Multidisciplinary Team Training to Enhance Family Communication in the ICU*:

Using Nurse Ratings of Physician Communication in the ICU To Identify Potential Targets for Interventions To Improve End-of-Life Care

BACKGROUND

Communication among doctors, nurses, and families contributes to high-quality end-of-life care, but is difficult to improve.

OBJECTIVE

Our objective was to identify aspects of communication appropriate for interventions to improve quality of dying in the intensive care unit (ICU).

METHODS

This observational study used data from a cluster-randomized trial of an interdisciplinary intervention to improve end-of-life care at 15 Seattle/Tacoma area hospitals (2003-2008). Nurses completed surveys for patients dying in the ICU. We examined associations between nurse-assessed predictors (physician-nurse communication, physician-family communication) and nurse ratings of patients' quality of dying (nurse-QODD-1).

RESULTS

Based on 1173 nurse surveys, four of six physician-nurse communication topics were positively associated with nurse-QODD-1: family questions, family dynamics, spiritual/religious issues, and cultural issues. Discussions between nurses and physicians about nurses' concerns for patients or families were negatively associated. All physician-family communication ratings, as assessed by nurses, were positively associated with nurse-QODD-1: answering family's questions, listening to family, asking about treatments patient would want, helping family decide patient's treatment wishes, and overall communication. Path analysis suggested overall physician-family communication and helping family incorporate patient's wishes were directly associated with nurse-QODD-1.

CONCLUSIONS

Several topics of physician-nurse communication, as rated by nurses, were associated with higher nurse-rated quality of dying, whereas one topic, nurses' concerns for patient or family, was associated with poorer ratings. Higher nurse ratings of physician-family communication were uniformly associated with higher quality of dying, highlighting the importance of this communication. Physician support of family decision making was particularly important, suggesting a potential target for interventions to improve end-of-life care.

"It's Parallel Universes": An Analysis of Communication Between Surgeons and Intensivists

OBJECTIVES

The intensivist-led model of ICU care requires surgical consultants and the ICU team to collaborate in the care of ICU patients and to communicate effectively across teams. We sought to characterize communication between intensivists and surgeons and to assess enablers and barriers of effective communication.

DESIGN

Qualitative interview study. An inductive data analysis approach was taken.

SETTING

Seven intensivist-led ICUs in four academic hospitals.

SUBJECTS

Surgeons (attendings and residents), intensivists (attendings and residents), and ICU nurses participating in the care of surgical patients in the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Communication enablers and barriers existed at two distinct levels: 1) organizational and 2) cultural. At an organizational level, participants identified that formally sanctioned communication structures and processes often acted as barriers to communication. Participants had developed informal strategies to improve communication. At a cultural level, surgical and ICU participants often expressed conflicting perspectives regarding patient ownership, scope of practice, and clinical expertise.

CONCLUSIONS

Major barriers to optimal communication between surgical and ICU teams exist in the intensivist-led ICU environment. Many are related to the structures and processes meant to facilitate communication across teams and others to how some aspects of care in the ICU are conceptualized. Multiple actionable opportunities exist to improve communication in the intensivist-led ICU.

Family-Reported Experiences Evaluation (FREE) study: a mixed-methods study to evaluate families’ satisfaction with adult critical care services in the NHS

Background

To improve care it is necessary to feed back experiences of those receiving care. Of patients admitted to intensive care units (ICUs), approximately one-quarter die, and few survivors recollect their experiences, so family members have a vital role. The most widely validated tool to seek their views is the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU).

Objectives

To test face and content validity and comprehensibility of the FS-ICU (phase 1). To establish internal consistency, construct validity and reliability of the FS-ICU; to describe family satisfaction and explore how it varies by family member, patient, unit/hospital and other contextual factors and by country; and to model approaches to sampling for future use in quality improvement (phase 2).

Design

Mixed methods: qualitative study (phase 1) and cohort study (phase 2).

Setting

NHS ICUs (n = 2, phase 1;n = 20, phase 2).

Participants

Health-care professionals, ex-patients, family members of ICU patients (n = 41, phase 1). Family members of ICU patients (n = 12,303, phase 2).

Interventions

None.

Main outcome measures

Key themes regarding each item of the 24-item FS-ICU (FS-ICU-24) (phase 1). Overall family satisfaction and domain scores of the FS-ICU-24 (phase 2).

