Clinical study
An intensive communication intervention for the critically ill

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Abstract

PURPOSE: We sought to determine the effects of a communication process that was designed to encourage the use of advanced supportive technology when it is of benefit, but to limit its burdens when it is ineffective. We compared usual care with a proactive, multidisciplinary method of communicating that prospectively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient. This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death.

MATERIALS AND METHODS: We performed a before-and-after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care. Multidisciplinary meetings were held within 72 hours of critical care admission. Patients, families, and the critical care team discussed the care plan and the patients’ goals and expectations for the outcome of critical care. Clinical “milestones” indicative of recovery were identified with time frames for their occurrence. Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient’s goals. We measured length of stay, mortality, and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention.

RESULTS: Intensive communication significantly reduced the median length of stay from 4 days (interquartile range, 2 to 11 days) to 3 days (2 to 6 days, P = 0.01 by survival analysis). This reduction remained significant after adjustment for acute physiology and chronic health evaluation (APACHE) 3 score [risk ratio (RR) = 0.81; 95% confidence interval (CI), 0.66 to 0.99; P = 0.04). Subgroup analysis revealed that this reduction occurred in our target group, patients with acuity scores in the highest quartile who died (RR = 0.60; 95% CI, 0.38 to 0.92; P = 0.02). The intervention, which allowed dying patients earlier access to palliative care, was not associated with increased mortality.

CONCLUSIONS: Intensive communication was associated with a reduction in critical care use by patients who died. Our multidisciplinary process targeted advanced supportive technology to patients who survived and allowed the earlier withdrawal of advanced supportive technology when it was ineffective.

Section snippets

Study design

In a prospective, nonblinded, change-of-practice intervention study, we measured ICU, hospital, and rehabilitation facility mortality rates; probability of remaining in the ICU as a function of time after admission; and survival to discharge from acute and rehabilitative care to home, skilled nursing, or chronic care facilities for 530 consecutive adult patients admitted to a general medical ICU in a tertiary care teaching hospital. We made our intervention in a 10-bed unit in which all

Results

The 134 patients in the preintervention group and the 396 patients in the intensive communication group had similar age, race, sex, and mean (Table 1)and median (Figure 1) APACHE 3 scores.

A greater percentage of attending physician–led meetings were held in the intensive communication period than in the preintervention period [273 of 396 (69%) vs 58 of 134 (43%), P <0.001]. Multidisciplinary meetings occurred with 270 (68%) of 396 intensive communication patients or their families within 72

Discussion

We undertook this intensive communication intervention to improve care for critically ill adult medical patients by encouraging advanced supportive technology when it was effective for accomplishing patient-directed goals and limiting it when ineffective. We confirmed that critical care effectively restores life and function in the majority of critically ill adults 1, 4, 15, 16, 17, 18, and we found that intensive communication accomplished this goal with greater concordance among patients,

Acknowledgements

The authors would like to recognize the tireless efforts of Father George Winchester, Carol Smith, Barbara Collishaw, and the Brigham and Women’s Hospital medical intensive care unit nurses for their support of critically ill patients and families. This study was supported by the Brigham and Women’s Hospital.

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Supported by Brigham and Women’s Hospital.

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