1. 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

2. 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

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

4. 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

5. 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)

6. 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

7. Target population
Histogram of ICU LOS

8. 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

9. 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

10. Results
Reduced outliers and large variations in LOS

11. 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

12. 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

13. 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!)

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