1Division of Pulmonary and Critical Care Medicine, Brown University School of Medicine, Providence, RI. 2Healthcentric Advisors, Providence, RI. 3Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA. 4Center for Biostatistics, The Ohio State University, Columbus, OH. 5Division of Palliative Care, Brown University School of Medicine, Providence, RI. 6Division of Geriatrics, Brown University School of Medicine, Providence, RI. 7Home and Hospice of Rhode Island, Providence, RI.
Crit Care Med. 2013 Oct;41(10):2275-83. doi: 10.1097/CCM.0b013e3182982671.
Despite recommendations supporting the importance of clinician-family communication in the ICU, this communication is often rated as suboptimal in frequency and quality. We employed a multifaceted behavioral-change intervention to improve communication between families and clinicians in a statewide collaboration of ICUs.
Our primary objective was to examine whether the intervention resulted in increased compliance with process measures that targeted clinician-family communication. As secondary objectives, we examined the ICU-level characteristics that might be associated with increased compliance (open vs closed, teaching vs nonteaching, and medical vs medical-surgical vs surgical) and patient-specific outcomes (mortality, length of stay).
The intervention was a multifaceted quality improvement approach targeting process measures adapted from the Institute of Health Improvement and combined into two "bundles" to be completed either 24 or 72 hours after ICU admission.
Significant increases were seen in full compliance for both day 1 and day 3 process measures. Day 1 compliance improved from 10.7% to 83.8% after 21 months of intervention (p<0.001). Day 3 compliance improved from 1.6% to 28.8% (p<0.001). Improvements in compliance varied across ICU type with less improvement in open, nonteaching, and mixed medical-surgical ICUs. Patient-specific outcome measures were unchanged, although there was a small increase in patients discharged from ICU to inpatient hospice (p=0.002).
We found that a multifaceted intervention in a statewide ICU collaborative improved compliance with specific process measures targeting communication with family members. The effect of the intervention varied by ICU type.
尽管有建议强调临床医生与患者家属在 ICU 中进行沟通的重要性，但这种沟通在频率和质量方面往往不尽如人意。我们采用了一种多方面的行为改变干预措施，以改善全州范围内 ICU 中临床医生与患者家属之间的沟通。
我们的主要目的是检验该干预措施是否能提高针对临床医生与患者家属沟通的特定流程措施的执行率。作为次要目标，我们还检验了与提高执行率相关的 ICU 层面的特征（开放性与封闭性、教学型与非教学型、内科型与内科-外科型与外科型）和患者特异性结局（死亡率、住院时间）。
该干预措施是一种多方面的质量改进方法，针对从健康促进研究所采用的流程措施，并结合成两个“捆绑包”，在 ICU 入院后 24 小时或 72 小时内完成。
第 1 天和第 3 天的流程措施完全执行率均显著提高。干预 21 个月后，第 1 天的执行率从 10.7%提高到 83.8%（p<0.001），第 3 天的执行率从 1.6%提高到 28.8%（p<0.001）。执行率的提高因 ICU 类型而异，开放性、非教学型和混合内科-外科型 ICU 的改善程度较小。患者特异性结局测量值保持不变，尽管 ICU 出院转至住院临终关怀病房的患者略有增加（p=0.002）。
我们发现，全州范围内 ICU 合作中的一种多方面干预措施提高了针对与患者家属沟通的特定流程措施的执行率。干预措施的效果因 ICU 类型而异。
