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Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.

Abstract：

RATIONALE:Because of high mortality, end-of-life care is an important component of intensive care. OBJECTIVES:We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. METHODS:We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. MEASUREMENTS AND MAIN RESULTS:All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81). CONCLUSIONS:We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

journal_name

Am J Respir Crit Care Med

journal_title

American journal of respiratory and critical care medicine

authors

Curtis JR,Nielsen EL,Treece PD,Downey L,Dotolo D,Shannon SE,Back AL,Rubenfeld GD,Engelberg RA

doi

10.1164/rccm.201006-1004OC

subject

Has Abstract

pub_date

2011-02-01 00:00:00

pages

348-55

issue

eissn

1073-449X

issn

1535-4970

pii

201006-1004OC

journal_volume

183

pub_type

杂志文章,随机对照试验

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Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial.