Orford Neil R, Milnes Sharyn, Simpson Nicholas, Keely Gerry, Elderkin Tania, Bone Allison, Martin Peter, Bellomo Rinaldo, Bailey Michael, Corke Charlie
Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.
School of Medicine, Deakin University, Geelong, Australia.
BMJ Support Palliat Care. 2019 Mar;9(1):e21. doi: 10.1136/bmjspcare-2016-001231. Epub 2017 Jun 28.
To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred for intensive care management.
Prospective before-and-after cohort study in a tertiary teaching hospital in Australia. The population was 222 adult patients with LLI referred to the intensive care unit (ICU). The study was divided into two periods, before (1 May to 31 July 2015) and after (15 September to 15December 2015) the intervention. The intervention was a 2-day, small group, simulated-patient, communication skills course, and process of care for patients with LLI. The primary outcome was documentation of patient-centred goals of care discussion (PCD) within 48 hours of referral to the ICU. Secondary outcomes included clinical outcomes and 90-day mortality.
The intervention was associated with increased documentation of a PCD from 50% to 69% (p=0.004) and 43% to 94% (p<0.0001) in patients deceased by day 90. A significant decrease in critical care as the choice of resuscitation goal (61% vs 42%, p=0.02) was observed. Although there was no decrease in admission to ICU, there was a significant decrease in medical emergency team call prevalence (87% vs 73%, p=0.009). The cancer and organ failure groups had a significant decrease in 90-day mortality (75% vs 44%, p=0.02; 42% vs 16%, p=0.01), and the frailty group had a significant decrease in 90-day readmissions (48% vs 19%, p=0.003).
The intervention was associated with increased PCD documentation and decrease in the choice of critical care as the resuscitation goal. Admissions to ICU did not decrease, and although limited by study design, condition-specific trajectory changes, clinical interventions and outcomes warrant further study.
描述沟通技能培训项目对转至重症监护病房接受强化治疗管理的患有危及生命疾病（LLI）的重症患者以患者为中心的护理目标记录及临床结局的影响。
在澳大利亚一家三级教学医院进行前瞻性前后队列研究。研究对象为222名转至重症监护病房（ICU）的成年LLI患者。研究分为两个阶段，干预前（2015年5月1日至7月31日）和干预后（2015年9月15日至12月15日）。干预措施为为期2天的小组模拟患者沟通技能课程以及针对LLI患者的护理流程。主要结局是在转至ICU后48小时内以患者为中心的护理讨论（PCD）记录。次要结局包括临床结局和90天死亡率。
干预后，PCD记录有所增加，在90天内死亡的患者中，从50%增至69%（p = 0.004），从43%增至94%（p < 0.0001）。作为复苏目标，选择重症监护的比例显著下降（61%对42%，p = 0.02）。虽然入住ICU的人数没有减少，但医疗急救团队呼叫发生率显著下降（87%对73%，p = 0.009）。癌症和器官衰竭组90天死亡率显著下降（75%对44%，p = 0.02；42%对16%，p = 0.01），虚弱组90天再入院率显著下降（48%对19%，p = 0.003）。
该干预措施与PCD记录增加以及作为复苏目标选择重症监护的比例下降有关。入住ICU的人数没有减少，尽管受研究设计限制，但特定病情轨迹变化、临床干预措施及结局值得进一步研究。
