title: Intensive communication: four-year follow-up from a clinical practice study.
abstract: OBJECTIVE
  To determine the durability of the effects of a change in practice designed to promote the use of advanced supportive technology when it is of benefit but to limit its burdens when it is ineffective. We have reported that institution of a process of intensive communication reduced length of intensive care unit stay for dying patients and reduced mortality in a before-and-after study in a cohort of patients admitted to an adult intensive care unit. We now report the results of a 4-yr extension of this intervention.
  
  
  METHODS
  The number of counseling sessions, intensive care unit length of stay, and mortality were measured for 2,361 adult medical patients consecutively admitted to a university tertiary care hospital. To determine the durability of the effects of our intervention, we compared our experience during the subsequent 4 yrs with that of the 134 consecutive patients before and 396 patients after our intensive communication intervention.
  
  
  RESULTS
  We conducted an equivalent number of intensive communication sessions in our subsequent practice as during the intervention (1.5 vs. 1.6 sessions per patient admitted to the intensive care unit). However, sessions tended to be of shorter duration, and direct participation by social workers, chaplains, and care coordinators was less frequent in our subsequent experience. Intensive communication produced a significant and durable reduction in length of stay (median length of stay, 4 days [2-11 days, interquartile range] before; 3 days [2-6 days, interquartile range] during the study; 3 days [2-6 days, interquartile range] subsequently). Our intervention was associated with a significant and durable reduction in intensive care unit mortality (31.3% before, 22.7% during the intervention, 18% subsequently; p <.001).
  
  
  CONCLUSIONS
  Intensive communication is associated with durable reductions in intensive care unit length of stay and reduced mortality in critically ill adult medical patients. Intensive communication was applied more efficiently subsequent to the intervention, and its effectiveness does not seem to be dependent on nondirect caregivers' participation in the sessions. This process encourages the continuation of advanced supportive technology to patients with the potential to survive and allows the earlier withdrawal of advanced supportive technology when it is ineffective.
authors.affiliation: Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Craig M
authors.initials: CM
authors.lastname: Lilly
authors.forename: L A
authors.initials: LA
authors.lastname: Sonna
authors.forename: K J
authors.initials: KJ
authors.lastname: Haley
authors.forename: A F
authors.initials: AF
authors.lastname: Massaro
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003142:Communication; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D007902:Length of Stay / Q000639:trends*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods; D010347:Patient Care Planning; D010348:Patient Care Team / Q000458:organization & administration; D010817:Physician-Patient Relations; D011368:Professional-Family Relations; D014481:United States