1 Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
2 Oregon Health & Science University, Portland, Oregon; and.
Ann Am Thorac Soc. 2016 May;13(5):690-8. doi: 10.1513/AnnalsATS.201508-501OC.
RATIONALE: To understand how well palliative care is provided in the intensive care unit (ICU) and to direct improvements, measurement of the quality of care delivered is requisite. OBJECTIVES: To measure the quality of palliative care delivered in the ICU, using chart review-derived process quality measures of palliative care in critically ill patients, and to compare these measures with family and nursing perspectives on the quality of care provided. METHODS: We developed and operationalized a comprehensive quality evaluation measure set from previously endorsed palliative care measure statements, using a rigorous multidisciplinary Delphi process focused on optimizing the validity and feasibility of chart review-derived metrics. Fourteen process measures assessed the quality of care delivered across established domains of palliative care for the ICU. We assessed the quality of care for ICU patients with ICU length of stay exceeding 2 days from three perspectives: medical record reviews, family satisfaction reports, and nurse ratings from those providing care in the ICU. MEASUREMENTS AND MAIN RESULTS: We evaluated the care over a 7-month period of 150 patients (mean age, 63.9 yr [SD 13.4], average ICU length of stay, 7.5 d [SD 7.2]). Overall, ICU patients received 53.1% of recommended palliative care. The Family Satisfaction with Care in the Intensive Care Unit total scores from 136 family members (response rate, 91%) were high, 85.7 (SE 2.0) and 86.0 (SE 1.6), at the two sites but not correlated to measured quality delivered. Nurses rated the quality of care higher than medical record review (mean, 77.3% [SD 13.4]; n = 135) and similarly correlation with chart based process measures was poor. CONCLUSIONS: Delivering high-quality palliative care in the ICU requires assessing key patient-centered domains. However, assessments from different perspectives do not always agree with technical quality of care as measured through chart-based metrics. We found deficits across seven domains of technical quality that were not correlated with either nurse or family ratings. Despite care gaps, families were generally satisfied with the care delivered. We conclude that each measurement perspective provides an independent view that can guide quality improvement and innovation work as well as subsequent research.
背景：为了了解重症监护病房（ICU）提供姑息治疗的效果，并进行改进，必须对提供的护理质量进行测量。
目的：使用重症患者姑息治疗的图表审查衍生过程质量测量来衡量 ICU 提供的姑息治疗质量，并将这些措施与家庭和护理人员对提供的护理质量的看法进行比较。
方法：我们使用先前认可的姑息治疗测量标准制定了一个全面的质量评估工具集，并通过严格的多学科德尔菲法（Delphi）流程进行了优化，重点是提高图表审查衍生指标的有效性和可行性。14 项流程测量评估了 ICU 中姑息治疗的既定领域的护理质量。我们从三个角度评估 ICU 患者的护理质量：住院时间超过 2 天的 ICU 患者的病历审查、家庭满意度报告和 ICU 护理人员的评分。
测量和主要结果：我们在 7 个月内评估了 150 名患者（平均年龄 63.9 岁[标准差 13.4]，平均 ICU 住院时间为 7.5 天[标准差 7.2]）的护理情况。总体而言，ICU 患者接受了 53.1%的推荐姑息治疗。来自 136 名家属（回复率 91%）的《重症监护病房家属护理满意度》总分为 85.7（SE 2.0）和 86.0（SE 1.6），在两个地点都很高，但与所测量的护理质量无关。护士对护理质量的评分高于病历审查（平均 77.3%[标准差 13.4]；n=135），且与基于图表的流程测量相关性也较差。
结论：在 ICU 提供高质量的姑息治疗需要评估以患者为中心的关键领域。然而，来自不同角度的评估并不总是与通过图表计量的护理技术质量一致。我们发现七个技术质量领域存在缺陷，与护士或家庭的评分均无相关性。尽管存在护理差距，但家庭通常对提供的护理感到满意。我们的结论是，每个测量角度都提供了一个独立的观点，可以指导质量改进和创新工作，以及后续的研究。
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