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Integrating Palliative and Critical Care

Evaluation of a Quality-Improvement Intervention

¹ Division of Pulmonary and Critical Care, Harborview Medical Center, and Department of Medicine, University of Washington, Seattle, Washington; ² Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, Washington; and ³ Patient Care Services, Harborview Medical Center, Seattle, Washington

Correspondence and requests for reprints should be addressed to J. Randall Curtis, M.D., M.P.H., Professor of Medicine, Division of Pulmonary and Critical Care, Box 359762, Harborview Medical Center, University of Washington, Seattle, WA 98104. E-mail: jrc{at}u.washington.edu

Rationale: Palliative care in the intensive care unit (ICU) is an important focus for quality improvement.

Objectives: To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU.

Methods: We performed a single-hospital, before–after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results.

Measurements and Main Results: There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01).

Conclusions: We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Key Words: intensive care • critical care • withdrawing life support • end-of-life care • palliative care

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject One in five Americans die in the intensive care unit and yet palliative care in this setting is often of poor quality. Therefore, this is an important focus for quality improvement. What This Study Adds to the Field We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, but there was significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

 

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				J. R. Curtis and D. B. White Practical Guidance for Evidence-Based ICU Family Conferences Chest, October 1, 2008; 134(4): 835 - 843. [Abstract] [Full Text] [PDF]