title: Integrating palliative and critical care: evaluation of a quality-improvement intervention.
abstract: BACKGROUND
  Palliative care in the intensive care unit (ICU) is an important focus for quality improvement.
  
  
  OBJECTIVE
  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 = 253) and postintervention (n = 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.
  
  
  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 = 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 family-assessed 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.
authors.affiliation: Division of Pulmonary and Critical Care, Box 359762, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA. jrc@u.washington.edu
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Patsy D
authors.initials: PD
authors.lastname: Treece
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Nielsen
authors.forename: Lois
authors.initials: L
authors.lastname: Downey
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Shannon
authors.forename: Theresa
authors.initials: T
authors.lastname: Braungardt
authors.forename: Darrell
authors.initials: D
authors.lastname: Owens
authors.forename: Kenneth P
authors.initials: KP
authors.lastname: Steinberg
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Engelberg
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003422:Critical Care / Q000379:methods*; D003625:Data Collection; D005190:Family; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009726:Nurses; D010166:Palliative Care / Q000379:methods*; D010549:Personal Satisfaction; D011368:Professional-Family Relations; D011787:Quality of Health Care; D013727:Terminal Care / Q000379:methods*