1 Department of Medicine, Division of Pulmonary & Critical Care Medicine, Duke University, Durham, North Carolina.
2 Program to Support People and Enhance Recovery, Duke University, Durham, North Carolina.
Ann Am Thorac Soc. 2018 Jan;15(1):59-68. doi: 10.1513/AnnalsATS.201706-500OC.
The quality and patient-centeredness of intensive care unit (ICU)-based palliative care delivery is highly variable.
To develop and pilot an app platform for clinicians and ICU patients and their family members that enhances the delivery of needs-targeted palliative care.
In the development phase of the study, we developed an electronic health record (EHR) system-integrated mobile web app system prototype, PCplanner (Palliative Care Planner). PCplanner screens the EHR for ICU patients meeting any of five prompts (triggers) for palliative care consultation, allows families to report their unmet palliative care needs, and alerts clinicians to these needs. The evaluation phase included a prospective before/after study conducted at a large academic medical center. Two control populations were enrolled in the before period to serve as context for the intervention. First, 25 ICU patients who received palliative care consults served as patient-level controls. Second, 49 family members of ICU patients who received mechanical ventilation for at least 48 hours served as family-level controls. Afterward, 14 patients, 18 family members, and 10 clinicians participated in the intervention evaluation period. Family member outcomes measured at baseline and 4 days later included acceptability (Client Satisfaction Questionnaire [CSQ]), usability (Systems Usability Scale [SUS]), and palliative care needs, assessed with the adapted needs of social nature, existential concerns, symptoms, and therapeutic interaction (NEST) scale; the Patient-Centeredness of Care Scale (PCCS); and the Perceived Stress Scale (PSS). Patient outcomes included frequency of goal concordant treatment, hospital length of stay, and discharge disposition.
Family members reported high PCplanner acceptability (mean CSQ, 14.1 [SD, 1.4]) and usability (mean SUS, 21.1 [SD, 1.7]). PCplanner family member recipients experienced a 12.7-unit reduction in NEST score compared with a 3.4-unit increase among controls (P = 0.002), as well as improved mean scores on the PCCS (6.6 [SD, 5.8]) and the PSS (-0.8 [SD, 1.9]). The frequency of goal-concordant treatment increased over the course of the intervention (n = 14 [SD, 79%] vs. n = 18 [SD, 100%]). Compared with palliative care controls, intervention patients received palliative care consultation sooner (3.9 [SD, 2.7] vs. 6.9 [SD, 7.1] mean days), had a shorter mean hospital length of stay (20.5 [SD, 9.1] vs. 22.3 [SD, 16.0] patient number), and received hospice care more frequently (5 [36%] vs. 5 [20%]), although these differences were not statistically significant.
PCplanner represents an acceptable, usable, and clinically promising systems-based approach to delivering EHR-triggered, needs-targeted ICU-based palliative care within a standard clinical workflow. A clinical trial in a larger population is needed to evaluate its efficacy.
重症监护病房（ICU）姑息治疗的质量和以患者为中心的程度差异很大。
开发并试点一种针对临床医生和 ICU 患者及其家属的应用程序平台，以增强以需求为导向的姑息治疗的实施。
在研究的开发阶段，我们开发了一种电子健康记录（EHR）系统集成的移动网络应用程序系统原型，即 PCplanner（姑息治疗计划器）。PCplanner 从符合以下五种提示（触发条件）之一的 ICU 患者的 EHR 中筛选出姑息治疗咨询对象，允许家属报告他们未满足的姑息治疗需求，并向临床医生发出这些需求的警报。评估阶段包括在一家大型学术医疗中心进行的前瞻性前后研究。在干预前阶段，纳入了两个对照组，作为干预的背景。首先，25 名接受姑息治疗咨询的 ICU 患者作为患者层面的对照组。其次，49 名接受至少 48 小时机械通气的 ICU 患者的家属作为家庭层面的对照组。之后，14 名患者、18 名家属和 10 名临床医生参与了干预评估阶段。基线和 4 天后评估的家庭成员结果包括可接受性（客户满意度问卷 [CSQ]）、可用性（系统可用性量表 [SUS]），以及通过适应后的社会需求、存在问题、症状和治疗互动（NEST）量表、关怀患者程度量表（PCCS）和压力知觉量表（PSS）评估的姑息治疗需求。患者结果包括目标一致治疗的频率、住院时间和出院去向。
家属报告 PCplanner 的接受度（平均 CSQ，14.1[SD，1.4]）和可用性（平均 SUS，21.1[SD，1.7]）均很高。与对照组的 3.4 分增加相比，PCplanner 家属的 NEST 评分降低了 12.7 分（P = 0.002），PCCS（6.6[SD，5.8]）和 PSS（-0.8[SD，1.9]）的平均得分也有所提高。治疗目标的一致性在干预过程中有所增加（n = 14[SD，79%] vs. n = 18[SD，100%]）。与姑息治疗对照组相比，干预组患者更早接受姑息治疗咨询（3.9[SD，2.7] vs. 6.9[SD，7.1]平均天数），住院时间更短（20.5[SD，9.1] vs. 22.3[SD，16.0]患者数），更频繁地接受临终关怀（5[36%] vs. 5[20%]），尽管这些差异没有统计学意义。
PCplanner 是一种可接受、可用且具有临床前景的系统方法，可在标准临床工作流程中提供基于 EHR 触发的、以需求为导向的 ICU 姑息治疗。需要在更大的人群中进行临床试验来评估其疗效。
