Serna Myrna Katalina, Yoon Catherine, Fiskio Julie, Lakin Joshua R, Dalal Anuj K, Schnipper Jeffrey L
Division of General Medicine, University of Texas Medical Branch, Galveston, Texas, USA.
Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
J Hosp Med. 2025 May;20(5):437-445. doi: 10.1002/jhm.13537. Epub 2024 Oct 29.
Serious Illness Conversations (SICs) are not consistently integrated into existing inpatient workflows.
We assessed the implementation of multiple interventions aimed at encouraging SICs with hospitalized patients.
We used the Consolidated Framework for Implementation Research to identify determinants for conducting SICs by interviewing providers and the Expert Recommendations for Implementing Change to develop a list of interventions. Adult patient encounters with a Readmission Risk Score (RRS) > 28% admitted to a general medicine service from January 2019 to October 2021 and without standardized SIC documentation in the prior year were included. A multivariable segmented logistic regression model, suitable for an interrupted time series analysis, was used to assess changes in the odds of standardized SIC documentation.
Barriers included those associated with the COVID-19 pandemic, such as extreme census. Facilitators included the presence of the Speaking About Goals and Expectations program and palliative care consultations. Key interventions included patient identification via the existing Quality and Safety Dashboard (QSD), weekly emails, in-person outreach, and training for faculty and trainees. There was no significant change in the odds of standardized SIC documentation despite interventions (change in temporal trend odds ratio (OR) 1.16, 95% Confidence Interval (CI) 0.98-1.39).
The lack of significant change in standardized SIC documentation may be attributed to insufficient or ineffective interventions and COVID-19-related challenges. Although patient identification is a known barrier to SICs, this issue was minimized with the use of the QSD and RRS. Further research is needed to enhance the implementation of SICs in inpatient settings.
重病谈话（SICs）并未始终如一地纳入现有的住院患者工作流程。
我们评估了旨在鼓励与住院患者进行重病谈话的多项干预措施的实施情况。
我们使用实施研究综合框架，通过访谈提供者来确定进行重病谈话的决定因素，并利用实施变革专家建议制定干预措施清单。纳入了2019年1月至2021年10月入住普通内科、再入院风险评分（RRS）>28%且上一年无标准化重病谈话记录的成年患者。采用适用于中断时间序列分析的多变量分段逻辑回归模型，评估标准化重病谈话记录几率的变化。
障碍包括与新冠疫情相关的因素，如极高的 census。促进因素包括目标与期望谈话计划的存在以及姑息治疗会诊。关键干预措施包括通过现有的质量与安全仪表板（QSD）识别患者、每周发送电子邮件、亲自进行外展以及对教员和学员进行培训。尽管采取了干预措施，但标准化重病谈话记录的几率没有显著变化（时间趋势优势比（OR）变化为1.16，95%置信区间（CI）为0.98 - 1.39）。
标准化重病谈话记录缺乏显著变化可能归因于干预措施不足或无效以及与新冠疫情相关的挑战。尽管识别患者是重病谈话的一个已知障碍，但通过使用QSD和RRS，这个问题得到了最小化。需要进一步研究以加强重病谈话在住院环境中的实施。
