cardiac ICU, 122 acute care beds, and no intermediate care unit (i.e., a hospital unit that provides a level of care between intensive care and care on the general acute care ward). 18 In the Pre-Design phase of human-centered design methodology, we first created a stakeholder taskforce representing clinicians and hospital administrators across the continuum of inpatient care. To identify participants for the taskforce, we approached the facility’s ICU director for participation; we then employed snowball sampling to identify a multidisciplinary taskforce of physicians, nurses, and respiratory therapists from the emergency department, ICU, and medical/surgical wards. In total, we invited 11 clinicians (each with a concomitant administrative role in their respective clinical sections) to participate in the study, with 10 consenting to do so (Table 1 ). Table 1 Self-reported Characteristics of Taskforce Participants Clinical Role Gender Hospital Location Nurse #1 Male Emergency Department Nurse #2 Male Emergency Department Nurse #3 Male Medical/Surgical Ward Nurse #4 Female Intensive Care Unit Respiratory Therapist #1 Male Hospital-wide Respiratory Therapist #2 Male Hospital-wide Physician #1 Male Emergency Department Physician #2 Female Medical/Surgical Ward Physician #3 Male Medical/Surgical Ward Physician #4 Male Intensive Care Unit Data Collection We conducted a series of four, one-hour virtual design workshops with taskforce members over a 5-month period in 2022. Three research team members, including a critical care physician and health services researcher (KCV), an experienced qualitative researcher and social scientist (SEG), and a research coordinator (AY) conducted the meetings and took field notes. Prior to the first meeting, we created a facilitation guide ( Supplement 1 ) based on a conceptual model adapted from a study measuring hospital-level variation in ICU utilization. 19 All workshops lasted between 55–65 minutes and were video-recorded and transcribed verbatim by trained research staff. Between each design workshop, KCV, SEG, and AY performed directed qualitative content analysis to identify themes relevant to ICU triage processes and inform the development of a prototype hospital-level intervention as described below. Phase 1: Pre-design phase of human-centered design Prior to the first workshop, we generated a preliminary service blueprint map depicting the continuum of care for patients who present to the emergency department with acute respiratory failure based on prior literature synthesized with clinical experience. 20 , 21 Patients with acute respiratory failure were defined broadly as those requiring admission for treatment of an acute, primary respiratory issue (e.g., shortness of breath, hypoxemia, and/or hypercapnia), without specifying underlying etiologies. During the first workshop, taskforce members were shown the preliminary service blueprint map and asked to describe whether/how the map depicted their experiences caring for and triaging patients who present to the emergency department with acute respiratory failure. Taskforce members were asked to provide modifications to the service blueprint map to enable a more accurate depiction of their clinical workflows. After the first design workshop, the study team performed qualitative analyses of the group’s discussion as outlined below to help visualize and identify gaps in key healthcare processes; results from these analyses were used to revise and refine the service blueprint map prior to the second workshop and to inform the subsequent discussion of a future intervention. During the second workshop, the service blueprint map was iteratively refined by taskforce members until consensus was reached. Taskforce members were then asked to identify barriers to and/or facilitators of efficient, high-quality care for patients hospitalized with acute respiratory failure, leveraging their deep contextual knowledge of clinical care and hospital workflows. After the second design workshop, the study team again performed qualitative analyses of the focus group’s discussion; results from these analyses were used to inform the following co-design of a prototype hospital-level intervention described below. Phase 2: Generative phase of human-centered design During the third design workshop, informed by results from qualitative analyses during the Phase 1, taskforce members co-designed a prototype, system-level intervention to guide triage and care of patients presenting to the emergency department with acute respiratory failure. Following the third design workshop, study team members conducted semi-structured interviews with individual taskforce members to refine the intervention and elicit feedback from participants outside the group setting. The study team again performed qualitative analyses of semi-structured interviews between the third and fourth design workshops; results from these analyses were used to inform the subsequent refinement of the prototype hospital-level intervention described below. At the fourth design workshop, taskforce members iterated and finalized the intervention, and discussed strategies for implementation (to be reported in a future publication). Data Analysis As described above, KCV, SEG, and AY used inductive and deductive thematic approaches to perform directed qualitative content analysis of the transcripts and field notes taken during each design workshop and semi-structured interview. KCV and SEG read the first two transcripts to create a preliminary codebook. After discussion, we independently coded the same first two transcripts and met to compare and reach consensus. Next, AY read the first two transcripts to become familiar with the data and the codebook. AY and SEG coded the next two transcripts together while refining the codebook, after which point no other changes were made. We coded the remaining six transcripts independently, using Atlas.ti v9 for data organization and an audit trail and memos for organization and synthesis. Our sample contained sufficient information power (i.e., capacity of a sample to provide appropriate and rich data) given our relatively narrow study aim, the specific deep expertise of our participants, robust dialogue with participants, and rigorous analyses. 22 This study was approved by our Institutional Review Board (#4439). Results The taskforce included four nurses, four physicians, and two respiratory therapists, with representation across the emergency department, general acute care wards, and the ICU (Table 1 ). The finalized service blueprint map of acute care delivery for adults presenting to the emergency department with acute respiratory failure is depicted in Fig. 2. This map represents the journey of a patient upon presentation to the emergency department, the actions taken by clinicians in caring for these patients, and additionally depicts the hospital-level organizational factors that impact these processes. Of note, the study team added clarifying labels in the final map. Qualitative Analyses In qualitative analyses of the design workshops, we identified three themes, each with several subthemes, encompassing factors that influence triage decisions and care delivery for patients hospitalized with acute respiratory failure. These include: 1) hospital organization and care processes; 2) available resources; and 3) communication and coordination between staff. Below, we describe each theme with representative quotations with additional quotes embedded in Fig. 3. Theme 1: Hospital organization and care processes Lack of explicit ICU admission criteria leads to variability in ICU admitting decisions. Participants described how ICU admitting decisions from the ED varied depending on factors unrelated to patient needs (e.g., subjective clinician preference); they attributed much of this variation to the lack of explicit ICU admission criteria. Some participants were unsure as to whether specific ICU admission criteria existed, whereas others felt certain they did not. Participants noted that explicit admission criteria for patients with acute respiratory failure who did not require life-sustaining treatment would be helpful to standardize triage processes and avoid decisional conflicts and deliberation among clinicians regarding patients’ discharge dispositions. As one nurse stated “I do like the idea of having some sort of transparent criteria for what it looks like for patients that need to be admitted… It has always been kind of a push-pull [for] situations on the borderline.” Geographic dispersion of patients with acute respiratory failure contributes to workflow inefficiencies. Participants described how hospitalized patients with acute respiratory failure outside the ICU were often geographically dispersed across the hospital, leading to workflow inefficiencies. In particular, respiratory therapists described wasting a lot of time “running around the hospital” to find patients—time that they felt could be better spent providing treatments and tailoring respiratory support interventions for their patients. Participants felt that geographic cohorting of patients with acute respiratory failure who were not critically ill outside the ICU would help create an “economy of scale” by concentrating the expertise and