Meeting standards of high-quality intensive care unit palliative care: clinical performance and predictors.
OBJECTIVE
High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.


METHODS
Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.


METHODS
A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.


METHODS
Consecutive adult patients with length of intensive care unit stay ≥5 days.


METHODS
None.


RESULTS
Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.


CONCLUSIONS
Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.
Center for Research on Health Care Across Systems and Sites of Care, James J. Peters VA Medical Center, Bronx, NY, USA.
Joan D
JD
Penrod
Peter J
PJ
Pronovost
Elayne E
EE
Livote
Kathleen A
KA
Puntillo
Amy S
AS
Walker
Sylvan
S
Wallenstein
Alice F
AF
Mercado
Sandra M
SM
Swoboda
Debra
D
Ilaoa
David A
DA
Thompson
Judith E
JE
Nelson
D000046:Academic Medical Centers / Q000592:standards; D005260:Female; D006764:Hospitals, Community / Q000592:standards; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000592:standards*; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000592:standards; D011787:Quality of Health Care / Q000592:standards