Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?"

BACKGROUND: Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. METHODS: This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. RESULTS: Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). CONCLUSION: Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.

The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study.

BACKGROUND: In the hospital setting, inadequate engagement between healthcare professionals and seriously ill patients and their families regarding end-of-life decisions is common. This problem may lead to medical orders for life-sustaining treatments that are inconsistent with patient preferences. The prevalence of this patient safety problem has not been previously described. METHODS: Using data from a multi-institutional audit, we quantified the mismatch between patients' and family members' expressed preferences for care and orders for life-sustaining treatments. We recruited seriously ill, elderly medical patients and/or their family members to participate in this audit. We considered it a medical error if a patient preferred not to be resuscitated and there were orders to undergo resuscitation (overtreatment), or if a patient preferred resuscitation (cardiopulmonary resuscitation, CPR) and there were orders not to be resuscitated (undertreatment). RESULTS: From 16 hospitals in Canada, 808 patients and 631 family members were included in this study. When comparing expressed preferences and documented orders for use of CPR, 37% of patients experienced a medical error. Very few patients (8, 2%) expressed a preference for CPR and had CPR withheld in their documented medical orders (Undertreatment). Of patients who preferred not to have CPR, 174 (35%) had orders to receive it (Overtreatment). There was considerable variability in overtreatment rates across sites (range: 14-82%). Patients who were frail were less likely to be overtreated; patients who did not have a participating family member were more likely to be overtreated. CONCLUSIONS: Medical errors related to the use of life-sustaining treatments are very common in internal medicine wards. Many patients are at risk of receiving inappropriate end-of-life care.

Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians.

IMPORTANCE: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers. OBJECTIVE: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process. DESIGN, SETTING, AND PARTICIPANTS: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces. MAIN OUTCOMES AND MEASURES: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach. CONCLUSIONS AND RELEVANCE: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.

Increasing patient safety event reporting in 2 intensive care units: a prospective interventional study.

PURPOSE: The aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action. MATERIALS AND METHODS: A prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required. RESULTS: During the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P < .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards. CONCLUSIONS: After the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.

Evaluation of unnecessary central venous catheters in critically ill patients: a prospective observational study.

INTRODUCTION: Central venous catheters are used commonly in critical care. Evidence-based practices to prevent catheter-related bloodstream infections have been widely promoted. One such practice includes assessing the need for central venous catheters on a daily basis and removing those found to be unnecessary. However, little is known about the adherence to this recommendation. Our objective was to examine the prevalence of unnecessary central venous catheters in our intensive care units. METHODS: We performed a prospective observational study during 28 consecutive days in two adult intensive care units at an academic medical centre. The principal investigator screened patients daily for the presence of non-tunnelled central venous catheters and assessed whether there was an indication for continued central catheterization. Patients under the age of 18 were excluded, as were those undergoing palliative care. Standardized indications were abstracted from the patient's chart, and the patient's primary nurse was interviewed if there was no indication for central venous catheterization in the chart. If there were multiple catheters or indications, the most appropriate indication was recorded. The end point was to establish whether a patient had an appropriate indication for central catheterization rather than to attribute an indication to each catheter. RESULTS: Eighty-one patients experienced a total of 614 days with at least one central venous catheter. Forty-one (50.6%; 95% confidence interval [CI], 39.9-61.3%) of these patients had no indication on at least one central venous catheter day. Of all patient days with central venous catheters, 170 (27.7%; 95% CI, 19.5-37.9%) had no apparent indication. The proportion of patient days with central venous catheters without indication was 4.6 (95% CI, 2.6-8.2; P < 0.001) times greater in the level-2 unit than in the level-3 unit. DISCUSSION: In two academic adult intensive care units, a large proportion of patients with central venous catheters lacked an ongoing indication for their use during a significant period of time. Many patients were exposed to complications from unneeded catheters. Our findings will serve as a baseline for determining the success of quality-improvement interventions to prevent complications such as catheter-related infections in our program.

Brief history of patient safety culture and science.

The science of safety is well established in such disciplines as the automotive and aviation industry. In this brief history of safety science as it pertains to patient care, we review remote and recent publications that have guided the maturation of this field that has particular relevance to the complex structure of systems, personnel, and therapies involved in caring for the critically ill.