resources needed to care for these patients in a specific location. One respiratory therapist noted that if the hospital, “had a strategy to localize these patients that all had pretty similar [respiratory care] needs [outside of the ICU]… then we would provide better care.” Furthermore, widespread consensus existed among participants regarding the potential benefit of an intermediate care unit as a specific example of geographic cohorting for “borderline” patients to improve care efficiency and outcomes. However, substantial uncertainty existed among participants regarding policies and procedures involving intermediate care units (e.g., requirements for physical proximity to the ICU, staffing models, which patients were appropriate for admission, etc.). Such administrative and logistical uncertainty has served as a substantial barrier to the creation of an intermediate care unit in the past and was perceived to be a substantial burden to future development of such a unit. Concerns about inadequate detection of clinical deterioration among patients on the ward lead to unnecessary ICU admissions. Participants described one example of deliberation when patients who do not require life-sustaining interventions are commonly admitted to the ICU due to concerns that clinical deterioration may go underrecognized on the ward. They raised concerns that currently-used rapid response teams designed to facilitate ICU transfer for unstable patients on the ward are often too reactive; several pointed out the potential benefits of shifting the role of rapid response teams to be more proactive in their assessments of “borderline” patients admitted outside the ICU. Domain 2: Available resources outside the ICU Staffing and bed shortages on the ward leads to ICU overuse for non-critically ill patients. Inadequate staffing (particularly nurses and respiratory therapists) and bed availability on the wards was consistently mentioned as a barrier to the efficient and appropriate triage of patients with acute respiratory failure; participants described how this problem existed prior to the COVID-19 pandemic but had since been exacerbated by it. For example, participants noted how, due to staffing limitations, respiratory therapists are not stationed in the emergency department but are instead called there as needed. This staffing model often resulted in emergency department clinicians–who do not have specific expertise in applying or titrating devices such as high flow nasal cannula–managing patients with acute respiratory failure without the immediate assistance of respiratory therapists. For that reason, participants felt it would be beneficial to have a dedicated respiratory therapy stationed in the emergency department to facilitate earlier assessment of patients with acute respiratory failure and provide more tailored therapies. Bed shortages on the ward (sometimes related to limited staffing) leads to “overtriage” of patients to the ICU, when patients otherwise could have been managed on the ward with similar outcomes, but ended up in the ICU for reasons unrelated to their severity of illness or clinical needs. For example, one hospitalist said, “We already are very tight with our [ward] beds and so it limits our ability to place patients [outside the ICU] at times." Theme 3: Staff interactions Clinical silos, lack of communication, and power dynamics between clinicians contribute to delays in care Many participants described how the care of patients with acute respiratory failure was influenced by interactions between clinicians, who often exist in geographic and clinical silos. Participants also felt that power dynamics (particularly in a teaching hospital) influenced the quality of care patients received. For example, one physician explained: “sometimes you’ve got [emergency medicine] attendings on one hand…and 2nd year brand new residents on the other end of the phone… so you’ve got these [power] differentials” that lead to conflict and delayed care. One physician explained how patients often end up “like a ping pong ball between the ICU and the ward teams.” Participants noted the value of face-to-face interactions between clinicians to improve communication and care coordination; they also noted the importance of early involvement of attending physicians when conflicts arise between clinical teams. Intervention Prototype The taskforce conceptualized four potential interventions that could be combined at a system-level depending on what is necessary and/or feasible within the context of a specific hospital environment as an outcome of the UCD process. Here, we briefly describe the intervention components that represent the output of UCD methodology, recognizing that the intervention itself has not been tested and is not the focus of this manuscript. Component 1: Create Explicit ICU Admission Criteria First, we propose the creation of standardized ICU admission criteria that are sensitive to the hospital-specific environment. Specifically, these criteria would define the need for ICU admission as patients requiring life-sustaining treatment at the time of their ED presentation and would lessen the effect of some communication issues. Creating a culture of open dialogue and shared space between clinicians may also facilitate coordination and communication, especially regarding admitting discussions. Component 2: Assign Levels of Care to Patients Based on Clinical Needs at Time of Admission Complementary to component #1, we propose that patients presenting to the ED with acute respiratory failure be assigned a level of care based on objective criteria reflecting their clinical needs/acuity level. This classification could potentially help standardize triage processes by focusing on each patient’s specific monitoring and care requirements, 23 with the goal of reducing variability in ICU admitting decisions. Component #3: Geographically Cohort Patients with Shared Needs To help overcome persistent staffing shortages and address existing workflow inefficiencies, we propose using a systems-engineering approach to geographically cohort patients with acute respiratory failure with similar clinical needs (e.g., frequent suctioning, respiratory toilet) but who are not critically ill in a specific ward location. Participants felt that cohorting patients in this way, with or without the creation of a dedicated “intermediate care unit,” could help create an economy of scale outside the ICU, streamlining workflows and maximizing efficiency of staffing resources, with the potential to improve patient outcomes. Component 4: Re-engineer Rapid Response Team to Proactively Follow Patients Outside the ICU We propose shifting the paradigm for hospitals’ existing rapid response teams from being reactive to proactive . 24 , 25 Specifically, this team (referred to as the “mobile surveillance team” by participants) could perform preemptive, scheduled evaluations of patients identified as “high-risk” for needing ICU transfer (according to assigned level of care as described in component 2) for a pre-set time period following admission. Discussion In this study, we created a multidisciplinary taskforce and created a service blueprint map as a first step in a human-centered design process to develop a prototype, system-level intervention that can help optimize critical care delivery (including ICU admitting decisions) for patients presenting to the ED with acute respiratory failure. 26 To our knowledge, this study is among the first to apply human-centered design methodology as part of efforts to improve the quality and efficiency of our critical care delivery system. More broadly, this approach offers a potentially adaptable framework to systematically address existing complex problems within our healthcare delivery system (e.g., staffing shortages, inefficient use of resources). 27 Our study adds to the literature in several ways. First, this study is unique in its application of human-centered design to develop system-level interventions designed to optimize critical care delivery for patients. While human-centered design is increasingly being used in the outpatient setting, 28 – 30 few studies report its use within the inpatient healthcare delivery system. One recent study utilized human-centered design to redesign handoffs between operating room and surgical ICU staff; 31 another applied human-centered design to design bar-coded medication administration among hospitalized patients. 32 Our study builds on this prior work by using human-centered design to create a system-level intervention that spans the continuum of inpatient care, taking into account how distinct departments and clinicians across specialties interact with each other to coordinate care for patients hospitalized with acute respiratory failure. Additionally, our use of human-centered design methodology enabled the study team to identify important communication barriers that exist across clinical silos, while simultaneously gaining buy-in of organizational leaders by incorporating them within the intervention development process. Second, the creation of a service blueprint map in the context of healthcare delivery is relatively novel, 33 particularly across the continuum of inpatient care. Specifically, the service blueprint map enabled participants to visualize key “pain points” that interfere with the delivery of efficient care within a complex system and identify opportunities for improvement in these areas. In this way, service blueprint maps represent a useful tool within healthcare improvement initiatives since they allow participants to identify, reflect, and ideate on the interplay between user workflows, resource constraints, and physical spaces to create innovate solutions. Taken together, our methods and results provide a basis for future efforts to design and implement complex interventions within our inpatient care delivery system to improve efficiency and optimize the overall value of care. Finally, we found that communication and coordination between clinicians in different specialties was perceived by study participants to substantially impact patient care. Prior literature has demonstrated that miscommunication between clinicians during transitions of care drives diagnostic error. 34 Our study builds on this by identifying how the lack of communication and collaboration between clinicians may negatively impact patient outcomes in the form of mis-triage of patients. Our findings suggest that such miscommunication may be, in part, mitigated by the creation of standardized ICU admitting processes and highlight the need for future research aimed at improving organizational culture and communication practices across clinical silos. Our study also has limitations. First, the intervention has not yet been tested for feasibility, acceptability, or impact on outcomes. Second, participants were from a single VA site, limiting generalizability; however, a benefit of human-centered design methodology is its ability to tailor solutions to meet end users’ needs within a particular context. Furthermore, while the intervention itself may not be generalizable, the methods used to develop the intervention are generalizable to various settings. Additionally, because this study was focused on care processes and organizational factors influencing triage decisions and care delivery for patients with acute respiratory failure, we did not include patients in the human-centered design process; however, we recognize that patients’ perspectives are important to elicit and incorporate in future implementation studies. Conclusions This study illustrates how human-centered design, combined with service blueprint mapping and rapid team-based qualitative analysis, can be utilized to derive insights from stakeholders across existing healthcare silos and design system-level interventions to improve the efficiency and value of critical care delivery. This works serves as a model for how to leverage these methods when addressing existing complex problems within our inpatient healthcare delivery system. Declarations Ethics approval and consent to participate: Approved by the VA Portland institutional Review Board (#4439) in accordance with the Belmont Report and Declaration of Helskini. All participants provided informed consent prior to participation. Consent for publication: Not applicable Competing interests: All authors declare no conflicts of interest with the work presented in this manuscript. Funding: This study and Dr. Vranas are supported by an award from the Department of Veterans Affairs [CDA 18-191]. It was also supported by resources from the Center to Involve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR. Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available to protect the privacy of our participants. Acknowledgements: The authors would like to acknowledge the participation and thoughtfulness of all of the participants in this study. C orresponding Author Sara Golden, PhD, MPH 3710 SW US Veterans Hospital Rd. R&D 66 Portland, OR 97239, USA E-mail: [email protected] Running Title: Applying human-centered design to ICU triage The Department of Veterans Affairs did not have a role in the conduct of the study, in the collection, management, analysis, interpretation of data, or in the preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government. Author contributions: Sara E. Golden: Methodology, validation, formal analysis, investigation, data curation, writing-original draft, writing-review & editing Patrick G. Lyons: Writing-review & editing, visualization Allison Young: Validation, data curation, writing-review & editing, visualization, project administration Scott Warner: Writing-review & editing Anaïs Tuepker: Methodology, writing-review & editing Ian Ilea: Data curation, writing-review & editing, visualization, project administration Donald R. Sullivan: Writing-review & editing Christopher G. Slatore: Conceptualization, writing-review & editing, supervision Kelly C. 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Exploring Patient Journey Mapping and the Learning Health System: Scoping Review. JMIR Hum Factors. 2023;10:e43966. 10.2196/43966 . PMID: 36848189; PMCID: PMC10012009. Gershengorn HB, Chan CW, Xu Y, Sun H, Levy R, Armony M, Gong MN. The Impact of Opening a Medical Step-Down Unit on Medically Critically Ill Patient Outcomes and Throughput: A Difference-in-Differences Analysis. J Intensive Care Med. 2020;35(5):425–37. Epub 2018 Mar 18. PMID: 29552955. Seymour CW, Iwashyna TJ, Ehlenbach WJ, Wunsch H, Cooke CR. Hospital-level variation in the use of intensive care. Health Serv Res. 2012;47(5):2060-80. 10.1111/j.1475-6773.2012.01402.x . Epub 2012 Mar 30. Erratum in: Health Serv Res. 2013;48(2 Pt 1):681. PMID: 22985033; PMCID: PMC3513618. Kruser JM, Viglianti EM, Mylvaganam R, Krolikowski KA, Khorzad R, Detsky ME, Wiegmann DA, Wunderink RG, Holl JL. Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure. IISE Trans Healthc Syst Eng. 2024;14(1):32–41. Epub 2023 Apr 20. PMID: 38646086; PMCID: PMC11025699. Antonacci G, Lennox L, Barlow J, Evans L, Reed J. Process mapping in healthcare: a systematic review. BMC Health Serv Res. 2021;21(1):342. 10.1186/s12913-021-06254-1 . PMID: 33853610; PMCID: PMC8048073. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753–60. 10.1177/1049732315617444 . Epub 2016 Jul 10. PMID: 26613970. Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, Fowler CS, Byrum D, Miles WS, Bailey H, Sprung CL. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med. 2016;44(8):1553 – 602. 10.1097/CCM.0000000000001856 . PMID: 27428118. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139 – 46. 10.1056/NEJMra0910926 . PMID: 21751906. Mitchell OJL, Motschwiller CW, Horowitz JM, Friedman OA, Nichol G, Evans LE, Mukherjee V. Rapid Response and Cardiac Arrest Teams: A Descriptive Analysis of 103 American Hospitals. Crit Care Explor. 2019;1(8):e0031. PMID: 32166272; PMCID: PMC7063949. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26. 10.1097/MLR.0b013e3182408812 . PMID: 22310560; PMCID: PMC3731143. Buchanan R. Wicked problems in design thinking. Des Issues. 1992;8(2):5–21. 10.2307/1511637 . Catalani C, Green E, Owiti P, Keny A, Diero L, Yeung A, Israelski D, Biondich P. A clinical decision support system for integrating tuberculosis and HIV care in Kenya: a human-centered design approach. PLoS ONE. 2014;9(8):e103205. 10.1371/journal.pone.0103205 . PMID: 25170939; PMCID: PMC4149343. Trail-Mahan T, Heisler S, Katica M. Quality Improvement Project to Improve Patient Satisfaction With Pain Management: Using Human-Centered Design. J Nurs Care Qual. 2016 Apr-Jun;31(2):105 – 12; quiz 113-4. 10.1097/NCQ.0000000000000161 . PMID: 26447343. Zikmund-Fisher BJ, Tuepker A, Metcalf EE, Strange W, Teo AR. Applying user-centered design in the development of nudges for a pragmatic trial to reduce no-shows among veterans. Patient Educ Couns. 2022;105(6):1620–7. 10.1016/j.pec.2021.10.024 . Epub 2021 Oct 23. PMID: 34756639; PMCID: PMC9033881. Segall N, Bonifacio AS, Barbeito A, Schroeder RA, Perfect SR, Wright MC, Emery JD, Atkins BZ, Taekman JM, Mark JB. Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9):400–14. 10.1016/s1553-7250(16)42081-7 . PMID: 27535457; PMCID: PMC6152817. Ching JM, Williams BL, Idemoto LM, Blackmore CC. Using lean automation with a human touch to improve medication safety: a step closer to the perfect dose. Jt Comm J Qual Patient Saf. 2014;40(8):341 – 50. 10.1016/s1553-7250(14)40045-x . PMID: 25208439. Ly S, Runacres F, Poon P. Journey mapping as a novel approach to healthcare: a qualitative mixed methods study in palliative care. BMC Health Serv Res. 2021;21(1):915. 10.1186/s12913-021-06934-y . PMID: 34479541; PMCID: PMC8417950. Santhosh L, Cornell E, Rojas JC, Lyons P. Diagnostic safety across transitions of care throughout the healthcare system: current state and a call to action [Internet]. 2023 [cited 2023 Jul 18]. Available from: https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html Additional Declarations No competing interests reported. Supplementary Files Supplement1.FacilitationGuidefinal.pdf Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 17 Sep, 2025 Reviews received at journal 19 Aug, 2025 Reviews received at journal 11 Aug, 2025 Reviewers agreed at journal 11 Aug, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers invited by journal 18 Jul, 2025 Editor assigned by journal 16 Jul, 2025 Editor invited by journal 25 Jun, 2025 Submission checks completed at journal 24 Jun, 2025 First submitted to journal 24 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6874775","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":488730986,"identity":"02a1b514-ec02-4506-92ed-a493de739e9b","order_by":0,"name":"Sara E. Golden","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie2PoQrCUBSGzxiYDuYJsvsKRywGtfoayuBaZhcMapllurrHmZywcjWvicVkWBxi0Ami6eqa4P3SCffj+y+AwfDDNCEBSPIqCt4VaxtXVWzGb56K1e6Yw6WL9XSdcC/ogxiEpFVIjduOtZHYUPshTwIPWkp9UECCY4WMlPnEvrKhFcuhflh0souHcjgTd9T8swKZrDlQlBUkhimDcLxEPyw71TqjRfkXn7bhNEVC1isiknaWX7tuPVXtvKCZK1bLhX5YySh43Uj6xpPre/eLhsFgMPwXN7BPSM6T3Pu+AAAAAElFTkSuQmCC","orcid":"","institution":"VA Portland Health Care System","correspondingAuthor":true,"prefix":"","firstName":"Sara","middleName":"E.","lastName":"Golden","suffix":""},{"id":488730987,"identity":"0ec9d2eb-e9fc-4a65-833a-716606a4f00e","order_by":1,"name":"Patrick G. Lyons","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"G.","lastName":"Lyons","suffix":""},{"id":488730989,"identity":"16fe81e8-4e6f-4a02-8c8b-ac457fcf18b3","order_by":2,"name":"Allison Young","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Allison","middleName":"","lastName":"Young","suffix":""},{"id":488730990,"identity":"0aa7ea48-dd64-4a9e-9aad-5be81ea34ca3","order_by":3,"name":"Scott Warner","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Scott","middleName":"","lastName":"Warner","suffix":""},{"id":488730991,"identity":"f302ee0e-0af1-47cd-afef-adb233795150","order_by":4,"name":"Anais Tuepker","email":"","orcid":"","institution":"VA Portland Health Care System","correspondingAuthor":false,"prefix":"","firstName":"Anais","middleName":"","lastName":"Tuepker","suffix":""},{"id":488730992,"identity":"fdd517e6-7321-4713-8888-c17bff209774","order_by":5,"name":"Ian Ilea","email":"","orcid":"","institution":"VA Portland Health Care System","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Ilea","suffix":""},{"id":488730993,"identity":"9e77280d-cdbf-45d0-b47e-a87d239c2d7b","order_by":6,"name":"Donald R. Sullivan","email":"","orcid":"","institution":"VA Portland Health Care System","correspondingAuthor":false,"prefix":"","firstName":"Donald","middleName":"R.","lastName":"Sullivan","suffix":""},{"id":488730994,"identity":"1ef2632f-a41c-4233-b5aa-7940f6962655","order_by":7,"name":"Christopher G. Slatore","email":"","orcid":"","institution":"VA Portland Health Care System","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"G.","lastName":"Slatore","suffix":""},{"id":488730995,"identity":"38511b5f-a6a8-43b0-8ae5-0b085eff1239","order_by":8,"name":"Kelly C. Vranas","email":"","orcid":"","institution":"VA Portland Health Care System","correspondingAuthor":false,"prefix":"","firstName":"Kelly","middleName":"C.","lastName":"Vranas","suffix":""}],"badges":[],"createdAt":"2025-06-11 20:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6874775/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6874775/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13864-6","type":"published","date":"2025-12-30T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87663869,"identity":"700e6840-ae18-4466-9a4e-21fa6f9adcb2","added_by":"auto","created_at":"2025-07-27 10:55:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101562,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of Study Design Utilizing Human-Centered Design Methodology*\u003c/p\u003e\n\u003cp\u003e*adapted from Mastering design thinking. Sloan School of Management; 2023 [cited 2023 Jul 18]. Available from: https://executive.mit.edu/course/mastering-design-thinking/a056g00000URaa4AAD.html\u003c/p\u003e","description":"","filename":"Figure1.OverviewofHCD.png","url":"https://assets-eu.researchsquare.com/files/rs-6874775/v1/fbf2eb89475f8fb75b46cf9c.png"},{"id":87662798,"identity":"e73ce96b-c11e-47a7-8273-6630a53a0f13","added_by":"auto","created_at":"2025-07-27 10:47:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":104317,"visible":true,"origin":"","legend":"\u003cp\u003eService Blueprint Map of Acute Care Delivery for Adults Presenting with Acute Respiratory Failure. The map is divided into three rows, with the first row illustrating a patient presenting to the emergency department with acute respiratory failure’s journey through the acute care setting. The first and second rows are divided by the line of interaction that symbolizes the interplay between clinicians and patients that is more transparent. The second row depicts actions taken by clinicians in caring for these patients. The second and third rows are divided by the line of visibility that symbolizes the more hidden interplay between clinicians and the healthcare system. The third row illustrates hospital-level organizational factors that influence care delivery, but that may be less visible to patients and/or clinicians. Circular boxes indicate areas the intervention components address.\u003c/p\u003e","description":"","filename":"Figure2.ServiceBlueprintMap.png","url":"https://assets-eu.researchsquare.com/files/rs-6874775/v1/32d71030066430648c624784.png"},{"id":87662814,"identity":"a7317fa4-bdb6-4c78-ba81-77d05505ce59","added_by":"auto","created_at":"2025-07-27 10:47:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2310961,"visible":true,"origin":"","legend":"\u003cp\u003eThemes and Exemplary Quotes Describing Factors Influencing Triage Decisions and Care Delivery. This figure visually organizes our emerging themes and in combination with exemplary quotes serves to further describe factors influencing the triage and care of adults with acute respiratory failure at our VA hospital.\u003c/p\u003e","description":"","filename":"Figure3.ThemesandQuotes.png","url":"https://assets-eu.researchsquare.com/files/rs-6874775/v1/6c5a66286ce24dcdd1611b10.png"},{"id":99545267,"identity":"fd6e5acc-d2dd-4f9a-9bdd-3780db13090e","added_by":"auto","created_at":"2026-01-05 16:04:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2907583,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6874775/v1/784e2d1d-f02b-43ce-a99b-7fc114499912.pdf"},{"id":87662795,"identity":"2d142eb8-bf12-4b4d-ae5b-e9e83caf075f","added_by":"auto","created_at":"2025-07-27 10:47:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":146207,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement1.FacilitationGuidefinal.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6874775/v1/78c723639cfb6a119128383a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Applying Journey Mapping and Human-Centered Design to Improve Critical Care Delivery for Patients with Acute Respiratory Failure","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute respiratory failure is one of the most common reasons for hospitalization and intensive care unit (ICU) admission.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Although acute respiratory failure can be associated with high morbidity and mortality, many patients with this syndrome are not critically ill and do not require ICU-level care.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Hospitals vary widely in how ICU admitting decisions are made for these patients, and little evidence exists to guide such decisions.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Because ICU beds are a limited and costly resource, ICU admission for patients who are not critically ill can create waste and inefficiencies within the healthcare delivery system, while simultaneously exposing patients to unnecessary and potentially harmful invasive monitoring and treatments.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA key goal of optimizing critical care delivery and healthcare resource utilization is to identify and admit patients to the ICU who will truly benefit from such resource-intensive care.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, prior literature has found that hospital factors (e.g., hospital culture, practice patterns) unrelated to patients\u0026rsquo; illness severity or clinical needs contribute significantly to variability ICU admission for patient.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e These findings are of great policy relevance, as they suggest that comparable patients may be treated differently based on their location of treatment.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e They also highlight existing opportunity to improve the quality and efficiency of our critical care delivery system through the development of hospital-level interventions that guide ICU admitting decisions for patients with acute respiratory failure in a way that is tailored to different risk groups and sensitive to different health systems.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWhile recent studies have attempted to quantify the benefits of ICU admission for patients with acute respiratory failure,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e little is known about how to design or implement hospital-level interventions to guide triage of patients in the emergency department. Therefore, we sought to utilize human-centered design \u0026ndash; a research and innovation framework in which the needs, behaviors, and experiences of end users drive product or service design and implementation \u0026ndash; to develop a hospital-level intervention that guides ICU utilization with the goal of improving efficiency and quality of care for patients presenting to the emergency department with acute respiratory failure. Here, we describe using qualitative methods to evaluate clinicians\u0026rsquo; perspectives and using journey mapping to identify specific barriers and facilitators to efficient, high-quality care across the continuum of inpatient care. We then utilize these qualitative findings to inform the development of a hospital-level intervention designed to guide the triage of patients with acute respiratory failure throughout the acute care setting using human-centered methodology.