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Andersen SK, Chang CCH, Arnold RM, Pidro C, Darby JM, Angus DC, White DB. Impact of a family support intervention on hospitalization costs and hospital readmissions among ICU patients at high risk of death or severe functional impairment. Ann Intensive Care 2024; 14:103. [PMID: 38954149 PMCID: PMC11219699 DOI: 10.1186/s13613-024-01344-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Patients with advanced critical illness often receive more intensive treatment than they would choose for themselves, which contributes to high health care costs near the end of life. The purpose of this study was to determine whether a family support intervention delivered by the interprofessional ICU team decreases hospitalization costs and hospital readmissions among critically ill patients at high risk of death or severe functional impairment. RESULTS We examined index hospitalization costs as well as post-discharge utilization of acute care hospitals, rehabilitation and skilled nursing facilities, and hospice services for the PARTNER trial, a multicenter, stepped-wedge, cluster randomized trial of an interprofessional ICU family support intervention. We determined patients' total controllable and direct variable costs using a computerized accounting system. We determined post-discharge resource utilization (as defined above) by structured telephone interview at 6-month follow-up. We used multiple variable regression modelling to compare outcomes between groups. Compared to usual care, the PARTNER intervention resulted in significantly lower total controllable costs (geometric mean: $26,529 vs $32,105; log-linear coefficient: - 0.30; 95% CI - 0.49, - 0.11) and direct variable costs ($3912 vs $6034; - 0.33; 95% CI - 0.56, - 0.10). A larger cost reduction occurred for decedents ($20,304 vs. $26,610; - 0.66; 95% CI - 1.01, - 0.31) compared to survivors ($31,353 vs. $35,015; - 0.15; 95% CI - 0.35,0.05). A lower proportion in the intervention arm were re-admitted to an acute care hospital (34.9% vs 45.1%; 0.66; 95% CI 0.56, 0.77) or skilled nursing facility (25.3% vs 31.6%; 0.63; 95% CI 0.47, 0.84). CONCLUSIONS A family support intervention delivered by the interprofessional ICU team significantly decreased index hospitalization costs and readmission rates over 6-month follow-up. Trial registration Trial registration number: NCT01844492.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, Room 608, Pittsburgh, PA, 15261, USA
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Chung-Chou H Chang
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA, USA
| | - Caroline Pidro
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Douglas B White
- Program on Ethics and Decision Making, Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, Room 608, Pittsburgh, PA, 15261, USA.
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Amacher SA, Gross S, Becker C, Arpagaus A, Urben T, Gaab J, Emsden C, Tisljar K, Sutter R, Pargger H, Marsch S, Hunziker S. Misconceptions and do-not-resuscitate preferences of healthcare professionals commonly involved in cardiopulmonary resuscitations: A national survey. Resusc Plus 2024; 17:100575. [PMID: 38375442 PMCID: PMC10875294 DOI: 10.1016/j.resplu.2024.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Aims To assess the DNR preferences of critical care-, anesthesia- and emergency medicine practitioners, to identify factors influencing decision-making, and to raise awareness for misconceptions concerning CPR outcomes. Methods A nationwide multicenter survey was conducted in Switzerland confronting healthcare professionals with a case vignette of an adult patient with an out-of-hospital cardiac arrest (OHCA). The primary outcome was the rate of DNR Code Status vs. CPR Code Status when taking the perspective from a clinical case vignette of a 70-year-old patient. Secondary outcomes were participants' personal preferences for DNR and estimates of survival with good neurological outcome after in- and out-of-hospital cardiac arrest. Results Within 1803 healthcare professionals, DNR code status was preferred in 85% (n = 1532) in the personal perspective of the case vignette and 53.2% (n = 932) when making a decision for themselves. Main predictors for a DNR Code Status regarding the case vignette included preferences for DNR Code Status for themselves (n [%] 896 [58.5] vs. 87 [32.1]; adjusted odds ratio [OR] 2.97, 95% confidence interval [CI] 2.25-3.92; p < 0.001) and lower estimated OHCA survival (mean [±SD] 12.3% [±11.8] vs. 14.7%[±12.8]; adjusted OR 0.98, 95% CI 0.97-0.99; p = 0.001). Physicians chose a DNR order more often when compared to nurses and paramedics. Conclusions The estimation of outcomes following cardiac arrest and personal living conditions are pivotal factors influencing code status preferences in healthcare professionals. Healthcare professionals should be aware of cardiac arrest prognosis and potential implications of personal preferences when engaging in code status- and end-of-life discussions with patients and their relatives.
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Affiliation(s)
- Simon A. Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Armon Arpagaus
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Tabita Urben
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Switzerland
| | - Christian Emsden
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
- Post-Intensive Care Clinic, University Hospital Basel, Basel, Switzerland
| | - Kai Tisljar
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Hans Pargger
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Post-Intensive Care Clinic, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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Momiyama S, Kakeya K, Dannoue H, Yanagi H. A Survey of Emergency Nurses' Perceptions and Practices to Support Patients' Families as Surrogate Decision Makers. J Emerg Nurs 2023; 49:899-911. [PMID: 37690019 DOI: 10.1016/j.jen.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 06/21/2023] [Accepted: 08/01/2023] [Indexed: 09/11/2023]
Abstract
INTRODUCTION Family members acting as surrogate decision makers for severely ill patients in emergency and critical care centers face psychological burdens. This study aimed to investigate the actual situation of emergency nurses' perceptions and practices to support patients' families and its structural elements. METHODS We created an original 25-item questionnaire and surveyed 164 emergency nurses from 64 emergency and critical care centers regarding their perceptions of caring for people making surrogate decisions. Participants averaged 35.6 years old and 5.1 years as emergency nurses. RESULTS Cronbach's α coefficients for importance and practice on the original questionnaire were 0.936 and 0.933, respectively. We identified 4 elements of necessary support for patient families making surrogate decisions according to emergency nurses: "collaboration in understanding the condition of the patient as well as empathetic support," "care that addresses the needs of patient's family members," "confirming the role of nurses and surrogate decision making," and "participation in meeting with a doctor and patient families." In addition, we identified 5 elements that indicate the current state of practice: "support from specialists such as nurses and other professionals," "compassionate care for family members and those who are providing support to family members," "empathetic support for family members," "support for making arrangements that address the needs of family members," and "considerations for family members." DISCUSSION According to the findings of this study, emergency nurses should coordinate with other professionals and talk with family members and physicians to increase their understanding of the need to assist in surrogate decision making. In addition, emergency nurses also need to explain to patients' relatives how to support them in surrogate decision making.
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Paul N, Ribet Buse E, Knauthe AC, Nothacker M, Weiss B, Spies CD. Effect of ICU care bundles on long-term patient-relevant outcomes: a scoping review. BMJ Open 2023; 13:e070962. [PMID: 36806060 PMCID: PMC9944310 DOI: 10.1136/bmjopen-2022-070962] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE Care bundles are considered a key tool to improve bedside quality of care in the intensive care unit (ICU). We explored their effect on long-term patient-relevant outcomes. DESIGN Systematic literature search and scoping review. DATA SOURCES We searched PubMed, Embase, CINAHL, APA PsycInfo, Web of Science, CDSR and CENTRAL for keywords of intensive care, care bundles, patient-relevant outcomes, and follow-up studies. ELIGIBILITY CRITERIA Original articles with patients admitted to adult ICUs assessing bundle implementations and measuring long-term (ie, ICU discharge or later) patient-relevant outcomes (ie, mortality, health-related quality of life (HrQoL), post-intensive care syndrome (PICS), care-related outcomes, adverse events, and social health). DATA EXTRACTION AND SYNTHESIS After dual, independent, two-stage selection and charting, eligible records were critically appraised and assessed for bundle type, implementation strategies, and effects on long-term patient-relevant outcomes. RESULTS Of 2012 records, 38 met inclusion criteria; 55% (n=21) were before-after studies, 21% (n=8) observational cohort studies, 13% (n=5) randomised controlled trials, and 11% (n=4) had other designs. Bundles pertained to sepsis (n=11), neurocognition (n=6), communication (n=4), early rehabilitation (n=3), pharmacological discontinuation (n=3), ventilation (n=2) or combined bundles (n=9). Almost two-thirds of the studies reported on survival (n=24), 45% (n=17) on care-related outcomes (eg, discharge disposition), and 13% (n=5) of studies on HrQoL. Regarding PICS, 24% (n=9) assessed cognition, 13% (n=5) physical health, and 11% (n=4) mental health, up to 1 year after discharge. The effects of bundles on long-term patient-relevant outcomes was inconclusive, except for a positive effect of sepsis bundles on survival. The inconclusive effects may have been due to the high risk of bias in included studies and the variability in implementation strategies, instruments, and follow-up times. CONCLUSIONS There is a need to explore the long-term effects of ICU bundles on HrQoL and PICS. Closing this knowledge gap appears vital to determine if there is long-term patient value of ICU bundles.
