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Measure Summary
Title
Intensive care unit (ICU) palliative care: percent of patients who have documentation of ICU efforts to identify a health care proxy (or other appropriate surrogate decision-maker) on or before Day One of the ICU admission.
Source(s)
VHA Inc. TICU care and communication bundle: care and communication quality measures. Irving (TX): VHA Inc.; 2006 Sep 15. 8 p.

Measure Domain

Primary Measure Domain
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to assess the percent of patients with documentation of intensive care unit (ICU) efforts to identify a health care proxy (or other appropriate surrogate decision-maker) on or before Day One of the ICU admission.

Rationale

Palliative care focuses on prevention and relief of suffering, improving communication, promoting concordance between treatment and individual preferences, and facilitating transitions across care settings for patients with life threatening illness and their families. As such, it is increasingly accepted as an integral component of comprehensive intensive care unit (ICU) care for all critically ill patients, including those pursuing every reasonable treatment to prolong life. At the same time, evidence has accumulated that the quality of ICU palliative care needs improvement: patients experience high levels of pain and other distressing symptoms; families fail to understand basic information about diagnosis, prognosis, or critical care treatments and experience high levels of depression and anxiety; care plans diverge from patients' and families' preferences; and conflict among ICU clinicians, patients, and families is common.

The Institute of Medicine identified improvement of palliative care in the ICU and other care settings as a national health priority. For all healthcare providers and fields, it has also prioritized "closing the gap" between the current knowledge of optimal care and current clinical practice.

This measure is one of ten measures included in a palliative care bundle intended to close the "quality gap" between existing best evidence and current daily practice.

Evidence for Rationale
Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, Canoui P, Le Gall JR, Schlemmer B. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000 Aug;28(8):3044-9. PubMed External Web Site Policy

Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med. 2001 May;16(5):283-9. PubMed External Web Site Policy

Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med. 2004 May;30(5):770-84. [73 references] PubMed External Web Site Policy

Center to Advance Palliative Care. Palliative care tools, training & technical assistance. [Internet]. New York (NY): Center to Advance Palliative Care; [accessed 2006 Apr 01].

Cook DJ, Guyatt G, Rocker G, Sjokvist P, Weaver B, Dodek P, Marshall J, Leasa D, Levy M, Varon J, Fisher M, Cook R. Cardiopulmonary resuscitation directives on admission to intensive-care unit: an international observational study. Lancet. 2001 Dec 8;358(9297):1941-5. PubMed External Web Site Policy

Curtis JR, Rubenfeld GD, editor(s). Managing death in the ICU: the transition from cure to comfort. New York (NY): Oxford University Press; 2001.

Curtis JR, Rubenfeld GD. Improving palliative care for patients in the intensive care unit. J Palliat Med. 2005 Aug;8(4):840-54. [107 references] PubMed External Web Site Policy

Desbiens NA, Wu AW, Broste SK, Wenger NS, Connors AF Jr, Lynn J, Yasui Y, Phillips RS, Fulkerson W. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatmentm. Crit Care Med. 1996 Dec;24(12):1953-61. PubMed External Web Site Policy

Field MJ, Cassel CK, editor(s). Approaching death: improving care at the end of life. Washington (DC): National Academy Press (Institute of Medicine); 1997. 437 p.

Institute of Medicine, Committee on Quality of Health Care in America. Corrigan JM, et al, editor(s). Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. 337 p.

Keenan SP, Busche KD, Chen LM, McCarthy L, Inman KJ, Sibbald WJ. A retrospective review of a large cohort of patients undergoing the process of withholding or withdrawal of life support. Crit Care Med. 1997 Aug;25(8):1324-31. PubMed External Web Site Policy

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for quality palliative care, executive summary. J Palliat Med. 2004 Oct;7(5):611-27. [123 references] PubMed External Web Site Policy

Nelson JE, Danis M. End-of-life care in the intensive care unit: where are we now. Crit Care Med. 2001 Feb;29(2 Suppl):N2-9. [82 references] PubMed External Web Site Policy

Nelson JE, Meier DE, Oei EJ, Nierman DM, Senzel RS, Manfredi PL, Davis SM, Morrison RS. Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001 Feb;29(2):277-82. PubMed External Web Site Policy

Nelson JE, Meier DE. Palliative care in the intensive care unit, part 1. J Intensive Care Med. 1999;14:130-9.

Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006 Aug;15(4):264-71. [52 references] PubMed External Web Site Policy

Pochard F, Azoulay E, Chevret S, Lemaire F, Hubert P, Canoui P, Grassin M, Zittoun R, le Gall JR, Dhainaut JF, Schlemmer B, French FAMIREA Group. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. 2001 Oct;29(10):1893-7. PubMed External Web Site Policy

Stein-Parbury J, McKinley S. Patients' experiences of being in an intensive care unit: a select literature review. Am J Crit Care. 2000 Jan;9(1):20-7. [44 references] PubMed External Web Site Policy

Teno JM, Fisher E, Hamel MB, Wu AW, Murphy DJ, Wenger NS, Lynn J, Harrell FE Jr. Decision-making and outcomes of prolonged ICU stays in seriously ill patients. J Am Geriatr Soc. 2000 May;48(5 Suppl):S70-4. PubMed External Web Site Policy

Truog RD, Cist AF, Brackett SE, Burns JP, Curley MA, Danis M, DeVita MA, Rosenbaum SH, Rothenberg DM, Sprung CL, Webb SA, Wlody GS, Hurford WE. Recommendations for end-of-life care in the intensive care unit: the Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001 Dec;29(12):2332-48. [127 references] PubMed External Web Site Policy

White DB, Luce JM. Palliative care in the intensive care unit: barriers, advances, and unmet needs. Crit Care Clin. 2004 Jul;20(3):329-43, vii. [96 references] PubMed External Web Site Policy
Primary Health Components

Intensive care unit (ICU); critical care; palliative care; health care proxy

Denominator Description

Total number of patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients who have documentation of intensive care unit (ICU) efforts to identify a health care proxy (or other appropriate surrogate decision-maker) on or before Day One of the ICU admission (see the related "Numerator Inclusions/Exclusions" field)

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
Additional Information Supporting Need for the Measure
  • Over 85% of nearly 600 respondents to a recent national survey of physician and nurse directors of critical care units endorsed quality monitoring as a helpful strategy for improving Intensive Care Unit (ICU) palliative care, while only 25% reported the availability of such a program in their ICU.
  • During 2003 and 2004 many Transformation of the ICU project (TICU) clinical teams requested programmatic assistance from VHA to improve the quality of palliative care in their units. They reported serious concerns about conflict over care goals between teams and patients/families as well as among different disciplines and specialists caring for the same patients, about perceived inadequacies in clinicians' communication with patients and families, about unrelieved suffering of patients and families, and about other unmet family needs. The teams shared verbal and written complaints in these areas from patients and families, and described stresses and "burnout" among caregivers that the teams attributed to problems with palliative care in their ICUs.
Evidence for Additional Information Supporting Need for the Measure
Nelson JE, Angus DC, Weissfeld LA, Puntillo KA, Danis M, Deal D, Levy MM, Cook DJ, Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care. End-of-life care for the critically ill: A national intensive care unit survey. Crit Care Med. 2006 Oct;34(10):2547-53. PubMed External Web Site Policy

Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006 Aug;15(4):264-71. [52 references] PubMed External Web Site Policy
Extent of Measure Testing

Pilot implementation in a total of 19 intensive care units (ICUs) showed that the measures are feasible and usable and that opportunities exist for quality improvement. Refer to the article by Nelson, et al. for details.