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eHuman-centered design is a systematic method to optimize the design of products or interventions using an iterative approach, taking into account the contexts of use, local environment, user characteristic, and workflow.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Of note, it places strong emphasis on developing empathy for the end user to enable targeting the most relevant problem and prioritizing feasible, acceptable solutions.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e For this study, we utilized a previously described methodological framework for design that includes four distinct phases: (1) Pre-design, in which feedback is sought from users about their experience of using products and systems, and sensitizing to the problem to be addressed in the design process; (2) Generative, in which ideas, insights, and concepts are tested and refined with users in preparation for the development of prototype interventions; (3) Evaluative, in which prototypes are further developed and their effects and effectiveness tested with end-users; and (4) Post-design, which examines how users experience the design in practice in order to iterate in future design cycles based on identified needs and use patterns (Fig.\u0026nbsp;1).\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Herein, we report the Pre-design and Generative phases of this human-centered design framework, including qualitative data collected through design workshops with a multidisciplinary taskforce comprised of clinicians and hospital administrators.\u003c/p\u003e\u003cp\u003eAs a first step in the human-centered design process, we created a journey map depicting the current-state triage processes for patients presenting to the emergency department with acute respiratory failure. Journey mapping \u0026ndash; an emerging concept that has evolved out of the service design field \u0026ndash; is increasingly being applied in healthcare to visually map the care continuum and identify efficiencies and inefficiencies in care processes.\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e For this study, we chose to create a service blueprint map, a specific form of journey map that describes a service experience from a systems view, typically in a chronological format.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In contrast to a patient journey map \u0026ndash; which focuses on what patients experience when they experience clinical care \u0026ndash; a service blueprint map goes deeper to illustrate the clinicians\u0026rsquo; actions and organizational processes that may or may not be visible to the patient. Service blueprint maps typically contain several categories that illustrate the main components of the service being mapped out and how they may (or may not) interact with each other.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Notably, with its focus on healthcare delivery rather than the patient experience, a service blueprint map represents the perspectives and experiences of clinical and administrative stakeholders, allowing for illustration of critical timepoints in patients\u0026rsquo; movement through the acute care setting through an organizational lens.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSetting and Participants\u003c/h3\u003e\n\u003cp\u003eThis study was conducted at a Veterans Affairs hospital located in the United States. The hospital is high complexity with a combined 24-bed medical/surgical/cardiac ICU, 122 acute care beds, and no intermediate care unit (i.e., a hospital unit that provides a level of care between intensive care and care on the general acute care ward).\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In the Pre-Design phase of human-centered design methodology, we first created a stakeholder taskforce representing clinicians and hospital administrators across the continuum of inpatient care. To identify participants for the taskforce, we approached the facility\u0026rsquo;s ICU director for participation; we then employed snowball sampling to identify a multidisciplinary taskforce of physicians, nurses, and respiratory therapists from the emergency department, ICU, and medical/surgical wards. In total, we invited 11 clinicians (each with a concomitant administrative role in their respective clinical sections) to participate in the study, with 10 consenting to do so (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSelf-reported Characteristics of Taskforce Participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical Role\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital Location\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse #1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse #2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse #3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical/Surgical Ward\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse #4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespiratory Therapist #1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital-wide\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespiratory Therapist #2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHospital-wide\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysician #1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysician #2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical/Surgical Ward\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysician #3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical/Surgical Ward\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysician #4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eWe conducted a series of four, one-hour virtual design workshops with taskforce members over a 5-month period in 2022. Three research team members, including a critical care physician and health services researcher (KCV), an experienced qualitative researcher and social scientist (SEG), and a research coordinator (AY) conducted the meetings and took field notes. Prior to the first meeting, we created a facilitation guide (\u003cb\u003eSupplement 1\u003c/b\u003e) based on a conceptual model adapted from a study measuring hospital-level variation in ICU utilization.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e All workshops lasted between 55\u0026ndash;65 minutes and were video-recorded and transcribed verbatim by trained research staff. Between each design workshop, KCV, SEG, and AY performed directed qualitative content analysis to identify themes relevant to ICU triage processes and inform the development of a prototype hospital-level intervention as described below.\u003c/p\u003e\n\u003ch3\u003ePhase 1: Pre-design phase of human-centered design\u003c/h3\u003e\n\u003cp\u003ePrior to the first workshop, we generated a preliminary service blueprint map depicting the continuum of care for patients who present to the emergency department with acute respiratory failure based on prior literature synthesized with clinical experience.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Patients with acute respiratory failure were defined broadly as those requiring admission for treatment of an acute, primary respiratory issue (e.g., shortness of breath, hypoxemia, and/or hypercapnia), without specifying underlying etiologies. During the first workshop, taskforce members were shown the preliminary service blueprint map and asked to describe whether/how the map depicted their experiences caring for and triaging patients who present to the emergency department with acute respiratory failure. Taskforce members were asked to provide modifications to the service blueprint map to enable a more accurate depiction of their clinical workflows. After the first design workshop, the study team performed qualitative analyses of the group\u0026rsquo;s discussion as outlined below to help visualize and identify gaps in key healthcare processes; results from these analyses were used to revise and refine the service blueprint map prior to the second workshop and to inform the subsequent discussion of a future intervention.\u003c/p\u003e\u003cp\u003eDuring the second workshop, the service blueprint map was iteratively refined by taskforce members until consensus was reached. Taskforce members were then asked to identify barriers to and/or facilitators of efficient, high-quality care for patients hospitalized with acute respiratory failure, leveraging their deep contextual knowledge of clinical care and hospital workflows. After the second design workshop, the study team again performed qualitative analyses of the focus group\u0026rsquo;s discussion; results from these analyses were used to inform the following co-design of a prototype hospital-level intervention described below.