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Affiliation(s)
- Nicolas Paul
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elena Ribet Buse
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anna-Christina Knauthe
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies in Germany (AWMF), Philipps-Universität Marburg, Marburg, Germany
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Allum L, Apps C, Pattison N, Connolly B, Rose L. Informing the standardising of care for prolonged stay patients in the ICU: A scoping review of quality improvement tools. Intensive Crit Care Nurs 2022; 73:103302. [PMID: 35931596 DOI: 10.1016/j.iccn.2022.103302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To inform design of quality improvement (QI) tools specific to patients with prolonged intensive care unit (ICU) stay, we determined characteristics (format/content), development, implementation, and outcomes of published multi-component QI tools used in ICU irrespective of length of stay. RESEARCH METHODOLOGY Scoping review searching electronic databases, trial registries and grey literature (January 2000 to January 2022). RESULTS We screened 58,378 citations, identifying 96 studies. All tools were designed for use commencing at ICU admission except 3 tools implemented at 3, 5 or 14 days. We identified 32 studies of locally developed checklists, 28 goal setting/structured communication templates, 23 care bundles, and 9 studies of mixed format tools. Most (43 %) tools were designed for use during rounds, fewer tools were designed for use throughout the ICU day (27 %) or stay (9 %). Most studies (55 %) reported process objectives i.e., improving communication, care standardisation, or rounding efficiency. Most common clinical processes QI tools were used to standardise were sedation (62, 65 %), ventilation and weaning (55, 57 %), and analgesia management (58, 60 %). 44 studies reported the effect of the tool on patient outcomes. Of these, only two identified a negative effect - increased ICU length of stay and increased ICU days with pain and delirium. CONCLUSION Although we identified numerous QI tools for use in ICU settings, few were designed to specifically address actionable processes of care relevant to the unique needs of prolonged ICU stay patients. Tools that address these needs are urgently required. SYSTEMATIC REVIEW REGISTRATION The review protocol is registered on the Open Science Framework, https://osf.io/, DOI 10.17605/OSF.IO/Z8MRE.
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Affiliation(s)
- Laura Allum
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, SE1 8WA London, UK; Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH London, UK.
| | - Chloe Apps
- Critical Care Research Group and Physiotherapy Department, St. Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Rd, London SE1 7EH, UK.
| | - Natalie Pattison
- University of Hertfordshire, College Lane, Hatfield AL109AB, UK; East & North Herts NHS Trust, Coreys Mill Lane, Stevenage SG14AB, UK.
| | - Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH London, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Centre for Human and Applied Physiological Sciences, King's College London, UK; Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, SE1 8WA London, UK; Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, SE1 7EH London, UK.
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Boulton AJ, Jordan H, Adams CE, Polgarova P, Morris AC, Arora N. Intensive care unit visiting and family communication during the COVID-19 pandemic: A UK survey. J Intensive Care Soc 2022; 23:293-296. [PMID: 36033248 PMCID: PMC9403523 DOI: 10.1177/17511437211007779] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Frequent visiting and communication with patients' families are embedded within normal ICU practice, however the COVID-19 pandemic has challenged this, and it is unclear how ICUs are managing. We aimed to investigate how NHS ICUs are approaching family communications and visiting during the COVID-19 pandemic. Methods An electronic snapshot survey was delivered between 16th April and 4th May 2020 and was open to NHS ICUs. Replies from 134 individual ICUs with COVID patients were included. Results All reported that visiting was more restricted than normal with 29 (22%) not allowing any visitors, 71 (53%) allowing visitors at the end of a patient's life (EOL) only, and 30 (22%) allowing visitors for vulnerable patients or EOL. Nearly all (n = 130, 97%) were updating families daily, with most initiating the update (n = 120, 92%). Daily telephone calls were routinely made by the medical (n = 75, 55%) or nursing team (n = 50, 37%). Video calling was used by 63 (47%), and 39 (29%) ICUs had developed a dedicated family communication team. Resuscitation and EOL discussions were most frequently via telephone (n = 129, 96%), with 24 (18%) having used video calling, and 15 (11%) reporting discussions had occurred in person. Clinicians expressed their dissatisfaction with the situation and raised concerns about the detrimental effect on patients, families, and staff. Conclusions COVID-19 has resulted in significant changes across NHS ICUs in how they interact with families. Many units are adapting and moving toward distant and technology-assisted communication. Despite innovative solutions, challenges remain and there may be a role for local and national guidance.
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Affiliation(s)
- Adam J Boulton
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.,Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Jordan
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Claire E Adams
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Petra Polgarova
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.,John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Nitin Arora
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Gautier WC, Abaye M, Dev S, Seaman JB, Butler RA, Norman MK, Arnold RM, Witteman HO, Cook TE, Mohan D, White DB. An Online Training Program to Improve Clinicians' Skills in Communicating About Serious Illness. Am J Crit Care 2022; 31:189-201. [PMID: 35466353 DOI: 10.4037/ajcc2022105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Large-scale efforts to train clinicians in serious-illness communication skills are needed, but 2 important gaps in knowledge remain. (1) No proven training method exists that can be readily scaled to train thousands of clinicians. (2) Though the value of interprofessional collaboration to support incapacitated patients' surrogates is increasingly recognized, few interventions for training intensive care unit (ICU) nurses in important communication skills can be leveraged to provide interprofessional family support. OBJECTIVE To develop and test a web/videoconference-based platform to train nurses to communicate about serious illness. METHODS A user-centered process was used to develop the intervention, including (1) iteratively engaging a stakeholder panel, (2) developing prototype and beta versions of the platform, and (3) 3 rounds of user testing with 13 ICU nurses. Participants' ratings of usability, acceptability, and perceived effectiveness were assessed quantitatively and qualitatively. RESULTS Stakeholders stressed that the intervention should leverage interactive learning and a streamlined digital interface. A training platform was developed consisting of 6 interactive online training lessons and 3 group-based video-conference practice sessions. Participants rated the program as usable (mean summary score 84 [96th percentile]), acceptable (mean, 4.5/5; SD, 0.7), and effective (mean, 4.8/5; SD, 0.6). Ten of 13 nurses would recommend the intervention over 2-day in-person training. CONCLUSIONS Nurses testing this web-based training program judged it usable, acceptable, and effective. These data support proceeding with an appropriately powered efficacy trial.
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Affiliation(s)
- William C. Gautier
- William C. Gautier is a medical student, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Menna Abaye
- Menna Abaye is a research project manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Shelly Dev
- Shelly Dev is an assistant professor, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Jennifer B. Seaman
- Jennifer B. Seaman is an assistant professor, School of Nursing, Department of Acute and Tertiary Care, University of Pittsburgh, Pennsylvania
| | - Rachel A. Butler
- Rachel A. Butler is a research program manager, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Marie K. Norman
- Marie K. Norman is an associate professor, School of Medicine, General Internal Medicine, Medicine and Clinical and Translational Science, Innovation Design for Education and Assessment (IDEA) Lab, University of Pittsburgh, Pennsylvania
| | - Robert M. Arnold
- Robert M. Arnold is a professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, and University of Pittsburgh Medical Center Palliative and Supportive Institute, Pennsylvania
| | - Holly O. Witteman
- Holly O. Witteman is a professor, Department of Family and Emergency Medicine & Office of Education and Professional Development, Faculty of Medicine, Laval University, Québec, Canada
| | - Tara E. Cook
- Tara E. Cook was an assistant professor, School of Medicine, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pennsylvania
| | - Deepika Mohan
- Deepika Mohan is an associate professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
| | - Douglas B. White
- Douglas B. White is a professor, School of Medicine; Department of Critical Care Medicine; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh, Pennsylvania
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Seaman JB, Rak KJ, Carpenter AK, Arnold RM, White DB. Intensive Care Unit Clinicians' Perspectives on Achieving Proactive Interprofessional Family Meetings. Am J Crit Care 2022; 31:129-136. [PMID: 35229153 DOI: 10.4037/ajcc2022719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although proactive interprofessional family meetings are widely recommended as a best practice for patient- and family-centered care in intensive care units (ICUs), adherence to this recommendation is low. OBJECTIVES To enhance understanding of practices, barriers, and facilitators related to the conduct of family meetings from the perspective of ICU clinicians and to elicit clinicians' ideas and opinions about strategies to achieve proactive interprofessional family meetings. METHODS Semistructured telephone interviews were conducted with ICU clinicians who were purposively selected from among a national sample. Constant comparative analysis was used to generate a matrix of themes; enrollment ceased when no new ideas emerged. RESULTS Interviews were conducted with 14 participants (10 nurses, 3 physicians, and 1 care manager). Rather than having a protocol for proactive family meetings, participants primarily held family meetings when physicians thought that it was time to discuss a transition to comfort-focused care. Other barriers included clinicians' discomfort with end-of-life conversations, physicians' time constraints, and nurses' competing clinical responsibilities. Facilitators included physicians' skill and comfort with difficult conversations, advocacy for family meetings from care managers/ social workers, and having full-time intensivists. Participants offered/endorsed multiple intervention ideas, including scheduling preemptively, monitoring unit performance, and adding discussion of a family meeting to daily rounds. CONCLUSIONS A key barrier to proactive family meetings is the mindset that family meetings need occur only when a clinical decision must be made, rather than proactively to support and engage families. Clinicians suggested ways to make proactive family meetings routine.