Evidence for Extent of Measure Testing
Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006 Aug;15(4):264-71. [52 references] PubMed External Web Site Policy

State of Use of the Measure

State of Use
Current routine use
Current Use
Care coordination
Collaborative inter-organizational quality improvement
Internal quality improvement
Quality of care research

Application of the Measure in its Current Use

Measurement Setting
Hospital Inpatient
Intensive Care Units
Transition
Type of Care Coordination
Coordination between providers and patient/caregiver
Professionals Involved in Delivery of Health Services
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Social Workers
Least Aggregated Level of Services Delivery Addressed
Single Health Care Delivery or Public Health Organizations
Statement of Acceptable Minimum Sample Size
Unspecified
Target Population Age

Unspecified

Target Population Gender
Either male or female

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Effective Communication and Care Coordination
Person- and Family-centered Care
Prevention and Treatment of Leading Causes of Mortality

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Timeliness

Data Collection for the Measure

Case Finding Period

5 days or more after the day of intensive care unit (ICU) admission

Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Institutionalization
Denominator Time Window
Time window precedes index event
Denominator Inclusions/Exclusions

Inclusions
Total number of patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days

Exclusions

  • Patients discharged (or transferred out of the ICU) on or before Day One of the ICU admission
  • Patients expired on or before Day One of the ICU admission
  • Non-responsive patients with unidentified next of kin

Note: The day of ICU admission is considered Day Zero and the following calendar day beginning at 0001 hours is considered Day One.

Exclusions/Exceptions
Unspecified
Numerator Inclusions/Exclusions

Inclusions
Number of patients who have documentation of intensive care unit (ICU) efforts to identify a health care proxy (or other appropriate surrogate decision-maker) on or before Day One of the ICU admission

Note:

  • Documentation must be in the medical record and include one or more of the following:
    1. documentation that the patient has a health care proxy,
    2. documentation that the patient declined to appoint a health care proxy,
    3. documentation that the care-team discussed health care proxy appointment with the patient and/or family,
    4. documentation that the patient has an appropriate surrogate decision-maker other than a health-care proxy.
  • Definition of Health Care Proxy: An individual recognized as such through written documentation conforming to applicable state law. These documents and definitions can include health care proxy, health care agent, durable power of attorney, or any other term provided and accepted under state law.

Exclusions
Unspecified

Numerator Search Strategy
Institutionalization
Data Source
Paper medical record
Type of Health State
Does not apply to this measure
Instruments Used and/or Associated with the Measure

Unspecified

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Rate/Proportion
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
Internal time comparison

Identifying Information

Original Title

Quality indicator #1: medical decision-maker.

Submitter
VHA, Inc. - For Profit Organization
Developer
VHA, Inc. - For Profit Organization
Funding Source(s)

VHA, Inc.

Composition of the Group that Developed the Measure

Internal VHA, Inc. clinical subject matter experts along with external clinical subject matter faculty experts from various National and local research medical centers/hospitals

Financial Disclosures/Other Potential Conflicts of Interest

None; work was not supported by any third party vendors, contractors or for-profit health care companies including suppliers, device makers, or pharmaceutical firms.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC
2006 Sep
Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in November 2014.

Source(s)
VHA Inc. TICU care and communication bundle: care and communication quality measures. Irving (TX): VHA Inc.; 2006 Sep 15. 8 p.
Measure Availability

The individual measure, "Quality Indicator #1: Medical Decision-Maker," is published in "TICU Care and Communication Bundle: Care and Communication Quality Measures."

For more information, contact VHA, Inc. at: 220 E. Las Colinas Blvd., Irving, TX 75039; Phone: 1-800-842-5146 or 1-972-830-0626; Web site: www.vha.com External Web Site Policy.

Companion Documents

The following are available:

  • VHA, Inc. TICU care & communication bundle: data collection sheet. Irving (TX): VHA, Inc.; 2006 Sep 15. 1 p.
  • VHA, Inc. TICU care & communication bundle: care and communication quality measures form. Irving (TX): VHA, Inc.; 2006 Sep 15. 2 p.

For more information, contact VHA, Inc. at: 220 E. Las Colinas Blvd., Irving, TX 75039; Phone: 1-800-842-5146 or 1-972-830-0626; Web site: www.vha.com External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI on June 27, 2007. The information was verified by the measure developer on July 25, 2007.

This NQMC summary was retrofitted into the new template on May 11, 2011.

The information was reaffirmed by the measure developer on November 18, 2014.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions. Use or reproduction of this measure requires permission of VHA, Inc.

Disclaimer

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