Physician Quality and Safety Academy Leading Change to Improve Care Effect of an Early Family Conference on Decreasing Futile Care in Critically Ill Patients in the ICU Khalid F. Almoosa, MD, MS Ruthie Siska, RN, MICU Nurse Manager Bela Patel, MD, MICU Director Katherine Luther, RN, MPM, Director, Healthcare Improvement

Problem: futile care in the ICU What is futile care? Common Many causes Poor prognostication Sensitive topic, significant effect Multidisciplinary approach needed “inappropriate use of LST in the ICU” Used cause-and-effect analysis (fishbone) to determine causes/contributors Significant effects: prolongs dying, suffering for patient and family, costs, utilizes resources, poor quality care, decreased satisfaction Many causes: patient factors (culture, experience, lack of knowledge), team factors (beliefs, experience, legal, training), hospital (policies), ethical

Dartmouth Atlas -End of Life -2006 Jack Wennberg, PhD, Elliott Fisher, PhD

Aim Broad aim: reduce futile care through improved decision-making Specific aim: Increase family participation in end-of-life (decisions) via multidisciplinary family conferences Rationale: better communication  better decisions Strategic goals: Quality of care, patient-centered care, safety, satisfaction,  waste

Measures of success % of family participation in conference (& time) % of families de-escalating care (DNR) ICU length-of-stay for decedents (days prior to death – futile)

Intervention Multidisciplinary family conferences within 24 hours of patient’s ICU admission Objectives: Discuss clinical condition Determine family’s perspectives, patient’s wishes Make decisions on care Education

Target population Histogram of ICU LOS

Process Map Identify high-risk patients Assemble team Schedule conference Discussion template* Document Discuss patient status: dx, px, plans, needs Introductions Discuss patient status (Dx, Px, Tx) Determine patient’s wishes & establish surrogate. Answer questions Develop plan of care & make decisions Plan on future meetings

Results Intervention vs. control (historical) Control Intervention Number of patients 264 45 Age (mean) 60.7 63.7 % male 49.4% 49.8% Mortality risk 3.78 3.8 DRG weight 2.35 2.91 Met Iezonni criteria* 66.8% 71.1% Control Intervention % family conference 27% 60% Time to conference (days) 4.6 1.8 % made DNR 85% 98% Hospital length of stay (days) 10.6 8.3 Study period: 1.5 years control, 6 months intervention DRG – diagnosis related group (indicates costs of treating patients – how many times the average) - reflects cost and resource utilization CMI – case mix index = average DRG weight for all of a hospital’s medicare volume Iezonni criteria – characterizes a patient population at higher risk of death due to the presence of one or more of 13 chronic conditions

Results Reduced outliers and large variations in LOS

Challenges No conference room! Teamwork Communication Variety to clinical situations & family dynamics Teamwork: develop clinical plan, organize meetings, coordinate discussions Communication – among team, with families, feedback to team members

What we accomplished Family conference = part of standard of care  futile care*  satisfaction with care Improved quality of EOL care Improved communication Developed process & format for meetings Education for trainees LOS 2.3 days Costs: > 5 day group (~80) Avoided 184 days saved $847,504 Cost for ICU day: $4606 ~80 deaths/year in >5 day group Total deaths per year in MICU ~ 160 – 170 Opened dialogue among team members – easier to work together

Lessons Learned No silver bullet! Don’t know what we don’t know Communication is not easy! Focus…focus…focus… Structure intervention (details) Successes & failures Re-evaluate…feedback…revise Not everyone on board More ideas Benefit to intervention = more than expected! Successes and failures: times when feel doesn’t work (successful results and failed ones!)

“…For the secret to the care of the patient is in caring for the patient.” - Dr. Francis W. Peabody