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A Multifaceted Intervention to Improve Compliance With Process Measures for ICU Clinician Communication With ICU Patients and Families*

Black, Martin D.1; Vigorito, Margaret C.2; Curtis, J. Randall3; Phillips, Gary S.4; Martin, Edward W.5; McNicoll, Lynn6; Rochon, Therese7; Ross, Susan1; Levy, Mitchell M.1

doi: 10.1097/CCM.0b013e3182982671
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Rationale: Despite recommendations supporting the importance of clinician-family communication in the ICU, this communication is often rated as suboptimal in frequency and quality. We employed a multifaceted behavioral-change intervention to improve communication between families and clinicians in a statewide collaboration of ICUs.

Objectives: Our primary objective was to examine whether the intervention resulted in increased compliance with process measures that targeted clinician-family communication. As secondary objectives, we examined the ICU-level characteristics that might be associated with increased compliance (open vs closed, teaching vs nonteaching, and medical vs medical-surgical vs surgical) and patient-specific outcomes (mortality, length of stay).

Methods: The intervention was a multifaceted quality improvement approach targeting process measures adapted from the Institute of Health Improvement and combined into two “bundles” to be completed either 24 or 72 hours after ICU admission.

Measurements and Main Results: Significant increases were seen in full compliance for both day 1 and day 3 process measures. Day 1 compliance improved from 10.7% to 83.8% after 21 months of intervention (p < 0.001). Day 3 compliance improved from 1.6% to 28.8% (p < 0.001). Improvements in compliance varied across ICU type with less improvement in open, nonteaching, and mixed medical-surgical ICUs. Patient-specific outcome measures were unchanged, although there was a small increase in patients discharged from ICU to inpatient hospice (p = 0.002).

Conclusions: We found that a multifaceted intervention in a statewide ICU collaborative improved compliance with specific process measures targeting communication with family members. The effect of the intervention varied by ICU type.

1Division of Pulmonary and Critical Care Medicine, Brown University School of Medicine, Providence, RI.

2Healthcentric Advisors, Providence, RI.

3Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA.

4Center for Biostatistics, The Ohio State University, Columbus, OH.

5Division of Palliative Care, Brown University School of Medicine, Providence, RI.

6Division of Geriatrics, Brown University School of Medicine, Providence, RI.

7Home and Hospice of Rhode Island, Providence, RI.

* See also p. 2435.

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The ICU Collaborative was supported, in part, by the participating institutions and third-party insurers, including Blue-Cross & Blue Shield of Rhode Island, UnitedHealthcare, and Neighborhood Health Plan of Rhode Island.

Dr. Vigorito disclosed that Blue Cross Blue Shield of Rhode Island, United Healthcare of New England, and Neighborhood Health Plan of RI provided funding to the Rhode Island Quality Institute (RIQI) for the Rhode Island ICU Collaborative (The Palliative Care and Communication bundle initiative was a component of this improvement work. The RIQI subcontracted Project management activities to Dr. Vigorito’s employer, Healthcentric Advisors). Dr. Phillips received payment for statistical analysis from the Rhode Island Hospital and received grant support from the National Institutes of Health. Dr. McNicoll received grant support from Blue Cross Blue Shield of Rhode Island and United Healthcare of Rhode Island, received a consulting fee from Healthcentric Advisors, and received travel reimbursements from Blue Cross Blue Shield of Rhode Island and United Healthcare of Rhode Island. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Mitchell M. Levy, MD, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. E-mail:

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins