Integrating Palliative and Critical Care

Abstract

Rationale: Palliative care in the intensive care unit (ICU) is an important focus for quality improvement. Objectives: To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU. Methods: We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre-(n 5 253) and postintervention (n 5 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results. Measurements and Main Results: There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P 5 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P , 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P , 0.01). Conclusions: We found no significant improvement in familyassessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization

“…Of these, two focused on ICU system change. In a single-center study, Curtis et al (31) evaluated the impact of a quality improvement intervention targeted to ICU personnel and designed to integrate palliative care into the ICU; median ICU LOS was shorter in the postimplementation period (3 d vs 4 d; relative risk reduction for all patients 19%; p = 0.01). As described above, this difference was not observed in the follow-up multicenter cluster RCT (27).…”

Hospital Variation and Temporal Trends in Palliative and End-of-Life Care in the ICU*

“…Hospitals in the Seattle/Tacoma region were eligible if they had enough ICU deaths to meet sample size requirements (16, 17). Of 16 eligible hospitals, 15 agreed to participate (94%) in a study of a systems-level quality improvement intervention designed to improve palliative care in the ICU.…”

“…Each of the three FS-ICU scores has a potential range from 0 to 100, with 100 representing the highest satisfaction (12, 22, 23). The QODD questionnaire contains a single item rating the quality of dying (QOD-1) that is scored from 0 to 10, with 0 indicating “terrible” and 10 indicating “almost perfect”; this item has demonstrated construct validity correlating with other markers of the quality of palliative and end-of-life care (17, 20). …”

Critical Care Implications of the Affordable Care Act

“…Because integration of palliative care into critical care has demonstrated improved family satisfaction and reduction in ICU and hospital length of stay without increasing overall mortality, it may gain additional financial significance under both VBP and bundled payment reimbursement models (64, 65). There may also be an expanded role for hospice services under these new payment models, which may actually decrease ICU utilization in patients with poor prognoses (66).…”