RESUMEN
BACKGROUND: Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences. METHODS: We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay. RESULTS: A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001). CONCLUSIONS: Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates' burden of psychological symptoms, but the surrogates' ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492 .).
Asunto(s)
Cuidadores/psicología , Enfermería de Cuidados Críticos , Enfermedad Crítica , Toma de Decisiones , Unidades de Cuidados Intensivos , Relaciones Profesional-Familia , Estrés Psicológico/prevención & control , Anciano , Ansiedad/prevención & control , Comunicación , Cuidados Críticos , Enfermedad Crítica/terapia , Depresión/prevención & control , Familia , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Consentimiento por TercerosRESUMEN
Predictable and unpredictable patient care tasks compete for caregiver time and attention, making it difficult for patient care staff to reliably and consistently meet patient needs. We have piloted a redesigned care model that separates the work of patient care technicians based on task predictability and creates role specificity. This care model shows promise in improving the ability of staff to reliably complete tasks in a more consistent and timely manner.
Asunto(s)
Modelos de Enfermería , Modelos Organizacionales , Atención de Enfermería/organización & administración , Personal de Enfermería en Hospital/organización & administración , Análisis y Desempeño de Tareas , Flujo de Trabajo , Atención , Eficiencia Organizacional , Unidades Hospitalarias/organización & administración , Humanos , Rol de la Enfermera , Investigación en Administración de Enfermería , Investigación en Evaluación de Enfermería , Seguridad del Paciente , Proyectos PilotoRESUMEN
In many hospitals, addressing increasing financial and regulatory requirements has resulted in a decline in care managers' time spent communicating directly with patients, families, and healthcare providers. The authors discuss the redesign of a hospital care management model that increased the time care managers spend with patients, families, and other care professionals, while patient satisfaction increased, labor cost remained neutral, length of stay decreased, and the payment denial rate remained among the country's lowest.
Asunto(s)
Continuidad de la Atención al Paciente/organización & administración , Rol de la Enfermera , Alta del Paciente , Atención Dirigida al Paciente/organización & administración , Enfermería Primaria/organización & administración , Revisión de Utilización de Recursos/organización & administración , Comunicación , Eficiencia Organizacional , Humanos , Tiempo de Internación , Modelos de Enfermería , Investigación en Administración de Enfermería , Investigación en Evaluación de Enfermería , Evaluación de Resultado en la Atención de Salud , Educación del Paciente como Asunto , Satisfacción del Paciente , Pennsylvania , Proyectos Piloto , Servicio de Asistencia Social en Hospital/organización & administración , Estudios de Tiempo y MovimientoRESUMEN
The most common quality improvement methodologies used in healthcare involve repetitive testing of ideas for rapid-cycle quality improvement. They typically take place over weeks or months, as identification of problems and root causes and tests of change occur. The authors describe an alternative approach to care delivery redesign, which reduces the time frame of problem identification and implementation of tests of change from weeks or months to days.