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Early Family Meetings in the MICU for Older Adults With Multisystem Organ Failure: A Quality Improvement Initiative FREE TO VIEW

Sagar Patel; Sunena Tewani, MD; Nicholas Bosch, MD; Julian Mesa, MD; Michael Ieong, MD; Renda Wiener, MPH
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Boston University School of Medicine, Boston, MA

Chest. 2014;146(4_MeetingAbstracts):522A. doi:10.1378/chest.1965624
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SESSION TITLE: Quality & Clinical Improvement (Poster Discussion)

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM

PURPOSE: Guidelines suggest early family meetings to establish goals of care at the end of life for critically ill patients with an anticipated poor prognosis. The goal of the project was to assess the effect of a quality improvement (QI) initiative at a single urban medical center instituting early family meetings (within 4 days of MICU admission) for older adults with multi-system organ failure.

METHODS: ​A QI intervention was conducted between February-May 2012. The intervention consisted of two presentations to MICU staff explaining the rationale and desired content of early family meetings, introduction of a structured family meeting template into the electronic medical record, and regular reminders to MICU staff and residents about the intervention. For this study, the primary population included MICU patients over age 80 with 2 or more organ failures. Retrospective chart review was performed to compare proportion of early family meetings among MICU patients in the pre- (August 2011-January 2012) versus post-intervention (June-December 2012) cohorts. Of note, this study was part of a multi-component QI initiative to increase early family meetings in populations with anticipated poor prognosis; other triggers included patients with metastatic cancer and those status post cardiac arrest.

RESULTS: The pre- (n=63) and post-intervention (n=54) groups were similar with regard to demographics (age, sex, race). There was no significant difference in the proportion of early family meetings for patients over the age of 80 with two or more organ failures in the pre- vs. post-intervention cohorts (38.1% vs 37.0%, p=0.85). By contrast, the other populations in this QI initiative achieved significant increases in the proportion of early family meetings (metastatic cancer: 27 vs 61%, p=0.01; cardiac arrest: 36.5% vs 63.5%, p=0.001).

CONCLUSIONS: Our QI initiative did not achieve our primary outcome of increased proportion of early family meetings among patients aged 80 or over with 2 or more organ failures. While the other triggers in this QI initiative (metastatic cancer; cardiac arrest) were clear-cut, there was greater variability in disease severity and likely perceived prognosis of patients over age 80 with 2 or more organ failures. Such variabilty may have led to lack of buy-in for this trigger among MICU staff, resulting in a failure to adhere to the QI initiative.

CLINICAL IMPLICATIONS: For QI initiatives to be successful, there must be consensus among staff about the importance and appropriateness of the trigger.

DISCLOSURE: The following authors have nothing to disclose: Sagar Patel, Sunena Tewani, Nicholas Bosch, Julian Mesa, Michael Ieong, Renda Wiener

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