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Improving Care in the Intensive Care Unit

Improving Care in the Intensive Care Unit

New Tool Gives Hospitals an Objective Way to Measure Quality

Millions of patients spend time in the hospital ICU each year being treated for pain, discomfort and shortness of breath. These patients also receive psychosocial and spiritual support, assistance with discussions involving family members and friends, and help with advance directives and end-of-life decisions. This treatment is often referred to as palliative care.

Richard Mularski, MD
Richard Mularski, MD

The primary goal of palliative care is to prevent and reduce patient suffering. But studies show wide gaps in the way this care is provided, and until now there has been no comprehensive, objective measurement tool to help health systems and hospitals determine whether ICU patients are receiving high-quality, evidence-based palliative care. Kaiser Permanente palliative and ICU specialist Richard Mularski, MD, led the research team that developed a new tool that does just that, and in this interview he answers questions about how this kind of measurement tool can improve care in the ICU.

How is quality in the ICU measured?

There are multiple ways to measure quality in the ICU. You can ask family members if they are satisfied with the care provided to their loved ones. You can ask the nurses who provide most ICU care to rate the care. Or you can check the patient’s medical record to see what care is documented. Kaiser Permanente did this for a recent study published in the Annals of the American Thoracic Society, and found that the answers depend on whom you ask.

We surveyed family members of 150 ICU patients who received care over 7 months and found that they were very satisfied with the care their loved one received, giving it 86 out of 100 points. When we asked nurses to rate the quality of the care provided to these patients, they estimated that their patients received about 77 percent of the care recommended by national guidelines.  But when we used our new measurement tool to examine the patient’s medical records, we found that just over half, or 53 percent, of the recommended care was actually documented in the patients’ medical records.  

That doesn’t mean that each of these methods of assessing care isn’t valuable—they all have a place—but this new tool provides a uniform, evidence-based set of standards to measure the care, rather than just relying on recollection or opinion. 

How did you develop the measurement tool?

We convened a panel of 14 palliative care experts including nurses, social workers, palliative care doctors, chaplains, administrators, ethicists, psychiatrists and lawyers.  We built on a set of quality indicators that had already been developed by an end-of-life workgroup, and through a consensus process, further refined these into a set of quality measurements that are based on scientific evidence and easy to implement.

In your study, what type of care was well-documented and what care could be improved?

Assessing and controlling symptoms like pain and dyspena (severe shortness of breath) was well-documented in patients’ medical records, and this type of symptom relief also received the highest marks from nurses. The areas with the greatest opportunity for improvement include offering spiritual and psychosocial support (which includes counseling from therapists and chaplains), helping patients with end-of-life care and advance directives, and holding clinician/family conferences to discuss patient care.  

Where did your study take place, and does it apply to all hospitals?

We conducted our study in two hospitals, an academic teaching hospital and a veterans hospital.  Even though these hospitals were located very close to each other, there was still wide variation in certain types of care.  For example, one hospital documented how well the patient could participate in decision-making in 41 percent of cases, while the other hospital documented this care in only 5 percent of cases. Ours is not the first study to show variation in care among hospitals. If hospitals want to reduce that variation and improve care in the ICU, they need to first start measuring the care they are providing and then implement a quality improvement plan to make the care better.  

How can hospitals access your tool?

We are making our quality measurement tool accessible as part of our recently published paper.

Do you have other advice for improving ICU care? 

Although this tool makes it possible to do an objective evaluation of palliative care in the ICU, our work suggests that also getting information from the nurse and family perspectives can further guide quality improvement and innovation.