A novel questionnaire to measure staff perception of end-of-life decision making in the intensive care unit--development and psychometric testing.

PURPOSE: The aim of this study was to create a questionnaire that measures barriers and facilitators of effective end-of-life (EOL) decision making and communication and associated stress as perceived by intensive care unit (ICU) staff. METHODS: The questionnaire was developed on the basis of a theoretical framework and discussion with ICU staff. It was pretested among 15 ICU nurses and physicians. A field test was conducted in 4 interdisciplinary ICUs of one university hospital Descriptive item analysis, exploratory factor analysis, and reliability and validity analysis were performed. RESULTS: Overall, 174 of 284 ICU staff participated in the field test (61% response). Factor analysis indicated a 7-factor solution: (1) collaboration in the EOL context, (2) role clarity in the EOL context, (3) work-related interruptions of communication with families, (4) emotional support, (5) stress by involvement in EOL decision making and communication with families, (6) stress by work overload, and (7) taking initiative toward EOL decision making. Internal consistency of the scales was acceptable (range, 0.69-0.85). Construct validity was shown by relationships of the scales to several constructs, for example, satisfaction with EOL decision making and emotional exhaustion. Overall, 26 of 31 expected relationships achieved significance. CONCLUSIONS: The new questionnaire meets psychometric criteria of reliability and validity and promises to be a useful quality measure of EOL decision making in the ICU.

Family satisfaction in the intensive care unit: a quantitative and qualitative analysis.

PURPOSE: To assess family satisfaction in the intensive care unit (ICU) and areas for improvement using quantitative and qualitative analyses. METHODS: Prospective cohort study performed in four (mixed surgical, neurological, and cardiological) intensive care units of a university hospital in Germany, using a translated and validated version of the Family Satisfaction in the ICU (FS-ICU) questionnaire, with questions answerable on a rating scale and three open-ended questions about strengths and weaknesses. Quantitative analysis was performed to identify items with low performance and high importance. For qualitative analysis, comments were coded and analyzed to identify important themes. Patient-related data were obtained from an electronic patient data management system. RESULTS: Participants were 215 family members visiting adult intensive care patients with length of stay over 48 h. Response rate was 28 %. Respondents were highly satisfied; summary scores were 78.3 ± 14.3 [mean ± standard deviation (SD)] on a scale of 0 (poor) to 100 (excellent). Regression analysis failed to identify association with patient- or family-related factors. The following themes for possible improvement emerged from both quantitative and qualitative analyses: patient agitation-consistency, clarity and completeness of information-emotional support-respect and compassion towards families. Families were also dissatisfied with the waiting room, ICU atmosphere, and amenities for visiting relatives. CONCLUSIONS: Families report high satisfaction with intensive care. Nevertheless, there is room for improvement, in particular regarding how ICU staff communicate with families and provide emotional support.

Systematic analysis of hydroxyethyl starch (HES) reviews: proliferation of low-quality reviews overwhelms the results of well-performed meta-analyses.

PURPOSE: Hydroxyethyl starch (HES) is a synthetic colloid used widely for resuscitation despite the availability of safer, less costly fluids. Numerous HES reviews have been published that may have influenced clinicians' practice. We have therefore examined the relationship between the methodological quality of published HES reviews, authors' potential conflicts of interest (pCOI) and the recommendations made. METHODS: Systematic analysis of reviews on HES use. RESULTS: Between 1975 and 2010, 165 reviews were published containing recommendations for or against HES use. From the 1990s onwards, favorable reviews increased from two to eight per year and HES's share of the artificial colloid market tripled from 20 to 60 %. Only 7 % (12/165) of these reviews of HES use contained meta-analyses; these 7 % had higher Overview Quality Assessment Questionnaire (OQAQ) scores [median (range) 6.5 (3-7)] than reviews without meta-analysis [2 (1-4); p < 0.001]. The rates of recommending against HES use are 83 % (10/12) in meta-analyses and 20 % (31/153) in reviews without meta-analysis (p < 0.0001). Fourteen authors published the majority (70/124) of positive reviews, and ten of these 14 had or have since developed a pCOI with various manufacturers of HES. CONCLUSIONS: Low-quality HES reviews reached different conclusions than high-quality meta-analyses from independent entities, such as Cochrane Reviews. The majority of these low-quality positive HES reviews were written by a small group of authors, most of whom had or have since established ties to industry. The proliferation of positive HES reviews has been associated with increased utilization of an expensive therapy despite the lack of evidence for meaningful clinical benefit and increased risks. Clinicians need to be more informed that marketing efforts are potentially influencing scientific literature.