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Affiliation(s)
- Jennifer B. Seaman
- Jennifer B. Seaman is an assistant professor of nursing, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Kimberly J. Rak
- Kimberly J. Rak is a medical anthropologist, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amanda K. Carpenter
- Amanda K. Carpenter, former research coordinator in the Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, is currently the operations manager for North Jersey Community Research Initiative, Newark, New Jersey
| | - Robert M. Arnold
- Robert M. Arnold is a distinguished service professor of medicine, Department of General Internal Medicine; chief, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, and medical director, UPMC Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | - Douglas B. White
- Douglas B. White is a vice chair and professor of critical care medicine, and director, Program on Ethics and Decision Making in Critical Illness, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine
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Zante B, Erne K, Grossenbacher J, Camenisch SA, Schefold JC, Jeitziner MM. Symptoms of post-traumatic stress disorder (PTSD) in next of kin during suspension of ICU visits during the COVID-19 pandemic: a prospective observational study. BMC Psychiatry 2021; 21:477. [PMID: 34587929 PMCID: PMC8480126 DOI: 10.1186/s12888-021-03468-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND During the COVID-19 pandemic, suspension of visits by next of kin to patients in intensive care units (ICU), to prevent spread of the SARS-CoV-2 virus, has been a common practice. This could impede established family-centered care and may affect the mental health of the next of kin. The aim of this study was to explore symptoms of post-traumatic stress syndrome (PTSD) in the next of kin of ICU patients. METHODS In this prospective observational single-center study, next of kin of ICU patients were interviewed by telephone, using the Impact of Event Scale-Revised (IES-R), to assess symptoms of acute stress disorder during the ICU stay and PTSD symptoms at 3 months after the ICU stay. The primary outcome was the prevalence of severe PTSD symptoms (IES-R score ≥ 33) at 3 months. The secondary outcomes comprised the IES-R scores during the ICU stay, at 3 months, and the prevalence of severe symptoms of acute stress disorder during ICU stay. An inductive content analysis was performed of the next of kin's comments regarding satisfaction with patient care and the information they were given. RESULTS Of the 411 ICU patients admitted during the study period, 62 patients were included together with their next of kin. An IES-R score > 33 was observed in 90.3% (56/62) of next of kin during the ICU stay and in 69.4% (43/62) 3 months later. The median IES-R score was 49 (IQR 40-61) during the ICU stay and 41 (IQR 30-55) at 3 months. The inductive content analysis showed that communication/information (55%), support (40%), distressing emotions (32%), and suspension of ICU visits (24%) were mentioned as relevant aspects by the next of kin. CONCLUSIONS During the suspension of ICU visits in the COVID-19 pandemic, high prevalence and severity of both symptoms of acute stress disorder during the ICU stay and PTSD symptoms 3 months later were observed in the next of kin of ICU patients.
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Affiliation(s)
- Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - Katja Erne
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Julia Grossenbacher
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Sabine A. Camenisch
- grid.5734.50000 0001 0726 5157Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C. Schefold
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Marie-Madlen Jeitziner
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland ,grid.6612.30000 0004 1937 0642Department of Public Health, Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland
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10
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Vlake JH, van Bommel J, Wils EJ, Korevaar T, Hellemons ME, Klijn E, Schut AF, Labout JA, Van Bavel MP, van Mol MM, Gommers D, van Genderen ME. Virtual reality for relatives of ICU patients to improve psychological sequelae: study protocol for a multicentre, randomised controlled trial. BMJ Open 2021; 11:e049704. [PMID: 34588250 PMCID: PMC8479939 DOI: 10.1136/bmjopen-2021-049704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Intensive care unit (ICU) admission of a relative might lead to psychological distress and complicated grief (post-intensive care syndrome-family; PICS-F). Evidence suggests that increased distress during ICU stay increases risk of PICS-F, resulting in difficulty returning to their normal lives after the ICU experience. Effective interventions to improve PICS-F are currently lacking. In the present trial, we hypothesised that information provision using ICU-specific Virtual Reality for Family members/relatives (ICU-VR-F) may improve understanding of the ICU and subsequently improve psychological well-being and quality of life in relatives of patients admitted to the ICU. METHODS AND ANALYSIS This multicentre, clustered randomised controlled trial will be conducted from January to December 2021 in the mixed medical-surgical ICUs of four hospitals in Rotterdam, the Netherlands. We aim to include adult relatives of 160 ICU patients with an expected ICU length of stay over 72 hours. Participants will be randomised clustered per patient in a 1:1 ratio to either the intervention or control group. Participants allocated to the intervention group will receive ICU-VR-F, an information video that can be watched in VR, while the control group will receive usual care. Initiation of ICU-VR-F will be during their hospital visit unless participants cannot visit the hospital due to COVID-19 regulations, then VR can be watched digitally at home. The primary objective is to study the effect of ICU-VR-F on psychological well-being and quality of life up to 6 months after the patients' ICU discharge. The secondary outcome is the degree of understanding of ICU treatment and ICU modalities. ETHICS AND DISSEMINATION The Medical Ethics Committee of the Erasmus Medical Centre, Rotterdam, the Netherlands, approved the study and local approval was obtained from each participating centre (NL73670.078.20). Our findings will be disseminated by presentation of the results at (inter)national conferences and publication in scientific, peer-reviewed journals. TRIAL REGISTRATION NUMBER Netherlands Trial Register (TrialRegister.nl, NL9220).
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Affiliation(s)
- Johan H Vlake
- Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jasper van Bommel
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Evert-Jan Wils
- Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Tim Korevaar
- Department of Internal Medicine, Academic Centre for Thyroid Diseases, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Eva Klijn
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Anna Fc Schut
- Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands
| | - Joost Am Labout
- Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Marten P Van Bavel
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Margo Mc van Mol
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
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11
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A Pilot Randomized Trial of an Interactive Web-based Tool to Support Surrogate Decision Makers in the Intensive Care Unit. Ann Am Thorac Soc 2021; 18:1191-1201. [PMID: 33326348 DOI: 10.1513/annalsats.202006-585oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Breakdowns in clinician-family communication in intensive care units (ICUs) are common, yet there are no easily scaled interventions to prevent this problem.Objectives: To assess the feasibility, usability, acceptability, and perceived effectiveness of a communication intervention that pairs proactive family meetings with an interactive, web-based tool to help surrogates prepare for clinician-family meetings.Methods: We conducted a two-arm, single-blind, patient-level randomized trial comparing the Family Support Tool with enhanced usual care in two ICUs in a tertiary-care hospital. Eligible participants included surrogates of incapacitated patients judged by their physicians to have ≥40% risk of death or severe long-term functional impairment. The intervention group received unlimited tool access, with prompts to complete specific content upon enrollment and before two scheduled family meetings. Before family meetings, research staff shared with clinicians a one-page summary of surrogates' main questions, prognostic expectations, beliefs about the patient's values, and attitudes about goals of care. The comparator group received usual care enhanced with scheduled family meetings. Feasibility outcomes included the proportion of participants who accessed the tool before the first family meeting, mean number of logins, and average tool engagement time. We assessed tool usability with the System Usability Scale, assessed tool acceptability and perceived effectiveness with internally developed questionnaires, and assessed quality of communication and shared decision-making using the Quality of Communication questionnaire.Results: Of 182 screened patients, 77 were eligible. We enrolled 52 (67.5%) patients and their primary surrogate. Ninety-six percent of intervention surrogates (24/25) accessed the tool before the first family meeting (mean engagement time, 62 min ± 27.7) and logged in 4.2 times (±2.1) on average throughout the hospitalization. Surrogates reported that the tool was highly usable (mean, 82.4/100), acceptable (mean, 4.5/5 ± 0.9), and effective (mean, 4.4/5 ± 0.2). Compared with the control group, surrogates who used the tool reported higher overall quality of communication (mean, 8.9/10 ± 1.6 vs. 8.0/10 ± 2.4) and higher quality in shared decision-making (mean, 8.7/10 ± 1.5 vs. 8.0/10 ± 2.4), but the difference did not reach statistical significance.Conclusions: It is feasible to deploy an interactive web-based tool to support communication and shared decision-making for surrogates in ICUs. Surrogates and clinicians rated the tool as highly usable, acceptable, and effective.
