Simple InterventionsSignificant Impact

Michael C. Hartlieb and William J. Sibbald

Sunnybrook and Women's, College Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

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With the growing appreciation that patients are consumers of health care, physicians and hospitals are implementing lessons from the business world to improve health service delivery (1, 2). One of the tenets long held by successful businesses is that optimizing communication with consumers improves their perception of quality and promotes "brand loyalty." Data are also accumulating to show that the simple act of communication can have similar far-reaching consequences in health care. For example, good communication between the physician and patient appears to reduce the risk of subsequent medical malpractice claims (3, 4). Strategies such as multidisciplinary communication sessions with families, in which care plans for critically ill patients are reviewed and determined, can reduce intensive care unit (ICU) resource utilization while not changing patient outcomes (5). The importance of good communication has also been emphasized in the Agency for Healthcare Research and Quality report "Making Health Care Safer: a Critical Analysis of Patient Safety Practices" in the context of the informed consent process. This report concluded that written information during the informed consent discussion probably increases comprehension (6).

Patients admitted to critical care units are often unable to participate in discussions about their diagnosis, proposed treatments, and prognosis. In this case, family members are turned to as surrogate decision makers with regard to consent for complex interventions and for end-of-life decision making. All of this occurs in a complex and poorly understood environment, at a time when family members are likely to be experiencing significant emotional strain. It is in this context that the critical care team needs to provide appropriate and unambiguous information so that family members are in a position to make informed decisions. Unfortunately, poor communication between care providers and patient surrogates appears to be common in the ICU. For example, family members in one study frequently reported inadequate communication with their physicians (7). Although family members have reported conflict surrounding end-of-life decisions, this may in fact have more to do with doctor-family communication than with the decision about withdrawing or withholding care (8). Inquiries established to understand and improve the limitations of current health care delivery have reinforced the concept that good communication is fundamental to delivering high-quality care (9). Physicians must take seriously the concept that good communication with patients and families affects the perception of quality in health service delivery, and may reciprocally affect the delivery of care itself.

Interventions that improve communication with patients and families should therefore be of great interest to ICU physicians and health administrators. Fortunately, it is often the simple interventions that have the greatest impact. A good example is the study by Azoulay and coworkers in this issue of the Journal (pp. 438-442), in which a family information leaflet was systematically examined for its effect on the comprehension and satisfaction of the family members of patients admitted to an ICU (10). Family members were given a family information leaflet that merely provided general information about the ICU environment and did not disclose any patient-specific information. The authors suggest that this simple intervention ultimately improved family members' understanding of more difficult concepts such as diagnosis and proposed interventions. The authors also suggest that better comprehension may be associated with improved satisfaction among family members.

However, although the conclusions are tantalizing, we must first determine whether the evaluation was of sufficient methodological quality to be considered a "generalizable" intervention (11). The study by Azoulay and coworkers involved a broad range of 34 different ICU environments and a response rate from family members that approached 97%. Although only 70% of ICUs canvassed actually agreed to participate, the study effectively used ICUs as their own controls, thus limiting the potential impact of selection bias. Participating ICUs reflected a mix of university versus community and surgical versus medical ICUs, a mix that should make the results generally applicable. There were no adverse effects associated with the intervention as there was no difference found in mortality, length of stay, or requests for help by a hospital psychologist between the intervention and control groups. The investigators chose a computer-generated block-stratified design limited to six patients per center in an attempt to avoid any center-specific effects on study results. An attempt was made to ensure concealment of allocation, including blinding outcome assessors as to treatment versus control groups. Specific outcome assessors using prospectively designed and previously validated questions assessed the outcomes of patient comprehension and satisfaction. In fact, the only serious criticism of the study may be that whereas the information leaflet provided no specific information with respect to diagnosis or prognosis, it did include information that may have tautologically biased the comprehension of treatment (i.e., a glossary of terms commonly used in the ICU, including common interventions), a criticism that is unlikely to seriously cripple the results. Finally, the intervention proposed is simple and feasible among a wide variety of ICU environments.

We can conclude that the study by Azoulay and coworkers was a well-executed randomized control trial of a relatively simple intervention that proved effective in improving family comprehension of both diagnosis and treatment. The study did not demonstrate any effect on the family's understanding of prognosis, which, as the authors noted, is a concept that may be more difficult both to explain and to comprehend. Although not statistically significant for all participants, the family information leaflet did appear to improve satisfaction among those family members with good comprehension. The authors concluded that improved comprehension and satisfaction may be the result of the leaflet being perceived as a welcome message to family members by the ICU staff. Although the leaflet may also have been perceived as an invitation to physician- family interaction, there was no difference between the intervention and control groups with regard to the number of family meetings. This is consistent with the hypothesis that the leaflet improved comprehension and satisfaction without providing patient-specific information. One outstanding concern is the culture-specific interpretation of the process and content of a family information leaflet, although we could find no compelling data to suggest that this would significantly influence the outcome of such an intervention.

In the technologically complex environment of the ICU the most valuable tools for use by ICU physicians are still those simple, commonsense interventions that are increasingly showing the greatest benefit to patient outcomes. For example, clinical evaluations have demonstrated the importance of glycemic control, infection control, deep venous thrombosis prophylaxis, and nutritional support (6, 12). If we accept the premise that comprehension and satisfaction not only measure but also affect health care, then the study by Azoulay and coworkers gives us another simple and common sense tool with which to optimize the quality of our care. We can also then reaffirm the concept that simple interventions can have significant consequences.

	References

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