title: Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.
abstract: 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).
authors.affiliation: Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle Washington, USA. jrc@u.washington.edu
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Nielsen
authors.forename: Patsy D
authors.initials: PD
authors.lastname: Treece
authors.forename: Lois
authors.initials: L
authors.lastname: Downey
authors.forename: Danae
authors.initials: D
authors.lastname: Dotolo
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Shannon
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Back
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Rubenfeld
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Engelberg
mesh_terms: 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