Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review

Abstract

Objectives: To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience. Data Sources: Two authors independently searched electronic, systemic review, and trial registration databases (inception to November 2016). Study Selection: We included studies with an ICU length of stay of greater than or equal to 7 days as an inclusion criterion and reported actionable processes of care; quality improvement indicators, measures, or tools; or patient/family experience. We excluded case series/reports of less than 10 patients. Data Extraction: Paired authors independently extracted data and performed risk of bias assessment. Data Synthesis: We screened 13,130 references identifying 114 primary studies and 102 relevant reviews. Primary studies reported data on 24,252 participants; median (interquartile range) sample size of 70 (32–182). We identified 42 distinct actionable processes of care, the most commonly investigated related to categories of 1) weaning methods (21 studies; 27 reviews); 2) rehabilitation, mobilization, and physiotherapy (20 studies; 40 reviews); and 3) provision of information, prognosis, and family communication (14 studies; 11 reviews). Processes with limited evidence were generally more patient-centered categories such as communication, promotion of sleep, symptom management, or family support. Of the 21 randomized controlled trials, only two were considered at low risk of bias across all six domains, whereas just two cohort studies and one qualitative study were considered of high quality. Conclusions: We identified 42 distinct actionable processes of care relevant to patients with persistent or chronic critical illness and their families, with most frequently studied processes relating to weaning, rehabilitation/mobilization, and family communication. Qualitative studies highlighted the need to address psychologic needs and distressing symptoms as well as enabling patient communication. Our findings are informative for clinicians and decision-makers when planning high-quality patient and family-focused care.

Standardising care in the ICU: a protocol for a scoping review of tools used to improve care delivery

“…International work [32] to identify and prioritise the processes of care that most improve the experience of patients with prolonged ICU stay and their families is ongoing, using principles of experience-based co-design. The findings of this review will inform the design and implementation of quality improvement tools to improve/ standardise the delivery of these identified processes of care, to assist knowledge translation to clinical practice.…”

“…Given the demonstrable benefits of ICU quality improvement tools for patients in the acute phase of ICU admission, knowledge of the elements and factors that facilitate successful implementation could inform design of similar tools to address the distinct care needs of patients experiencing a prolonged ICU stay [32]. This is particularly important given the rising prevalence of these patients and their cost to the healthcare system.…”

Standardising Care in the ICU: A Protocol for a Scoping Review of Tools used to Improve Care Delivery

“…International work [32] to identify and prioritise the processes of care that most improve the experience of patients with prolonged ICU stay and their families is ongoing, using principles of experience-based co-design. The ndings of this review will inform the design and implementation of quality improvement tools to improve/standardise the delivery of these identi ed processes of care, to assist knowledge translation to clinical practice.…”

Standardising Care in the ICU: A Protocol for a Scoping Review of Tools used to Improve Care Delivery

“…International work (32) to identify and prioritise the processes of care that most improve the experience of patients with prolonged ICU stay and their families is ongoing, using principles of experience-based co-design. This growing population experience high levels of ongoing disability at large cost to individuals and the health system and the findings of this review will inform the design and implementation of quality improvement tools using these identified processes of care, to ensure effective knowledge translation in clinical practice.…”

“…However, these tools most commonly focus on medically-orientated priorities of care delivery during the acute period of a patients' stay (29)(30)(31). Such tools may be less relevant to more stable patients requiring aspects of care delivery such as mobilisation, communication aids and patient-led goal setting (12,32). Additionally, many of these tools are designed for delivery of a single element of care, such as the prevention of infection associated with central line insertion, rather than the coordination of a range of tasks by the interprofessional team.…”