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12
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Anstey MH, Mitchell IA, Corke C, Murray L, Mitchell M, Udy A, Sarode V, Nguyen N, Flower O, Ho KM, Litton E, Wibrow B, Norman R. Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:287. [PMID: 34376239 PMCID: PMC8353726 DOI: 10.1186/s13054-021-03712-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/28/2021] [Indexed: 11/11/2022]
Abstract
Background To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. Methods Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. Results A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. Conclusion The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03712-4.
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Affiliation(s)
- Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia. .,School of Population Health, Curtin University, Bentley, Australia. .,School of Medicine, University of Western Australia, Crawley, Australia.
| | - Imogen A Mitchell
- Australian National University, Canberra, Australia.,Canberra Hospital, Canberra, Australia
| | | | - Lauren Murray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Marion Mitchell
- Griffith University, Griffith, QLD, Australia.,Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - Vineet Sarode
- Monash University, Melbourne, Australia.,Cabrini Hospital, Melbourne, Australia
| | - Nhi Nguyen
- Nepean Hospital, Kingswood, NSW, Australia
| | | | - Kwok M Ho
- School of Medicine, University of Western Australia, Crawley, Australia.,Royal Perth Hospital, Perth, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
| | - Edward Litton
- School of Medicine, University of Western Australia, Crawley, Australia.,Fiona Stanley Hospital, Perth, Australia
| | - Bradley Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia.,School of Medicine, University of Western Australia, Crawley, Australia
| | - Richard Norman
- School of Population Health, Curtin University, Bentley, Australia
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13
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Impact of a Visual Support Dedicated to Prognosis on Symptoms of Stress of ICU Family Members: A Before-and-After Implementation Study. Crit Care Explor 2021; 3:e0483. [PMID: 34278313 PMCID: PMC8280076 DOI: 10.1097/cce.0000000000000483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Family members commonly have inaccurate expectations of patient's prognosis in ICU. Adding to classic oral information, a visual support, depicting day by day the evolution of the condition of the patient, improves the concordance in prognosis estimate between physicians and family members. The objective of this study was to evaluate the impact of this tool on symptoms of anxiety/depression of family members. DESIGN Bicenter prospective before-and-after study. SETTING A nonacademic and a university hospital. SUBJECTS Relatives of consecutive patients admitted in the two ICUs. INTERVENTIONS In the period "before," family members received classic oral information, and in the period "after," they could consult the visual support in the patient's room. The primary endpoint was the Hospital Anxiety and Depression Scale score of relatives at day 5. Secondary outcomes were the prevalence of symptoms of anxiety (Hospital Anxiety and Depression Scale anxiety subscale score > 7) and depression (Hospital Anxiety and Depression Scale depression subscale score > 7) at day 5 and Hospital Anxiety and Depression Scale score at day 90. MEASUREMENTS AND MAIN RESULTS A total of 140 patients and their referent family members were included (77 in period before and 63 after). Characteristics of patients of the two groups were similar regarding age, reason for admission, Simplified Acute Physiology Score II at admission, and Sequential Organ Failure Assessment score at day 5. At day 5, median Hospital Anxiety and Depression Scale score was 17 (9-25) before and 15 (10-22) after the implementation of the visual support (p = 0.43). The prevalence of symptoms of anxiety and depression was similar in the two groups (66.2% and 49.4% before and 68.3% and 36.5% after [not significant], respectively). At day 90, median Hospital Anxiety and Depression Scale score was 11 before (7-16) and 9 (5-16) after the implementation of the tool (p = 0.38). CONCLUSIONS In this study, the use of a visual support tool dedicated to prognosis did not modify the level of stress of family members.
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14
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Mroz EL, Olasoji E, Henke C, Lim C, Pacheco SC, Swords G, Hester J, Weisbrod N, Babi MA, Busl K, Baron-Lee J. Applying the Care and Communication Bundle to Promote Palliative Care in a Neuro-Intensive Care Unit: Why and How. J Palliat Med 2021; 24:1849-1857. [PMID: 34191600 DOI: 10.1089/jpm.2020.0730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Delivery of palliative care in neurointensive care units (neuro-ICUs) can be inconsistent, often due to absence of formal care triggers. The Care and Communication Bundle (CCB) of Quality Indicators provides a standardized process to deliver effective palliative care services in ICUs, but application of these indicators in this setting has not yet been systemically assessed. Objectives: To evaluate the fit of a CCB in the neuro-ICU through a novel scoring system and identify barriers to adherence. Design: CCB standards for a neuro-ICU were delineated. Assessment of documented indicators and barriers was conducted through electronic medical record retrospective review. Setting/Subjects: A 30-bed neuro-ICU in a large Academic Medical Center in the Southeastern United States. Chart reviews were conducted for 133 critically ill neurology and neurosurgery patients who expired between November 2018 and January 2020. Results: Results demonstrate moderate adherence to CCB standards, including excellent consistency in establishment of patient-centered communication and referral to supportive services (e.g., social work, spiritual support). Identified areas for improvement include documentation of patient and family involvement in care process (i.e., advance directive completion, interdisciplinary team meetings). Conclusions: Application of the CCB in the neuro-ICU is useful for examining adherence to time-based triggers of palliative care standards. The novel scoring system offers opportunities to motivate improvement and reduce variation in palliative care integration.
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Affiliation(s)
- Emily L Mroz
- Department of Psychology, University of Florida, Gainesville, Florida, USA.,Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Esther Olasoji
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Charlotte Henke
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Christina Lim
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Sean C Pacheco
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Gabriel Swords
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Jeannette Hester
- Neuromedicine Intensive Care Unit, Department of Nursing and Patient Services, UF Health Shands Hospital, Gainesville, Florida, USA
| | - Neal Weisbrod
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Marc A Babi
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Katharina Busl
- Department of Neurology, University of Florida, Gainesville, Florida, USA
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15
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Al-Yahyai Rn Bsn ANS, Arulappan Rn Rm Bsc N Msc N PhD N DNSc J, Matua GA, Al-Ghafri Rn Bsn SM, Al-Sarakhi Rn Bsn SH, Al-Rahbi Rn Bsn KKS, Jayapal SK. Communicating to Non-Speaking Critically Ill Patients: Augmentative and Alternative Communication Technique as an Essential Strategy. SAGE Open Nurs 2021; 7:23779608211015234. [PMID: 34159256 PMCID: PMC8186114 DOI: 10.1177/23779608211015234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/22/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Communication with hospitalized patients is crucial to improve the quality and safety of health care. Methods The study assessed the communication methods used by nurses while communicating to non-speaking critically ill patients. The participants included staff nurses working in ICU, CICU, HD units of neuro- surgical, orthopedic, medical and oncology wards. Purposive sampling technique was used to recruit a total number of 194 nurses. The communication methods used were assessed by a questionnaire comprised of a list of 21 strategies used to communicate with non-speaking patients. Results The most commonly used strategies were reading the patient’s mouthing words, encouraging the patient by telling them that they are doing well and nurses helping them to get better, assessing the patients for their communication ability, “thumps up” to indicate “yes”, “shake head” indicating “no”, use OK, or point to body parts, speaking slowly and waiting for the patient’s response, spending time to listen patiently to what the patient say and touching the non-speaking critically ill patient when the nurse speaks with the patient. Conclusion The study reported that the nurses used variety of communication strategies while communicating to non- speaking critically ill patients. However very few nurses used Augmentative and alternative communication strategies to communicate to non-speaking critically ill patients. The study recommends the importance of establishing Augmentative and Alternative Communication strategies in the hospitals.
