Open Access Research article

Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty

Irene J Higginson1*, Jonathan Koffman1, Philip Hopkins2, Wendy Prentice1, Rachel Burman1, Sara Leonard2, Caroline Rumble1, Jo Noble2, Odette Dampier2, William Bernal2, Sue Hall1, Myfanwy Morgan3 and Cathy Shipman1

Author Affiliations

1 Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, School of Medicine, Bessemer Road, Denmark Hill, London SE5 9PJ, UK

2 Intensive Care Unit, King’s College Hospital NHS Foundation Trust, London, UK

3 Division of Health and Social Care Research, King’s College London, London, UK

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BMC Medicine 2013, 11:213  doi:10.1186/1741-7015-11-213

Published: 1 October 2013

Abstract

Background

There are widespread concerns about communication and support for patients and families, especially when they face clinical uncertainty, a situation most marked in intensive care units (ICUs). Therefore, we aimed to develop and evaluate an interventional tool to improve communication and palliative care, using the ICU as an example of where this is difficult.

Methods

Our design was a phase I-II study following the Medical Research Council Guidance for the Development and Evaluation of Complex Interventions and the (Methods of Researching End-of-life Care (MORECare) statement. In two ICUs, with over 1900 admissions annually, phase I modeled a new intervention comprising implementation training and an assessment tool. We conducted a literature review, qualitative interviews, and focus groups with 40 staff and 13 family members. This resulted in the new tool, the Psychosocial Assessment and Communication Evaluation (PACE). Phase II evaluated the feasibility and effects of PACE, using observation, record audit, and surveys of staff and family members. Qualitative data were analyzed using the framework approach. The statistical tests used on quantitative data were t-tests (for normally distributed characteristics), the χ2 or Fisher’s exact test (for non-normally distributed characteristics) and the Mann–Whitney U-test (for experience assessments) to compare the characteristics and experience for cases with and without PACE recorded.

Results

PACE provides individualized assessments of all patients entering the ICU. It is completed within 24 to 48 hours of admission, and covers five aspects (key relationships, social details and needs, patient preferences, communication and information status, and other concerns), followed by recording of an ongoing communication evaluation. Implementation is supported by a training program with specialist palliative care. A post-implementation survey of 95 ICU staff found that 89% rated PACE assessment as very or generally useful. Of 213 family members, 165 (78%) responded to their survey, and two-thirds had PACE completed. Those for whom PACE was completed reported significantly higher satisfaction with symptom control, and the honesty and consistency of information from staff (Mann–Whitney U-test ranged from 616 to 1247, P-values ranged from 0.041 to 0.010) compared with those who did not.

Conclusions

PACE is a feasible interventional tool that has the potential to improve communication, information consistency, and family perceptions of symptom control.

Keywords:
Palliative care; Communication; Uncertainty; Critical care unit; Intensive therapy unit; End-of-life care; Intensive care unit; Psychosocial