Results

In phase 1, face validity, content validity and comprehensibility were good. Adaptation to the UK required only minor edits. In phase 2, one to four family members were recruited for 60.6% of 10,530 patients (staying in ICU for 24 hours or more). Of 12,303 family members, 7173 (58.3%) completed the questionnaire. Psychometric assessment of the questionnaire established high internal consistency and criterion validity. Exploratory factor analysis indicated new domains:satisfaction with care,satisfaction with informationandsatisfaction with the decision-making process. All scores were high with skewed distributions towards more positive scores. For family members of ICU survivors, factors associated with increased/decreased satisfaction were age, ethnicity, relationship to patient, and visit frequency, and patient factors were acute severity of illness and invasive ventilation. For family members of ICU non-survivors, average satisfaction was higher but no family member factors were associated with increased/decreased satisfaction; patient factors were age, acute severity of illness and duration of stay. Neither ICU/hospital factors nor seasonality were associated. Funnel plots confirmed significant variation in family satisfaction across ICUs. Adjusting for family member and patient characteristics reduced variation, resulting in fewer ICUs identified as potential outliers. Simulations suggested that family satisfaction surveys using short recruitment windows can produce relatively unbiased estimates of average family satisfaction.

Conclusions

The Family-Reported Experiences Evaluation study has provided a UK-adapted, psychometrically valid questionnaire for overall family satisfaction and three domains. The large sample size allowed for robust multilevel multivariable modelling of factors associated with family satisfaction to inform important adjustment of any future evaluation.

Limitations

Responses to three free-text questions indicate the questionnaire may not be sensitive to all aspects of family satisfaction.

Future work

Reservations remain about the current questionnaire. While formal analysis of the free-text questions did not form part of this proposal, brief analysis suggested considerable scope for improvement of the FS-ICU-24.

Study registration

Current Controlled Trials ISRCTN47363549.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

How Do Residents Spend Their Time in the Intensive Care Unit?

PURPOSE

To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs).

METHODS

A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated.

RESULTS

Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation.

CONCLUSIONS

While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents' work in ICUs.

Questionnaires on Family Satisfaction in the Adult ICU: A Systematic Review Including Psychometric Properties

OBJECTIVES

To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview of their quality by evaluating their psychometric properties.

DATA SOURCES

We searched PubMed, Embase, The Cochrane Library, Web of Science, PsycINFO, and CINAHL from inception to October 30, 2013.

STUDY SELECTION

Experimental and observational research articles reporting on questionnaires on family satisfaction and/or needs in the ICU were included. Two reviewers determined eligibility.

DATA EXTRACTION

Design, application mode, language, and the number of studies of the tools were registered. With this information, the tools were globally categorized according to validity and reliability: level I (well-established quality), II (approaching well-established quality), III (promising quality), or IV (unconfirmed quality). The quality of the highest level (I) tools was assessed by further examination of the psychometric properties and sample size of the studies.

DATA SYNTHESIS

The search detected 3,655 references, from which 135 articles were included. We found 27 different tools that assessed overall or circumscribed aspects of family satisfaction with ICU care. Only four questionnaires were categorized as level I: the Critical Care Family Needs Inventory, the Society of Critical Care Medicine Family Needs Assessment, the Critical Care Family Satisfaction Survey, and the Family Satisfaction in the Intensive Care Unit. Studies on these questionnaires were of good sample size (n ≥ 100) and showed adequate data on face/content validity and internal consistency. Studies on the Critical Care Family Needs Inventory, the Family Satisfaction in the Intensive Care Unit also contained sufficient data on inter-rater/test-retest reliability, responsiveness, and feasibility. In general, data on measures of central tendency and sensitivity to change were scarce.

CONCLUSIONS

Of all the questionnaires found, the Critical Care Family Needs Inventory and the Family Satisfaction in the Intensive Care Unit were the most reliable and valid in relation to their psychometric properties. However, a universal "best questionnaire" is indefinable because it depends on the specific goal, context, and population used in the inquiry.

Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units

AIM

The aim of the study was to assess the validity of family members/friends as proxies by comparing perceptions of satisfaction with care and decision making between critically ill patients and their family/friends.

DESIGN

A comparative, descriptive cross-sectional study.

SETTING

Seven Critical Care Units across four public and military hospitals in the centre and southern regions of Jordan.

METHODS

A modified version of the Family Satisfaction-ICU (FS-ICU) questionnaire was distributed to Critical Care Unit (CCU) patients before hospital discharge. In addition, up to two family members/close friends were also asked to complete the questionnaire.

RESULTS

A total of 213 patients (response rate 72%) and 246 family members/friends (response rate 79%) completed and returned the questionnaire. Although the majority of family members/friends and patients were satisfied with overall care, patients were generally significantly less satisfied (mean (SD) care subscale 75.6 (17.8) and 70.9 (17.3), respectively, (p=0.005). When individual items were examined, significant differences in nursing care (family/friends 80.1 (20.7) versus patient 75.9 (22.2), p=0.038) and inclusion in decision making (family/friends 53.9 (33.2) versus patient 62.0 (34.2), p=0.010) were found.

