Evaluating effectiveness of a communication facilitator to reduce distress and improve goal concordant care for critically ill patients and their families

项目总结 由于我们的人口老龄化以及在有效性和有效性方面的进步，危重疾病的影响正在增加 提供危重护理服务。危重病人和他们的家人承受着严重的 抑郁、焦虑和创伤后压力在一定程度上是由于零散的医疗保健，而医疗保健往往很差 与他们的目标保持一致。零散的医疗服务包括为患者和家属提供大量过渡 临床医生和跨环境，从ICU开始，延伸到急性护理、熟练护理设施或 回家。随着病情的发展，患者和家属努力在不同的护理目标之间导航，以匹配 他们的价值观和治疗目标，向他们的临床医生传达他们的目标，并使困难 不让未被满足的情感需求干扰的医疗决定。沟通不畅因这些原因而加剧 过渡使本已紧张的经历雪上加霜，给患者及其家人带来了痛苦。已被占用 这些问题共同导致在ICU期间和之后缺乏有效的沟通，这往往会导致高 强度“默认”的护理，这可能是不需要的。使用随机试验，该应用程序建议评估 ICU护士辅导员支持、示范和教授沟通的创新护理模式 使患者和家属能够获得与他们在疾病轨迹上的目标一致的护理的战略， 从重症监护室开始，一直到社区。辅导员将使用沟通技能、附件 1)患者及家属与临床医生沟通的自我效能感 和跨环境；2)患者和家人对与临床医生沟通的结果期望 改善他们的护理；3)通过技能培养来解决障碍，提高患者和家属的行为能力 有效沟通和调解冲突。协助者将与重病患者(n=376)和 他们的家人(n=564)从重症监护病房开始入住，并跟踪他们超过3个月的过程。 干预的有效性将以患者和家庭为中心的结果来衡量，包括 抑郁、焦虑和创伤后应激的症状，以及生活质量和目标评估- 在随机化后1、3和6个月进行协调性护理。主要结果将是家庭成员的 6个月以上抑郁症状负担情况。我们还将评估干预措施是否有所改善 在降低医疗成本的同时改善患者和家庭结果，从而实现医疗保健的价值。最后，我们 将使用定性方法来探索实施因素(干预、环境、个人、流程) 与改进的执行成果(可接受性、保真度、渗透率)相关，以提供传播信息 支持患者及其家属的这类干预措施。这个应用程序将解决关键知识 评估方法严谨的干预以改善重症患者预后时存在的差距 在护理的轨迹和护理的目标范围内的疾病及其家人。

PROJECT SUMMARY The impact of critical illness is increasing due to our aging population as well as advances in effectiveness and availability of critical care. Critically ill patients and their families suffer a high burden of symptoms of depression, anxiety, and post-traumatic stress due, in part, to fragmented medical care that is often poorly aligned with their goals. Fragmented care includes numerous transitions for patients and families across clinicians and across settings, starting in the ICU and extending to acute care, skilled nursing facilities, or home. As illness progresses, patients and families struggle to navigate the spectrum of goals of care, to match their values and goals with treatments, to communicate their goals to their clinicians, and to make difficult medical decisions without letting unmet emotional needs interfere. Poor communication exacerbated by these transitions compounds an already stressful experience, causing distress to patients and their families. Taken together, these issues lead to ineffective communication during and after the ICU which can often result in high intensity “default” care that may be unwanted. Using a randomized trial, this application proposes to evaluate an innovative model of care in which ICU nurse facilitators support, model, and teach communication strategies that enable patients and families to secure care in line with their goals over an illness trajectory, beginning in the ICU and continuing into the community. Facilitators will use communication skills, attachment theory, and mediation to improve: 1) patients' and families' self-efficacy to communicate with clinicians within and across settings; 2) patients' and families' outcome expectation that communication with clinicians can improve their care; and 3) patients' and families' behavioral capability through skill building to resolve barriers to effective communication and mediate conflict. Facilitators will work with seriously ill patients (n=376) and their families (n=564) beginning with a critical care unit stay and following them over the course of 3 months. The intervention's effectiveness will be measured with patient- and family-centered outcomes including symptoms of depression, anxiety, and post-traumatic stress, as well as quality of life and assessments of goal- concordant care, at 1, 3, and 6 months post-randomization. The primary outcome will be family members' burden of symptoms of depression over the 6 months. We will also evaluate whether the intervention improves the value of healthcare by reducing healthcare costs while improving patient and family outcomes. Finally, we will use qualitative methods to explore implementation factors (intervention, settings, individuals, processes) associated with improved implementation outcomes (acceptability, fidelity, penetration) to inform dissemination of this type of intervention to support patients and their families. This application will address key knowledge gaps while evaluating a methodologically rigorous intervention to improve outcomes for patients with serious illness and their families across the trajectory of care and the spectrum of goals of care.