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Affiliation(s)
| | | | - Gerald Amandu Matua
- Department of Fundamentals and Administration, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
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Sepúlveda MI, Betancourt S, Güell M, Peña A, Barbagelata I, Higueras G, Muñoz R. GOBERNANZA DE ENFERMERÍA: ADAPTACIÓN EN TIEMPOS DE PANDEMIA. EXPERIENCIA EN CLÍNICA LAS CONDES. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [PMCID: PMC7849540 DOI: 10.1016/j.rmclc.2020.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
La pandemia SARS-CoV-2 ha desafiado el despliegue de todo el equipo de salud, movilizando no solo un recurso humano, también equipamiento, insumos y una infraestructura, que permita responder una alta demanda de pacientes críticos, que requirió abrir más camas críticas, manejada por un personal sanitario sin experiencia en UCI y con equipamiento e insumos limitados. El trabajo en equipo, la comunicación efectiva y el liderazgo en enfermería, son competencias esenciales en la primera ola de la pandemia, por lo que el objetivo de este artículo es describir la innovación de la orgánica estructural de enfermería, especialmente en las áreas de hospitalización de paciente crítico, para velar por el cuidado del paciente, la familia y el equipo de salud.
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17
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Mistraletti G, Gristina G, Mascarin S, Iacobone E, Giubbilo I, Bonfanti S, Fiocca F, Fullin G, Fuselli E, Bocci MG, Mazzon D, Giusti GD, Galazzi A, Negro A, De Iaco F, Gandolfo E, Lamiani G, Del Negro S, Monti L, Salvago F, Di Leo S, Gribaudi MN, Piccinni M, Riccioni L, Giannini A, Livigni S, Maglione C, Vergano M, Marinangeli F, Lovato L, Mezzetti A, Drigo E, Vegni E, Calva S, Aprile A, Losi G, Fontanella L, Calegari G, Ansaloni C, Pugliese FR, Manca S, Orsi L, Moggia F, Scelsi S, Corcione A, Petrini F. How to communicate with families living in complete isolation. BMJ Support Palliat Care 2020:bmjspcare-2020-002633. [PMID: 33060189 DOI: 10.1136/bmjspcare-2020-002633] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/25/2020] [Indexed: 12/23/2022]
Abstract
IMPORTANCE During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals. OBJECTIVE This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation. EVIDENCE REVIEW PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure. FINDINGS Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation. CONCLUSIONS AND RELEVANCE The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.
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Affiliation(s)
- Giovanni Mistraletti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milano, Italy
| | - Giuseppe Gristina
- Società Italiana Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Roma, Italy
| | - Sara Mascarin
- Educational Services for Health and Social Development, Officina Comunicativa, Treviso, Italy
| | - Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital of Macerata, Macerata, Italy
| | - Ilaria Giubbilo
- General and Neurosurgical ICU, Ospedale dell'Angelo, Aulss 3 Serenissima Veneto, Venezia, Italy
| | - Silvia Bonfanti
- Department of Palliative Care, Azienda USL di Piacenza, Piacenza, Italy
| | - Federico Fiocca
- Anestesia e Rianimazione 1, ASST Spedali Civili, Brescia, Italy
| | - Giorgio Fullin
- General and Neurosurgical ICU, Ospedale dell'Angelo, Aulss 3 Serenissima Veneto, Venezia, Italy
| | - Ennio Fuselli
- UOC Anestesia Rianimazione 1 Dip.to Emergenza Accettazione, A. O. San Camillo-Forlanini, Roma, Italy
| | - Maria Grazia Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Terapia Intensiva, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Davide Mazzon
- UOC Anestesia e Rianimazione, Ospedale di Belluno, Aulss 1 Dolomiti, Belluno, Italy
| | | | - Alessandro Galazzi
- Direction of Healthcare Professions, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Fabio De Iaco
- Emergency Department, Martini Hospital, ASL Città di Torino, Torino, Italy
| | - Enrico Gandolfo
- Emergency Department, Martini Hospital, ASL Città di Torino, Torino, Italy
| | - Giulia Lamiani
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Silvia Del Negro
- UOC Clinical Psychology, ASST Santi Paolo e Carlo, Milano, Italy
| | - Laura Monti
- Servizio Psicologia Ospedaliera, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Fabrizia Salvago
- Dipartimento di Neuroscienze, Azienda Ospedaliera G Brotzu, Cagliari, Italy
| | - Silvia Di Leo
- Psycho-oncology Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Mariassunta Piccinni
- Department of Political Science, Law and International Studies, Università degli Studi di Padova, Padova, Italy
| | | | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital, ASST Spedali Civili, Brescia, Italy
| | - Sergio Livigni
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Carla Maglione
- Società Italiana Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Napoli, Italy
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Franco Marinangeli
- Department of Anesthesiology and Intensive Care, University of L'Aquila, L'Aquila, Italy
| | - Luisa Lovato
- UO Anestesia e Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | | | - Elio Drigo
- Associazione Nazionale Infermieri di Area Critica (Aniarti), Udine, Italy
| | - Elena Vegni
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
- UOC Clinical Psychology, ASST Santi Paolo e Carlo, Milano, Italy
| | - Sally Calva
- Educational Services for Health and Social Development, Officina Comunicativa, Torino, Italy
| | - Anna Aprile
- Department of Molecular Medicine, Università degli Studi di Padova, Padova, Italy
| | | | - Lucia Fontanella
- Dipartimento di Scienze del Linguaggio e Letterature moderne e comparate, Università degli Studi di Torino, Torino, Italy
| | | | | | | | - Salvatore Manca
- SC Medicina e Chirurgia di Accettazione e di Urgenza, Ospedale di Oristano, Oristano, Italy
| | - Luciano Orsi
- Società Italiana di Cure Palliative (SICP), Milano, Italy
| | - Fabrizio Moggia
- DATeR Processo Assistenziale nelle Cure Palliative, Azienda USL di Bologna, Bologna, Italy
| | - Silvia Scelsi
- Dipartimento Infermieristico e delle professioni tecnico sanitarie, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Antonio Corcione
- UOC Anestesia e TIPO, Azienda dei Colli, Ospedale Monaldi-Cotugno, Napoli, Italy
| | - Flavia Petrini
- Perioperative Medicine, Pain Therapy, ICU and Emergency Department, ASL2 - Chieti Pescara University, Chieti, Italy
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Noll E, Muccioli C, Ludes PO, Pottecher J, Diemunsch P, Diemunsch S, Tchentcheli A, Clavert P, Joshi GP, Liverneaux PA. Surgical Support for Severe COVID-19 Patients: A Retrospective Cohort Study in a French High-Density COVID-19 Cluster. Surg Innov 2020; 27:564-569. [PMID: 32877312 PMCID: PMC8723901 DOI: 10.1177/1553350620954571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background. The COVID-19 epidemic has resulted in a massive
surge in the need for intensive care unit (ICU) care. To avoid being
overwhelmed, hospitals had to adapt and support the ICU teams in structured ICU
care including involving surgical teams. This work aims at describing the
collaborative efforts between the ICU care team and the Surgical Task Force
(STF) during a surge of ICU activity in a University Hospital in a French
high-density COVID-19 cluster. Study Design. This retrospective
single center study analyzed the STF workflow and the ICU population. The study
included 55 patients hospitalized in our ICU, ICU-converted step-down units, and
post-anesthesia care units. The primary measure was the global daily STF
activity. The secondary measure was the daily activity for each of the 5 tasks
accomplished by the STF. Results. The STF attempted 415 phone
calls for 55 patients’ families, 237 mobilizations of patients requiring prone
positions, follow-up of 20 patients requiring medevac, and contribution to
ethical discussion for 2 patients. The mean (SD) daily number of successful
phones calls, ethical discussions, mobilizations of patients requiring prone
positions and medevac follow-up were 18 (7), .1 (.4), 10 (7), and 2 (3),
respectively. No actions for discharge summaries writing were required. The
maximum number of daily mobilizations for patients requiring prone positions was
25. The maximum number of daily attempted phone calls and successful phone calls
were 37 and 26, respectively. Conclusion. Surgeons’ technical
and nontechnical skills represented an effective support for ICU teams during
the COVID-19 pandemic.