CONCLUSION

The study showed a degree of congruence between patients and their family members/friends in relation to their satisfaction with the CCU experience. Thus, views of family/friends may serve as a proxy in assessing care and decision making processes of critically ill patients.

RELEVANCE TO CLINICAL PRACTICE

Appropriate training of the critical care team and provision of strategies to address the concerns of patients' families are needed to improve overall patient satisfaction.

A multicenter study of key stakeholders' perspectives on communicating with surrogates about prognosis in intensive care units

RATIONALE

Surrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit (ICU) clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.

OBJECTIVE

To determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.

METHODS

This was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.

MEASUREMENTS AND MAIN RESULTS

There was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: (1) In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. (2) Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. (3) Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. (4) Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.

CONCLUSIONS

Family members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs.

[Expectations of relatives of critically ill patients regarding medical information. Qualitative research study]

OBJECTIVE

To determine and analyse the expectations, needs and experiences of relatives of critically ill patients as regards medical information and the level of their understanding. To find keys for improving communication and to draw up best practices in clinical information.

MATERIAL AND METHODS

Qualitative research study through semi-structured interviews carried out in a polyvalent adult intensive care unit (ICU) in a University Hospital.

PARTICIPANTS

relatives of patients who were admitted to the ICU and who were discharged alive from the Unit. Ten interviews were performed taking into account diversification variables such as, type of family relationship with patients, patient age, length of ICU stay, origin, and location at the time of the interview.

RESULTS

The results of the analysis of 10 interviews focused on: the subjective position of the family in the ICU (the agonizing wait), what the ICU represents for the family (surveillance and monitoring of a situation between life and death), perceived care (complete delegation of care), and medical information (what and how they expect and what and how they receive it), as much in the first information (sincerity, hope, delicacy) as in the successive.

CONCLUSIONS

There is divergence between what families expect and what they get as regards medical information. To know the expectations of the families will help to provide higher quality care and more humane treatment in the ICU.

The changing role of palliative care in the ICU

OBJECTIVES

Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.

DATA SOURCES

We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files.

STUDY SELECTION

Selected studies included all English-language articles concerning adult patients using the search terms 'intensive care' or 'critical care' with 'palliative care,' 'supportive care,' 'end-of-life care,' or 'ethics.'

DATA EXTRACTION

: After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus.

DATA SYNTHESIS

Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and families face challenges after discharge from intensive care.

CONCLUSIONS

Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis. A variety of strategies to improve ICU palliative care appear to be effective, and resources including technical assistance and tools are available to support improvement efforts. As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative care can help prepare and support patients and families for challenges after ICU discharge. Further research is needed to inform efforts to integrate palliative care with intensive care more effectively and efficiently in and after the ICU and to document improvement using valid and responsive outcome measures.

The Use of a Modified Delphi Technique to Create a List of ‘Top Ten Tips' for Communication with Patients and Relatives in Intensive Care

There are many barriers to good communication in intensive care. The authors used a Delphi technique to develop a set of ‘top tips' for good communication between doctors, patients and families in this environment. They worked with members of the Patients and Relatives Committee of the Intensive Care Society and ICUsteps, who have had experience of being patients or of having a relative who had been a patient receiving intensive care.

Team-training in healthcare: a narrative synthesis of the literature

BACKGROUND

Patients are safer and receive higher quality care when providers work as a highly effective team. Investment in optimising healthcare teamwork has swelled in the last 10 years. Consequently, evidence regarding the effectiveness for these interventions has also grown rapidly. We provide an updated review concerning the current state of team-training science and practice in acute care settings.

METHODS

A PubMed search for review articles examining team-training interventions in acute care settings published between 2000 and 2012 was conducted. Following identification of relevant reviews with searches terminating in 2008 and 2010, PubMed and PSNet were searched for additional primary studies published in 2011 and 2012. Primary outcomes included patient outcomes and quality indices. Secondary outcomes included teamwork behaviours, knowledge and attitudes.

RESULTS

Both simulation and classroom-based team-training interventions can improve teamwork processes (eg, communication, coordination and cooperation), and implementation has been associated with improvements in patient safety outcomes. Thirteen studies published between 2011 and 2012 reported statistically significant changes in teamwork behaviours, processes or emergent states and 10 reported significant improvement in clinical care processes or patient outcomes, including mortality and morbidity. Effects were reported across a range of clinical contexts. Larger effect sizes were reported for bundled team-training interventions that included tools and organisational changes to support sustainment and transfer of teamwork competencies into daily practice.

CONCLUSIONS

Overall, moderate-to-high-quality evidence suggests team-training can positively impact healthcare team processes and patient outcomes. Additionally, toolkits are available to support intervention development and implementation. Evidence suggests bundled team-training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer greatest impact on patient outcomes.