PURPOSE: High quality ICU care includes the provision of excellent palliative care. In order to achieve this goal, the health care system needs to identify, measure, and report specific targets for quality palliative care in the critically ill. Our objective was to operationalize a set of quality measures to assess palliative care in the critically ill and to study the specific contributions from nursing to the processes of care.
METHODS: Building from preliminary quality indicators identified in prior work, literature review, consensus statements, and adaptations from related fields, we used a modified Delphi technique to operationalize and specify process quality measures. The quality measure panel included broad representation from interdisciplinary nursing, medicine, psychiatry, geriatrics, social work, chaplaincy, and palliative care providers as well as administrators, ethicists, and legal counsel. Delphi process included two iterative voting rounds using 1-9 (9 highest agreement) standardized Likert scales for validity and feasibility grading divided by an in-person mediated expert panel.
RESULTS: We developed specifications for 14 process quality measures across six established domains of quality palliative care for the ICU: decision-making, communication, continuity of care, emotional support, symptom management, and spiritual support. Consensus mean grading scores exceeded 6 out of 9 maximum for all measures. Validity was ranked < 7 for four measures: two measures of dyspnea care and ones exploring spiritual and emotional support. Feasibility for audit was similarly ranked > 6 for all measures.
CONCLUSION: Our expert panel consensus group operationalized 14 process measures to assess the quality of palliative care delivered to critically ill patients across 6 domains. These quality measures are being deployed and tested using expert nurse abstractors and a medical record audit tool to assess nursing specific contributions to palliative care in two medical-surgical ICUs and being validated against nurse and family survey.
CLINICAL IMPLICATIONS: Our operationalized quality measures have broad application including utility in quality assessment of the palliative ICU care experience, as a guide for quality improvement and innovation work, and for conduct of subsequent research.
DISCLOSURE: Richard Mularski, No Financial Disclosure Information; No Product/Research Disclosure Information