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Affiliation(s)
- Eric Noll
- Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, France.,Institut Hospitalo-Universitaire (Image-Guided Surgery), Strasbourg University, Strasbourg, France
| | - Christophe Muccioli
- Department of Orthopaedic and Plastic Surgery, University Hospital of Strasbourg, FMTS, University of Strasbourg, France
| | - Pierre-Olivier Ludes
- Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, France
| | - Julien Pottecher
- Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, France
| | - Pierre Diemunsch
- Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, France.,Institut Hospitalo-Universitaire (Image-Guided Surgery), Strasbourg University, Strasbourg, France
| | - Sophie Diemunsch
- Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, France
| | - Anaëlle Tchentcheli
- Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, France
| | - Philippe Clavert
- Department of Orthopaedic and Plastic Surgery, University Hospital of Strasbourg, FMTS, University of Strasbourg, France
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, 89063UT Southwestern Medical, TX, USA
| | - Philippe A Liverneaux
- Department of Orthopaedic and Plastic Surgery, University Hospital of Strasbourg, FMTS, University of Strasbourg, France
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19
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O'Hanlon CE, Lindvall C, Lorenz KA, Giannitrapani KF, Garrido M, Asch SM, Wenger N, Malin J, Dy SM, Canning M, Gamboa RC, Walling AM. Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer. JCO Oncol Pract 2020; 17:e140-e148. [PMID: 32758085 DOI: 10.1200/op.20.00240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer. METHODS We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into "measure concepts" and higher-level groups. RESULTS Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care-specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1). CONCLUSION Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.
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Affiliation(s)
- Claire E O'Hanlon
- Veterans Affairs Greater Los Angeles Health Care System, Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; and Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karl A Lorenz
- Veterans Affairs Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Karleen F Giannitrapani
- Veterans Affairs Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Melissa Garrido
- Veterans Affairs Boston Healthcare System, Partnered Evidence-Based Policy Resource Center, Boston, MA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Steven M Asch
- Veterans Affairs Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Neil Wenger
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA
| | | | - Sydney Morss Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MDThe views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government
| | - Mark Canning
- Veterans Affairs Greater Los Angeles Health Care System, Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA
| | - Raziel C Gamboa
- Veterans Affairs Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA
| | - Anne M Walling
- Veterans Affairs Greater Los Angeles Health Care System, Center for the Study of Healthcare Innovation, Implementation and Policy, Los Angeles, CA.,Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA
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20
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Abstract
During critical illness, active discussions about a person's preferences are linked with better patient outcomes. Our intensive care unit implemented an evidence-based standardized communication bundle that included education to providers on effective family communication, focused patient/family discussions to identify Durable Power of Attorney/surrogate decision maker and obtaining advanced directive documents, and documenting conversations in the electronic medical record and appropriately updating the patient's code status. The aim of the bundle was to increase compliance with conducting and documenting family discussions, clearly identifying and documenting surrogate decisions makers, and to improve patient/family satisfaction and caregiver satisfaction.
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21
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Vuong C, Kittelson S, McCullough L, Yingwei Y, Hartjes T. Implementing primary palliative care best practices in critical care with the Care and Communication Bundle. BMJ Open Qual 2019; 8:e000513. [PMID: 31544163 PMCID: PMC6730599 DOI: 10.1136/bmjoq-2018-000513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 07/11/2019] [Accepted: 07/20/2019] [Indexed: 12/03/2022] Open
Abstract
Background Clinician–family communication is a central component of medical decision-making in the intensive care unit (ICU) and the quality of this communication has a direct impact on decisions made regarding care for patients who are critically ill. Aim The purpose of the project was to emphasise the need for quality improvement in the medical ICU at the University of Florida Health Hospital in regard to communication between the patients, families and providers. Method Interventions included development of a more systemic approach to primary palliative care by using the nationally recognised and published Care and Communication Bundle tool. The Bundle is a standardised clinical pathway of palliative care best practices. Results During the project period, staff satisfaction/engagement increased from tier 3 to tier 1 level, the medical ICU length of stay decreased from 4.97 days in fiscal year (FY) 2016 to 4.22 days in FY2017. Moreover, the number of patients discharged directly to hospice increased from 21 in FY2016 to 42 in FY2017, representing a 100% increase. Additionally, palliative care consults decreased in the medical ICU (FY2016=108, FY2017=82), as a result of an increase in daily primary palliative care interventions. The findings demonstrate an improvement in outcome measures during the project.
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Affiliation(s)
- Cristina Vuong
- University of Florida College of Nursing, Gainesville, Florida, USA
| | - Sheri Kittelson
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lindsay McCullough
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Yao Yingwei
- University of Florida College of Nursing, Gainesville, Florida, USA
| | - Tonja Hartjes
- University of Florida College of Nursing, Gainesville, Florida, USA
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22
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Ulrich RS, Cordoza M, Gardiner SK, Manulik BJ, Fitzpatrick PS, Hazen TM, Perkins RS. ICU Patient Family Stress Recovery During Breaks in a Hospital Garden and Indoor Environments. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2019; 13:83-102. [DOI: 10.1177/1937586719867157] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Measure the immediate change in intensive care unit (ICU) family members’ state stress levels from the beginning to the end of a person’s visit to a hospital garden and compare the changes produced by the garden with those associated with spending time in indoor hospital environments intended for respite and relaxation. Background: No previous research has compared the efficacy of different physical environments as interventions to foster stress reduction in family members of ICU patients, a group of hospital visitors known to experience high levels of distress. Method: A convenience sample of 42 ICU patient family (from 42 different families) completed the Present Functioning Visual Analogue Scales (PFVAS) before and after each visit (128 total visits) to a garden, an atrium/café, or ICU waiting room. Results: Stress scores significantly declined (i.e., improved) from the start to the end of a break on all PFVAS subscales ( p < .0001) in both the garden and indoors locations. However, it is noteworthy that garden breaks resulted in significantly greater improvement in the “sadness” scale than breaks in indoor locations ( p = .03), and changes in all five other PFVAS scores showed somewhat more reduction of stress for breaks spent in the garden than indoors, although these differences were not statistically significant. Conclusion: Creating an unlocked garden with abundant nature located close to an ICU can be an effective intervention for significantly mitigating state stress in family members of ICU patients and can be somewhat more effective than indoor areas expressly designed for family respite and relaxation.
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Affiliation(s)
- Roger S. Ulrich
- Center for Healthcare Architecture, Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Makayla Cordoza
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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23
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24
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Desai N, Schofield N, Richards T. Perioperative Patient Blood Management to Improve Outcomes. Anesth Analg 2018; 127:1211-1220. [DOI: 10.1213/ane.0000000000002549] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Sabnis A, Hagen E, Tarn DM, Zeltzer L. Increasing Timely Family Meetings in Neonatal Intensive Care: A Quality Improvement Project. Hosp Pediatr 2018; 8:679-685. [PMID: 30309897 DOI: 10.1542/hpeds.2018-0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Timely multidisciplinary family meetings (TMFMs) promote shared decision-making. Despite guidelines that recommend meetings for all patients with serious illness, our NICU TMFM rate was 10%. In this study, we aimed to document a meeting within 5 days of hospitalization for 50% of all new NICU patients hospitalized for ≥5 days within 1 year of introducing interventions. METHODS A multidisciplinary improvement team used the Model for Improvement to achieve the study aim by targeting key drivers of change. To make meetings easier, we introduced scheduling and documentation tools. To make meetings more customary, we provided education and reminders to professionals. We defined a TMFM as a documented discussion between a parent, a neonatologist, and a nonphysician professional, such as a nurse, within 5 days of hospitalization. We used statistical process control charts to assess the monthly proportion of new patients with a TMFM. In surveys and feedback sessions, family and clinician satisfaction with communication was assessed. RESULTS TMFM documentation tripled during the intervention year when compared with the previous year (28 of 267 [10.5%] vs 70 of 224 [31.3%]; P < .001), revealing evidence of special cause variation on the statistical process control chart. Clinicians predominantly used ad hoc documentation instead of our scheduling and documentation tools. Parental satisfaction with care and communication did not vary significantly after interventions. Most physicians reported satisfaction with meetings. Nurses reported feeling empowered to request meetings. CONCLUSIONS An academic, quaternary-care NICU tripled TMFM documentation after introducing a multifaceted intervention. This improvement may represent changes in professionals' attitudes about providing and documenting family meetings.
