Table 2

 Specifications and definitions for selected measures in palliative care bundle*

*The complete Care and Communication Bundle, including the measurement guide containing specifications and definitions for all measures and a data collection tool, is available through VHA Inc, 220 E. Las Colinas Blvd, Irving, TX, USA.
General population inclusion: Only patients with an ICU length of stay ⩾5 days are included for each indicator. The day of ICU admission is considered day 0 and the following calendar day beginning at 00:01 hours is considered day 1. Each indicator will require a retrospective review of the patient’s medical record from the date and time of ICU admission. Therefore, meticulous documentation from the time of ICU admission is crucial to the successful implementation and ongoing assessment of these indicators.
General definition: ICU family refers either to at least one member of the patient’s family who has authority to make medical decisions for the patient or to another authorized surrogate decision maker.
Quality indicator #2: Advance Directive Status
Documentation of advance directive status on or before day 1 of the ICU admission
Definition of indicator: percentage of patients with documentation of advance directive status on or before day 1 of the ICU admission
Specifications
Numerator: Number of patients who have documentation of advance directive status on or before day 1 of the ICU admission.
• Documentation must be in the medical record and include either of the following: (1) documentation that the patient has an advance directive, or (2) documentation that a full investigation failed to identify an advance directive.
• Definition of advance directive: Written or oral instructions from the patient specifying the type of medical treatment that is desired if the patient becomes incapacitated. Advance directives include living will, durable power of attorney (note state-specific status), or any document that state law recognizes as an “advance directive”.
Denominator: Total number of patients with an ICU length of stay ⩾5 days.
Exclusions:
• Patients discharged (or transferred out of the ICU) on or before day 1 of ICU admission
• Patients expired on or before day 1 of ICU admission
Quality Indicator #4: Family Information Leaflet
Documentation of information leaflet distribution to ICU family members on or before Day One of ICU admission
Definition of indicator: percentage of patients whose family was given a written information leaflet (personally by an ICU team member) on or before day 1 of ICU admission and action was documented in the medical record.
Specifications
Numerator: Number of patients whose family was personally given a written information leaflet by an ICU team member on or before day 1 of ICU admission.
• Documentation of this action must be in the medical record
• Definition of information leaflet: Written materials containing at a minimum the following information: general information about the ICU and hospital including visitation guidelines, services provided such as financial consultation services and bereavement programs, and logistical information (nearby hotels, banks, restaurants, directions, etc); names of ICU caregivers (physicians and nurses); diagram of a typical ICU room with the names of all devices; glossary of terms commonly used in the ICU.
Denominator: Total number of patients with an ICU length of stay ⩾5 days.
Exclusions:
• Patients discharged (or transferred out of the ICU) on or before day 1 of ICU admission
• Patients expired on or before day 1 of ICU admission
• Patients who were not visited by a family member on or before day 1 of ICU admission
Quality Indicator #9: Interdisciplinary Family Meeting
Adequate clinician-patient/family communication on or before day 5 of ICU admission
Definition of indicator: Percentage of patients with documentation that an interdisciplinary family meeting was conducted on or before day 5 of ICU admission.
Specifications
Numerator: Number of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before day 5 of ICU admission.
• Documentation must be in the medical record
• Definition of interdisciplinary: Involved at least the attending physician (either primary attending or ICU attending), a member of another discipline (nurse, social worker, or pastoral care representative), and the patient (and/or family). Whenever possible, a nurse should be involved along with the physician.
• Definition of family meeting: A discussion addressing each of the following topics is recommended: (1) the patient’s condition (diagnosis and prognosis), (2) goals of treatment; (3) the patient’s and family’s needs and preferences (could address preparation of an advance directive, if not already done), (4) the patient’s and family’s understanding of the patient’s condition and goals of treatment at the conclusion of the meeting.
For patients who were not visited by a family member on or before day 5 of the ICU admission, the indicator applies only to an interdisciplinary meeting with the patient. For patients who lack capacity to participate in such a meeting, the indicator applies only to an interdisciplinary meeting with the family. If the patient lacks the capacity to participate in such a meeting, the family meeting takes place in a space other than at the bedside.
Denominator: Total number of patients with an ICU length of stay ⩾5 days.
Exclusions:
• Patients who were not visited by a family member on or before day 5 of ICU admission AND who lack capacity to participate in such a meeting
• Patients who refused or whose family refused to participate in a family meeting