The Breakthrough Series team at Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, aimed to improve family satisfaction with patient care (in the ICU) and particularly with the management of pain, dyspnea, and sedation whenever life support is withdrawn and to achieve consistency in patient care. One of its most important activities was a study of variation in practice for ventilator cessation: Everyone involved had his or her own method.
In general, wide practice variation signals an opportunity for improvement. Usually, having as many ways to do something as there are people doing it is a sign that no one has really thought the process through and that no practice pattern will be implemented well by all.
The variation in practice survey asked nurses to respond to a given scenario; it was not a study of actual practice variation. Through responses to the scenario, however, the team measured the amount of sedation nurses recommended and their preferences for weaning and titration of FiO2 at the time life support was withdrawn. The Breakthrough Series team found that 65 percent of nurses wanted single-step reduction in FiO2, while 31 percent preferred a graded reduction. The amounts of morphine and lorazepam nurses recommended using varied widely. Based on the survey results, the team developed a sedation algorithm and a ventilator withdrawal checklist.
In addition to the practice variation study, the Breakthrough Series team tried several changes, which it measured by:
|Withdrawal of Life Support Checklist|
|Reprinted with permission of Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia|
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].