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Affiliation(s)
- Animesh Sabnis
- Division of Neonatology and Developmental Biology, Departments of Pediatrics,
| | - Eunice Hagen
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Lonnie Zeltzer
- Anesthesiology, and.,Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
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26
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Short SR, Thienprayoon R. Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU). Transl Pediatr 2018; 7:326-343. [PMID: 30460185 PMCID: PMC6212394 DOI: 10.21037/tp.2018.09.11] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.
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27
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Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study. Intensive Crit Care Nurs 2018; 48:75-84. [PMID: 29937078 DOI: 10.1016/j.iccn.2018.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility. RESEARCH DESIGN A mixed-methods study design was used. SETTING AND SAMPLE The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire. MAIN OUTCOME MEASURES The main outcomes were the acceptability and feasibility of the educational intervention. FINDINGS The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions. CONCLUSION Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.
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28
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White DB, Angus DC, Shields AM, Buddadhumaruk P, Pidro C, Paner C, Chaitin E, Chang CCH, Pike F, Weissfeld L, Kahn JM, Darby JM, Kowinsky A, Martin S, Arnold RM. A Randomized Trial of a Family-Support Intervention in Intensive Care Units. N Engl J Med 2018; 378:2365-2375. [PMID: 29791247 DOI: 10.1056/nejmoa1802637] [Citation(s) in RCA: 296] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences. METHODS We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay. RESULTS A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001). CONCLUSIONS Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates' burden of psychological symptoms, but the surrogates' ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492 .).
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Affiliation(s)
- Douglas B White
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Derek C Angus
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Anne-Marie Shields
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Praewpannarai Buddadhumaruk
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Caroline Pidro
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Cynthia Paner
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Elizabeth Chaitin
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Chung-Chou H Chang
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Francis Pike
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Lisa Weissfeld
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Jeremy M Kahn
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Joseph M Darby
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Amy Kowinsky
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Susan Martin
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
| | - Robert M Arnold
- From the Program on Ethics and Decision Making in Critical Illness (D.B.W., A.-M.S., P.B.), Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K.), Department of Critical Care Medicine (D.B.W., D.C.A., A.-M.S., P.B., C. Pidro, C.-C.H.C., J.M.K., J.M.D.), and the Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (R.M.A.), Department of Medicine (C.-C.H.C., R.M.A.), University of Pittsburgh School of Medicine, and the Intensive Care Unit Service Center (D.B.W., D.C.A., J.M.K.), the Wolff Center (C. Paner, A.K., S.M.), and the Palliative and Supportive Institute (E.C., R.M.A.), UPMC Health System - all in Pittsburgh; Eli Lilly, Indianapolis (F.P.); and the Statistics Collaborative, Washington, DC (L.W.)
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Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 45:1751-1761. [PMID: 28749855 DOI: 10.1097/ccm.0000000000002624] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine whether patient- and family-centered care interventions in the ICU improve outcomes. DATA SOURCES We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016. STUDY SELECTION We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs. DATA EXTRACTION We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes. DATA SYNTHESIS There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis. CONCLUSIONS Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.
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Abstract
OBJECTIVES To investigate family perceptions of having a nurse participating in family conferences and to assess the psychologic well being of the same families after ICU discharge. DESIGN Mixed-method design with a qualitative study embedded in a single-center randomized study. SETTING Twelve-bed medical-surgical ICU in a 460-bed tertiary hospital. SUBJECTS One family member for each consecutive patient who received more than 48 hours of mechanical ventilation in the ICU. INTERVENTION Planned proactive participation of a nurse in family conferences led by a physician. In the control group, conferences were led by a physician without a nurse. MEASUREMENTS AND MAIN RESULTS Of the 172 eligible family members, 100 (60.2%) were randomized; among them, 88 underwent semistructured interviews at ICU discharge and 86 completed the Peritraumatic Dissociative Experiences Questionnaire at ICU discharge and then the Hospital Anxiety Depression Questionnaire and the Impact of Event Scale (for posttraumatic stress-related symptoms) 3 months later. The intervention and control groups were not significantly different regarding the prevalence of posttraumatic stress-related symptoms (52.3 vs 50%, respectively; p = 0.83). Anxiety and depression subscale scores were significantly lower in the intervention group. The qualitative data indicated that the families valued the principle of the conference itself. Perceptions of nurse participation clustered into four main themes: trust that ICU teamwork was effective (50/88; 56.8%), trust that care was centered on the patient (33/88; 37.5%), trust in effective dissemination of information (15/88; 17%), and trust that every effort was made to relieve anxiety in family members (12/88; 13.6%). CONCLUSIONS Families valued the conferences themselves and valued the proactive participation of a nurse. These positive perceptions were associated with significant anxiety or depression subscale scores but not with changes in posttraumatic stress-related symptoms.
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Camal-Sanchez CA, Simpson T, Curtis JR, Owens D, Burr RL, Shannon SE. A Quality Improvement Project to Identify Patients With Advanced Heart Failure for Potential Palliative Care Referral in Telemetry and Cardiac Intensive Care Units. J Dr Nurs Pract 2017; 10:17-23. [PMID: 32751037 DOI: 10.1891/2380-9418.10.1.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Although national guidelines recommend timely initiation of palliative care for hospitalized patients with advanced heart failure (AHF), providers may not recognize which patients who have heart failure are most in need of consultation. Measures: A tool was developed and pilot-tested to screen patients admitted to a cardiology inpatient service with a left ventricular ejection fraction (LVEF) of 50% or less for potential triggers signifying palliative care needs in the telemetry or cardiac intensive care unit (CICU). Intervention: The tool was completed during cardiology rounds. Outcomes: Of the 21 patients evaluated, the median LVEF was lower in the telemetry group (22%) than in the CICU group (28%). Trigger patients in the telemetry unit were less adherent to medical management (χ2 = 6.034, p = .014) and had greater psychosocial and spiritual needs (χ2 = 3.956, p = .047) than those in the CICU. Conclusion: We describe a feasible palliative care screening tool for patients with AHF hospitalized in a telemetry unit or CICU that may identify opportunities for early palliative care referrals. Additional study is needed to determine whether this tool can be used to improve patient care or patient outcomes.
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Affiliation(s)
- Carlos A Camal-Sanchez
- University of Washington Medical Center, University of Washington School of Nursing, Seattle
| | | | - J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, Washington
| | - Darrell Owens
- UW Medicine Outpatient Primary, Palliative, and Supportive Care, Seattle, Washington
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Mistraletti G, Umbrello M, Mantovani ES, Moroni B, Formenti P, Spanu P, Anania S, Andrighi E, Di Carlo A, Martinetti F, Vecchi I, Palo A, Pinna C, Russo R, Francesconi S, Valdambrini F, Ferretti E, Radeschi G, Bosco E, Malacarne P, Iapichino G. A family information brochure and dedicated website to improve the ICU experience for patients' relatives: an Italian multicenter before-and-after study. Intensive Care Med 2016; 43:69-79. [PMID: 27830281 DOI: 10.1007/s00134-016-4592-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 10/12/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Good communication between ICU staff and patients' relatives may reduce the occurrence of post-traumatic stress disorder, anxiety or depression, and dissatisfaction with clinicians. An information brochure and website to meet relatives' needs were designed to explain in technical yet simple terms what happens during and after an ICU stay, to legitimize emotions such as fear, apprehension, and suffering, and to improve cooperation with relatives without increasing staff workload. The main outcomes were improved understanding of prognosis and procedures, and decrease of relatives' anxiety, depression, and stress symptoms. METHODS In this prospective multicenter before-and-after study, a self-administered questionnaire was used to investigate relatives' understanding of prognosis, treatments, and organ dysfunction, families' satisfaction, and symptoms of anxiety, depression, and post-traumatic stress. RESULTS A total of 551 relatives received questionnaires in nine Italian ICUs; 332 (60%) responded, 144 before and 179 after implementation of the brochure and website. Of the 179 relatives who responded after, 131 (73%) stated they had read the brochure and 34 (19%) reported viewing the website. The intervention was associated with increased correct understanding of the prognosis (from 69 to 84%, p = 0.04) and the therapeutic procedures (from 17 to 28%, p = 0.03). Multivariable analysis, together with non-modifiable factors (relative's gender, education level, relationship to patient, and patient status at ICU discharge), showed the intervention to be significantly associated with a lower incidence of post-traumatic stress symptoms (Poisson coefficient = -0.29, 95% CI -0.52/-0.07). The intervention had no effect on the prevalence of symptoms of anxiety and depression. CONCLUSION An information brochure and website designed to meet relatives' needs improved family members' comprehension and reduced their prevalence of stress symptoms.
