Objectives: High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.
Design: Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.
Settings: A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.
Patients: Consecutive adult patients with length of intensive care unit stay ≥5 days.
Measurements and Main Results: Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.
Conclusions: Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers. (Crit Care Med 2012; 40:–1112)
Center for Research on Health Care Across Systems and Sites of Care (JDP, EEL), James J. Peters VA Medical Center, Bronx, NY; Hertzberg Palliative Care Institute (JDP), Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY; Department of Anesthesiology and Critical Care Medicine (PJP), Quality and Safety Research Group, and Department of Health Policy and Management, Bloomberg School of Public Health, School of Nursing and Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD; School of Nursing (KAP), University of California, San Francisco, San Francisco, CA; Department of Medicine (ASW, AFM, JEN), Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai School of Medicine, New York, NY; Department of Community Medicine (SW), Mount Sinai School of Medicine, New York, NY; Department of Surgery (SMS, DAT), School of Medicine, and School of Nursing, Johns Hopkins University, Baltimore, MD; Norman Regional Health System (DI), Norman, OK.
*See also p. 1343.
Supported, in part, by R21 AG029955 from the National Institute on Aging. During the period of this work, Dr. Nelson was supported by a K02 Independent Scientist Research Career Development Award AG024476, followed by a K07 Academic Career Leadership Award, AG034234, both from the National Institute on Aging. Additional support was provided by the Department of Veterans Affairs, Health Services Research and Development Service (grant REA-08-260). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Work was performed at the Mount Sinai School of Medicine, New York, NY; James J. Peters VA Medical Center, Bronx, NY; Johns Hopkins University, Baltimore, MD; University of California, San Francisco, San Francisco, CA; Norman Regional Medical Center, Norman, OK.
Dr. Nelson consulted for the Voluntary Hospital Association, Inc. and Veterans Integrated Service Network 3 of the Department of Veterans Affairs. Dr. Puntillo consulted for Veterans Integrated Service Network 3 of the Department of Veterans Affairs and received honoraria/speaking fees from Providence Health and Science Center. The remaining authors have not disclosed any potential conflicts of interest.
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