\u003c/p\u003e\n\u003ch3\u003ePhase 2: Generative phase of human-centered design\u003c/h3\u003e\n\u003cp\u003eDuring the third design workshop, informed by results from qualitative analyses during the Phase 1, taskforce members co-designed a prototype, system-level intervention to guide triage and care of patients presenting to the emergency department with acute respiratory failure. Following the third design workshop, study team members conducted semi-structured interviews with individual taskforce members to refine the intervention and elicit feedback from participants outside the group setting. The study team again performed qualitative analyses of semi-structured interviews between the third and fourth design workshops; results from these analyses were used to inform the subsequent refinement of the prototype hospital-level intervention described below. At the fourth design workshop, taskforce members iterated and finalized the intervention, and discussed strategies for implementation (to be reported in a future publication).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAs described above, KCV, SEG, and AY used inductive and deductive thematic approaches to perform directed qualitative content analysis of the transcripts and field notes taken during each design workshop and semi-structured interview. KCV and SEG read the first two transcripts to create a preliminary codebook. After discussion, we independently coded the same first two transcripts and met to compare and reach consensus. Next, AY read the first two transcripts to become familiar with the data and the codebook. AY and SEG coded the next two transcripts together while refining the codebook, after which point no other changes were made. We coded the remaining six transcripts independently, using Atlas.ti v9 for data organization and an audit trail and memos for organization and synthesis. Our sample contained sufficient information power (i.e., capacity of a sample to provide appropriate and rich data) given our relatively narrow study aim, the specific deep expertise of our participants, robust dialogue with participants, and rigorous analyses.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e This study was approved by our Institutional Review Board (#4439).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe taskforce included four nurses, four physicians, and two respiratory therapists, with representation across the emergency department, general acute care wards, and the ICU (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The finalized service blueprint map of acute care delivery for adults presenting to the emergency department with acute respiratory failure is depicted in Fig.\u0026nbsp;2. This map represents the journey of a patient upon presentation to the emergency department, the actions taken by clinicians in caring for these patients, and additionally depicts the hospital-level organizational factors that impact these processes. Of note, the study team added clarifying labels in the final map.\u003c/p\u003e\n\u003ch3\u003eQualitative Analyses\u003c/h3\u003e\n\u003cp\u003eIn qualitative analyses of the design workshops, we identified three themes, each with several subthemes, encompassing factors that influence triage decisions and care delivery for patients hospitalized with acute respiratory failure. These include: 1) hospital organization and care processes; 2) available resources; and 3) communication and coordination between staff. Below, we describe each theme with representative quotations with additional quotes embedded in Fig.\u0026nbsp;3.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 1: Hospital organization and care processes\u003c/h2\u003e\u003cp\u003e\u003cem\u003eLack of explicit ICU admission criteria leads to variability in ICU admitting decisions.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants described how ICU admitting decisions from the ED varied depending on factors unrelated to patient needs (e.g., subjective clinician preference); they attributed much of this variation to the lack of explicit ICU admission criteria. Some participants were unsure as to whether specific ICU admission criteria existed, whereas others felt certain they did not. Participants noted that explicit admission criteria for patients with acute respiratory failure who did not require life-sustaining treatment would be helpful to standardize triage processes and avoid decisional conflicts and deliberation among clinicians regarding patients\u0026rsquo; discharge dispositions. As one nurse stated \u0026ldquo;I do like the idea of having some sort of transparent criteria for what it looks like for patients that need to be admitted\u0026hellip; It has always been kind of a push-pull [for] situations on the borderline.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cem\u003eGeographic dispersion of patients with acute respiratory failure contributes to workflow inefficiencies.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants described how hospitalized patients with acute respiratory failure outside the ICU were often geographically dispersed across the hospital, leading to workflow inefficiencies. In particular, respiratory therapists described wasting a lot of time \u0026ldquo;running around the hospital\u0026rdquo; to find patients\u0026mdash;time that they felt could be better spent providing treatments and tailoring respiratory support interventions for their patients. Participants felt that geographic cohorting of patients with acute respiratory failure who were \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003enot\u003c/span\u003e critically ill outside the ICU would help create an \u0026ldquo;economy of scale\u0026rdquo; by concentrating the expertise and resources needed to care for these patients in a specific location. One respiratory therapist noted that if the hospital, \u0026ldquo;had a strategy to localize these patients that all had pretty similar [respiratory care] needs [outside of the ICU]\u0026hellip; then we would provide better care.\u0026rdquo;\u003c/p\u003e\u003cp\u003eFurthermore, widespread consensus existed among participants regarding the potential benefit of an intermediate care unit as a specific example of geographic cohorting for \u0026ldquo;borderline\u0026rdquo; patients to improve care efficiency and outcomes. However, substantial uncertainty existed among participants regarding policies and procedures involving intermediate care units (e.g., requirements for physical proximity to the ICU, staffing models, which patients were appropriate for admission, etc.). Such administrative and logistical uncertainty has served as a substantial barrier to the creation of an intermediate care unit in the past and was perceived to be a substantial burden to future development of such a unit.\u003c/p\u003e\u003cp\u003e\u003cem\u003eConcerns about inadequate detection of clinical deterioration among patients on the ward lead to unnecessary ICU admissions.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants described one example of deliberation when patients who do not require life-sustaining interventions are commonly admitted to the ICU due to concerns that clinical deterioration may go underrecognized on the ward. They raised concerns that currently-used rapid response teams designed to facilitate ICU transfer for unstable patients on the ward are often too reactive; several pointed out the potential benefits of shifting the role of rapid response teams to be more proactive in their assessments of \u0026ldquo;borderline\u0026rdquo; patients admitted outside the ICU.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDomain 2: Available resources outside the ICU\u003c/h2\u003e\u003cp\u003e\u003cem\u003eStaffing and bed shortages on the ward leads to ICU overuse for non-critically ill patients.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInadequate staffing (particularly nurses and respiratory therapists) and bed availability on the wards was consistently mentioned as a barrier to the efficient and appropriate triage of patients with acute respiratory failure; participants described how this problem existed prior to the COVID-19 pandemic but had since been exacerbated by it. For example, participants noted how, due to staffing limitations, respiratory therapists are not stationed in the emergency department but are instead called there as needed. This staffing model often resulted in emergency department clinicians\u0026ndash;who do not have specific expertise in applying or titrating devices such as high flow nasal cannula\u0026ndash;managing patients with acute respiratory failure without the immediate assistance of respiratory therapists. For that reason, participants felt it would be beneficial to have a dedicated respiratory therapy stationed in the emergency department to facilitate earlier assessment of patients with acute respiratory failure and provide more tailored therapies.\u003c/p\u003e\u003cp\u003eBed shortages on the ward (sometimes related to limited staffing) leads to \u0026ldquo;overtriage\u0026rdquo; of patients to the ICU, when patients otherwise could have been managed on the ward with similar outcomes, but ended up in the ICU for reasons unrelated to their severity of illness or clinical needs. For example, one hospitalist said, \u0026ldquo;We already are very tight with our [ward] beds and so it limits our ability to place patients [outside the ICU] at times.