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Affiliation(s)
- Giovanni Mistraletti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, A.O. San Paolo-Polo Universitario, Via A. Di Rudinì 8, 20142, Milan, Italy. .,U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy.
| | - Michele Umbrello
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Elena Silvia Mantovani
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Benedetta Moroni
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, A.O. San Paolo-Polo Universitario, Via A. Di Rudinì 8, 20142, Milan, Italy
| | - Paolo Formenti
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Paolo Spanu
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Stefania Anania
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Elisa Andrighi
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Alessandra Di Carlo
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Federica Martinetti
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Irene Vecchi
- U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
| | - Alessandra Palo
- U.O. Anestesia e Rianimazione 1, I.R.C.C.S. San Matteo, Pavia, Italy
| | - Cristina Pinna
- U.O. Anestesia e Rianimazione, Dipartimento di Area Critica, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Riccarda Russo
- U.O.C. Rianimazione e Terapia Intensiva, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Francesconi
- U.O.C. Anestesia e Rianimazione, A. O. Ospedale Civile di Desio, Desio, Milan, Italy
| | - Federico Valdambrini
- U.O. Anestesia e Rianimazione, A.O. Ospedale Civile di Legnano, Legnano, Milan, Italy
| | - Enrica Ferretti
- S.C. Anestesia Rianimazione B DEA, Ospedale San Giovanni Bosco, Turin, Italy
| | - Giulio Radeschi
- U.O. Anestesia e Rianimazione, A.O. U. San Luigi Gonzaga di Orbassano, Orbassano, Turin, Italy
| | - Edda Bosco
- U.O. Anestesia e Rianimazione, A.O. Cardinal Massaia, Asti, Italy
| | - Paolo Malacarne
- U.O. Anestesia e Rianimazione-P.S, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Gaetano Iapichino
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, A.O. San Paolo-Polo Universitario, Via A. Di Rudinì 8, 20142, Milan, Italy.,U.O. Anestesia e Rianimazione, Dipartimento Emergenza-Urgenza, A.O. San Paolo-Polo Universitario, Milan, Italy
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Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates. Ann Am Thorac Soc 2016; 13:1624-8. [DOI: 10.1513/annalsats.201601-029ps] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Patient Blood Management Bundles to Facilitate Implementation. Transfus Med Rev 2016; 31:62-71. [PMID: 27317382 DOI: 10.1016/j.tmrv.2016.05.012] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/25/2016] [Accepted: 05/25/2016] [Indexed: 12/22/2022]
Abstract
More than 30% of the world's population are anemic with serious economic consequences including reduced work capacity and other obstacles to national welfare and development. Red blood cell transfusion is the mainstay to correct anemia, but it is also 1 of the top 5 overused procedures. Patient blood management (PBM) is a proactive, patient-centered, and multidisciplinary approach to manage anemia, optimize hemostasis, minimize iatrogenic blood loss, and harness tolerance to anemia. Although the World Health Organization has endorsed PBM in 2010, many hospitals still seek guidance with the implementation of PBM in clinical routine. Given the use of proven change management principles, we propose simple, cost-effective measures enabling any hospital to reduce both anemia and red blood cell transfusions in surgical and medical patients. This article provides comprehensive bundles of PBM components encompassing 107 different PBM measures, divided into 6 bundle blocks acting as a working template to develop institutions' individual PBM practices for hospitals beginning a program or trying to improve an already existing program. A stepwise selection of the most feasible measures will facilitate the implementation of PBM. In this manner, PBM represents a new quality and safety standard.
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The intensive care unit family conference. Teaching a critical intensive care unit procedure. Ann Am Thorac Soc 2016; 12:469-71. [PMID: 25897741 DOI: 10.1513/annalsats.201503-123ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW Although providing palliative care in the ICU has become a priority, the success of different methods to integrate palliative care into the ICU has varied. This review examines the current evidence supporting the different models of palliative care delivery and highlights areas for future study. RECENT FINDINGS The need for palliative care for ICU patients is substantial. A large percentage of patients meet criteria for palliative care consultation and there is frequent use of intensive care and other nonbeneficial care at the end of life. Overall, the consultative model of palliative care appears to have more of an impact on patient care. However, given the current workforce shortage of palliative care providers, a sustainable model of delivering palliative care requires both an effective integrative model, in which palliative care is delivered by ICU clinicians, and appropriate use of the consultative model, in which palliative care consultation is reserved for patients at highest risk of having unmet or long-term palliative care needs. SUMMARY Developing a mixed model of palliative care delivery is necessary to meet the palliative care needs of critically ill patients. Efforts focused on improving integrative models and appropriately targeting the use of palliative care consultants are needed.
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Integration of Palliative Care Services in the Intensive Care Unit: A Roadmap for Overcoming Barriers. Clin Chest Med 2015; 36:441-8. [PMID: 26304281 DOI: 10.1016/j.ccm.2015.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clinicians working in the intensive care unit (ICU) confront death and dying daily. ICU care can be inconsistent with a patient's values, preferences, and previously expressed goals of care. Current evidence promotes the integration of palliative care services within the ICU setting. Palliative care bridges the gap between comfort and cure, and these services are growing in the United States. This article discusses the benefits and barriers to integration of ICU and palliative care services, and a stepwise approach to implementation of palliative care services. Integration of palliative care services into ICU workflow is increasingly seen as essential to providing high-quality, comprehensive critical care.
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Hartjes TM. Predicting Which Patients Will Benefit From Palliative Care: Use of Bundles, Triggers, and Protocols. Crit Care Nurs Clin North Am 2015; 27:307-14. [PMID: 26333753 DOI: 10.1016/j.cnc.2015.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Intensive care units provide a wide range of care to patients with serious or life-threatening conditions. This care provides excellent state-of-the-art interventions, often concentrated on meeting national health priorities and performance measures. Overall patient care and the resultant outcomes in the intensive care unit are superb. However, one area that needs improvement is the provision of high-quality palliative care (PC) and end-of-life care. Many providers and administrators now realize implementing PC in the critical care setting is vital to optimal patient outcomes. PC improves patient and family satisfaction and quality of life, reduces length of stay and 30-day readmission rates, and patients can live longer with PC.
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Affiliation(s)
- Tonja M Hartjes
- Adult Gerontology Acute Care Nurse Practitioner Program, University of Florida, College of Nursing, 1225 Center Drive, PO Box 100187, Gainesville, FL 32610-0187, USA.
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Bakitas M, Dionne-Odom JN, Kamal A, Maguire JM. Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units. Crit Care Nurs Clin North Am 2015; 27:395-411. [PMID: 26333759 DOI: 10.1016/j.cnc.2015.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Defining the quality of intensive care unit (ICU) care when patients are dying is challenging. Palliative care has been recommended to improve outcomes of dying ICU patients; however, traditional ICU quality indicators do not always align with palliative care. Evidence suggests that some aspects of ICU care improve when palliative care is integrated; however, consensus is lacking concerning the outcomes that should be measured. Overcoming challenges to measuring palliative care will require consensus development and rigorous research on the best way to evaluate ICU palliative care services.
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Affiliation(s)
- Marie Bakitas
- School of Nursing, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, NB 2M019C, 1701 University Boulevard, Birmingham, AL 35233, USA.
| | - J Nicholas Dionne-Odom
- School of Nursing, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, NB 2M019C, 1701 University Boulevard, Birmingham, AL 35233, USA
| | - Arif Kamal
- Division of Medical Oncology, Duke Palliative Care, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, #8043, Durham, NC 27710, USA
| | - Jennifer M Maguire
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina - Chapel Hill, Bioinformatics Building, Suite 4124, Campus Box 7020, Chapel Hill, NC 27599, USA
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Abstract
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.
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Affiliation(s)
- Rebecca A Aslakson
- 1Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, MD. 2The Palliative Care Program at the Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA. 4Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Why Are They All So Keen on Communication?*. Crit Care Med 2013; 41:2435-6. [DOI: 10.1097/ccm.0b013e31829cb278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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