Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.
BACKGROUND
Because of high mortality, end-of-life care is an important component of intensive care.


OBJECTIVE
We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care.


METHODS
We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics.


RESULTS
All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81).


CONCLUSIONS
We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).
Curtis
J Randall
JR
Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle Washington, USA. jrc@u.washington.edu
Nielsen
Elizabeth L
EL
Treece
Patsy D
PD
Downey
Lois
L
Dotolo
Danae
D
Shannon
Sarah E
SE
Back
Anthony L
AL
Rubenfeld
Gordon D
GD
Engelberg
Ruth A
RA
D000368:Aged; D003258:Consumer Behavior; D005190:Family; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000592:standards; D058996:Quality Improvement; D011787:Quality of Health Care / Q000592:standards; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000379:methods* / Q000706:statistics & numerical data