\"\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Staff interactions\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eClinical silos, lack of communication, and power dynamics between clinicians contribute to delays in care\u003c/h2\u003e\u003cp\u003eMany participants described how the care of patients with acute respiratory failure was influenced by interactions between clinicians, who often exist in geographic and clinical silos. Participants also felt that power dynamics (particularly in a teaching hospital) influenced the quality of care patients received. For example, one physician explained: \u0026ldquo;sometimes you\u0026rsquo;ve got [emergency medicine] attendings on one hand\u0026hellip;and 2nd year brand new residents on the other end of the phone\u0026hellip; so you\u0026rsquo;ve got these [power] differentials\u0026rdquo; that lead to conflict and delayed care. One physician explained how patients often end up \u0026ldquo;like a ping pong ball between the ICU and the ward teams.\u0026rdquo; Participants noted the value of face-to-face interactions between clinicians to improve communication and care coordination; they also noted the importance of early involvement of attending physicians when conflicts arise between clinical teams.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eIntervention Prototype\u003c/h2\u003e\u003cp\u003eThe taskforce conceptualized four potential interventions that could be combined at a system-level depending on what is necessary and/or feasible within the context of a specific hospital environment as an outcome of the UCD process. Here, we briefly describe the intervention components that represent the output of UCD methodology, recognizing that the intervention itself has not been tested and is not the focus of this manuscript.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eComponent 1: Create Explicit ICU Admission Criteria\u003c/h2\u003e\u003cp\u003eFirst, we propose the creation of standardized ICU admission criteria that are sensitive to the hospital-specific environment. Specifically, these criteria would define the need for ICU admission as patients requiring life-sustaining treatment at the time of their ED presentation and would lessen the effect of some communication issues. Creating a culture of open dialogue and shared space between clinicians may also facilitate coordination and communication, especially regarding admitting discussions.\u003c/p\u003e\u003cp\u003e\u003cem\u003eComponent 2: Assign Levels of Care to Patients Based on Clinical Needs at Time of Admission\u003c/em\u003e\u003c/p\u003e\u003cp\u003eComplementary to component #1, we propose that patients presenting to the ED with acute respiratory failure be assigned a level of care based on objective criteria reflecting their clinical needs/acuity level. This classification could potentially help standardize triage processes by focusing on each patient\u0026rsquo;s specific monitoring and care requirements,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e with the goal of reducing variability in ICU admitting decisions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eComponent #3: Geographically Cohort Patients with Shared Needs\u003c/h2\u003e\u003cp\u003eTo help overcome persistent staffing shortages and address existing workflow inefficiencies, we propose using a systems-engineering approach to geographically cohort patients with acute respiratory failure with similar clinical needs (e.g., frequent suctioning, respiratory toilet) but who are not critically ill in a specific ward location. Participants felt that cohorting patients in this way, with or without the creation of a dedicated \u0026ldquo;intermediate care unit,\u0026rdquo; could help create an economy of scale outside the ICU, streamlining workflows and maximizing efficiency of staffing resources, with the potential to improve patient outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eComponent 4: Re-engineer Rapid Response Team to Proactively Follow Patients Outside the ICU\u003c/h2\u003e\u003cp\u003eWe propose shifting the paradigm for hospitals\u0026rsquo; existing rapid response teams from being \u003cem\u003ereactive\u003c/em\u003e to \u003cem\u003eproactive\u003c/em\u003e.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Specifically, this team (referred to as the \u0026ldquo;mobile surveillance team\u0026rdquo; by participants) could perform preemptive, scheduled evaluations of patients identified as \u0026ldquo;high-risk\u0026rdquo; for needing ICU transfer (according to assigned level of care as described in component 2) for a pre-set time period following admission.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we created a multidisciplinary taskforce and created a service blueprint map as a first step in a human-centered design process to develop a prototype, system-level intervention that can help optimize critical care delivery (including ICU admitting decisions) for patients presenting to the ED with acute respiratory failure.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e To our knowledge, this study is among the first to apply human-centered design methodology as part of efforts to improve the quality and efficiency of our critical care delivery system. More broadly, this approach offers a potentially adaptable framework to systematically address existing complex problems within our healthcare delivery system (e.g., staffing shortages, inefficient use of resources).\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOur study adds to the literature in several ways. First, this study is unique in its application of human-centered design to develop system-level interventions designed to optimize critical care delivery for patients. While human-centered design is increasingly being used in the outpatient setting,\u003csup\u003e\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e few studies report its use within the inpatient healthcare delivery system. One recent study utilized human-centered design to redesign handoffs between operating room and surgical ICU staff;\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e another applied human-centered design to design bar-coded medication administration among hospitalized patients.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Our study builds on this prior work by using human-centered design to create a system-level intervention that spans the continuum of inpatient care, taking into account how distinct departments and clinicians across specialties interact with each other to coordinate care for patients hospitalized with acute respiratory failure. Additionally, our use of human-centered design methodology enabled the study team to identify important communication barriers that exist across clinical silos, while simultaneously gaining buy-in of organizational leaders by incorporating them within the intervention development process.\u003c/p\u003e\u003cp\u003eSecond, the creation of a service blueprint map in the context of healthcare delivery is relatively novel,\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e particularly across the continuum of inpatient care. Specifically, the service blueprint map enabled participants to visualize key \u0026ldquo;pain points\u0026rdquo; that interfere with the delivery of efficient care within a complex system and identify opportunities for improvement in these areas. In this way, service blueprint maps represent a useful tool within healthcare improvement initiatives since they allow participants to identify, reflect, and ideate on the interplay between user workflows, resource constraints, and physical spaces to create innovate solutions. Taken together, our methods and results provide a basis for future efforts to design and implement complex interventions within our inpatient care delivery system to improve efficiency and optimize the overall value of care.\u003c/p\u003e\u003cp\u003eFinally, we found that communication and coordination between clinicians in different specialties was perceived by study participants to substantially impact patient care. Prior literature has demonstrated that miscommunication between clinicians during transitions of care drives diagnostic error.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Our study builds on this by identifying how the lack of communication and collaboration between clinicians may negatively impact patient outcomes in the form of mis-triage of patients. Our findings suggest that such miscommunication may be, in part, mitigated by the creation of standardized ICU admitting processes and highlight the need for future research aimed at improving organizational culture and communication practices across clinical silos.\u003c/p\u003e\u003cp\u003eOur study also has limitations. First, the intervention has not yet been tested for feasibility, acceptability, or impact on outcomes. Second, participants were from a single VA site, limiting generalizability; however, a benefit of human-centered design methodology is its ability to tailor solutions to meet end users\u0026rsquo; needs within a particular context. Furthermore, while the intervention itself may not be generalizable, the methods used to develop the intervention are generalizable to various settings. Additionally, because this study was focused on care processes and organizational factors influencing triage decisions and care delivery for patients with acute respiratory failure, we did not include patients in the human-centered design process; however, we recognize that patients\u0026rsquo; perspectives are important to elicit and incorporate in future implementation studies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e This study illustrates how human-centered design, combined with service blueprint mapping and rapid team-based qualitative analysis, can be utilized to derive insights from stakeholders across existing healthcare silos and design system-level interventions to improve the efficiency and value of critical care delivery. This works serves as a model for how to leverage these methods when addressing existing complex problems within our inpatient healthcare delivery system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Approved by the VA Portland institutional Review Board (#4439) in accordance with the Belmont Report and Declaration of Helskini. All participants provided informed consent prior to participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests: All authors declare no conflicts of interest with the work presented in this manuscript.\u003c/p\u003e\n\u003cp\u003eFunding: This study and Dr. Vranas are supported by an award from the Department of Veterans Affairs [CDA 18-191]. It was also supported by resources from the Center to Involve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available to protect the privacy of our participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to acknowledge the participation and thoughtfulness of all of the participants in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eorresponding Author\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSara Golden, PhD, MPH\u003c/p\u003e\n\u003cp\u003e3710 SW US Veterans Hospital Rd. R\u0026amp;D 66\u003c/p\u003e\n\u003cp\u003ePortland, OR 97239, USA\u003c/p\u003e\n\u003cp\u003eE-mail: [email protected]\u003c/p\u003e\n\u003cp\u003eRunning Title: Applying human-centered design to ICU triage\u003c/p\u003e\n\u003cp\u003eThe Department of Veterans Affairs did not have a role in the conduct of the study, in the collection, management, analysis, interpretation of data, or in the preparation of the manuscript.\u0026nbsp;The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.\u003c/p\u003e\n\u003cp\u003eAuthor contributions: \u003cstrong\u003eSara E. Golden:\u0026nbsp;\u003c/strong\u003eMethodology, validation, formal analysis, investigation, data curation, writing-original draft, writing-review \u0026amp; editing \u003cstrong\u003ePatrick G. Lyons:\u003c/strong\u003e Writing-review \u0026amp; editing, visualization \u003cstrong\u003eAllison Young:\u003c/strong\u003e Validation, data curation, writing-review \u0026amp; editing, visualization, project administration \u003cstrong\u003eScott Warner:\u003c/strong\u003e Writing-review \u0026amp; editing \u003cstrong\u003eAnaïs Tuepker:\u003c/strong\u003e Methodology, writing-review \u0026amp; editing \u003cstrong\u003eIan Ilea:\u003c/strong\u003e Data curation, writing-review \u0026amp; editing, visualization, project administration \u003cstrong\u003eDonald R. Sullivan:\u003c/strong\u003e Writing-review \u0026amp; editing \u003cstrong\u003eChristopher G. Slatore:\u003c/strong\u003e Conceptualization, writing-review \u0026amp; editing, supervision \u003cstrong\u003eKelly C. Vranas:\u003c/strong\u003e Conceptualization, methodology, validation, formal analysis, investigation, writing-original draft, writing-review \u0026amp; editing, supervision, funding acquisition\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStefan MS, Shieh MS, Pekow PS, Rothberg MB, Steingrub JS, Lagu T, Lindenauer PK. Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: a national survey. J Hosp Med. 2013;8(2):76\u0026ndash;82. Epub 2013 Jan 18. PMID: 23335231; PMCID: PMC3565044.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eValley TS, Sjoding MW, Ryan AM, Iwashyna TJ, Cooke CR. Intensive Care Unit Admission and Survival among Older Patients with Chronic Obstructive Pulmonary Disease, Heart Failure, or Myocardial Infarction. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html\u003c/span\u003e\u003cspan address=\"https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"human-centered design, triage, intensive care units, qualitative research, respiratory insufficiency","lastPublishedDoi":"10.21203/rs.3.rs-6874775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6874775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAcute respiratory failure is a common cause for hospitalization and intensive care unit (ICU) admission. Prior literature has found that hospital factors unrelated to patients\u0026rsquo; illness severity or clinical needs contribute to substantial variability in ICU admission rates across hospitals. Overuse of the ICU for patients unlikely to benefit from critical care is inefficient, contributes to rising costs, and may cause harm. As part of efforts to improve the value of critical care, we utilized human-centered design to create a prototype, system-level intervention designed to optimize ICU utilization for patients hospitalized with acute respiratory failure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe created a multidisciplinary taskforce and conducted four meetings over a 5-month period in 2022 at a VA medical center. We used journey mapping to depict the care continuum of acute respiratory failure patients and identify facilitators/barriers to high-value care; next, we integrated qualitative methods using rapid team-based analysis with human-centered design to develop a system-level intervention to guide triage decisions and tailor care-delivery processes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOur taskforce was comprised of ten participants (including nurses/physicians/respiratory therapists) with clinical and leadership roles in the emergency department, medical/surgical wards, and ICU. We created a service blueprint map and leveraged it to identify themes influencing ICU utilization among patients with acute respiratory failure, including: 1) hospital organization and care processes (e.g., lack of established ICU admission criteria); 2) available resources outside the ICU (e.g., staffing/bed shortages); and 3) staff interactions (e.g., lack of communication/coordination between clinicians/departments). Informed by these results, the taskforce designed a prototype intervention with four components: a) create explicit ICU admission criteria; b) assign levels of care based on patients\u0026rsquo; needs; c) geographically cohort patients with shared needs outside the ICU; and d) re-engineer rapid-response teams to proactively assess/follow patients outside the ICU.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003e We combined qualitative and human-centered design methodologies, in concert with creation of a service blueprint map, to develop a prototype intervention designed to improve the value of care for patients with acute respiratory failure. Our methods serve as a model to address complex problems within the inpatient healthcare delivery system. Future work includes pilot-testing the intervention for feasibility/acceptability.\u003c/p\u003e","manuscriptTitle":"Applying Journey Mapping and Human-Centered Design to Improve Critical Care Delivery for Patients with Acute Respiratory Failure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-27 10:47:18","doi":"10.21203/rs.3.rs-6874775/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-17T11:29:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T19:50:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T17:15:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279828771177617805790246676525596549996","date":"2025-08-11T11:20:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198446260471319412000288466704110701058","date":"2025-07-29T18:54:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-18T18:52:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-16T04:23:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-25T05:48:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-24T17:50:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-24T17:47:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26155ced-e5df-496c-9cea-2d1054677ee4","owner":[],"postedDate":"July 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T15:59:54+00:00","versionOfRecord":{"articleIdentity":"rs-6874775","link":"https://doi.org/10.1186/s12913-025-13864-6","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-12-30 15:57:29","publishedOnDateReadable":"December 30th, 2025"},"versionCreatedAt":"2025-07-27 10:47:18","video":"","vorDoi":"10.1186/s12913-025-13864-6","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13864-6","workflowStages":[]},"version":"v1","identity":"rs-6874775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6874775","identity":"rs-6874775","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}