Development and Evaluation of a Family-Partnered Care Pathway for Critically Ill Older Patients

Background: During ‘late life’, most Canadians will experience a critical illness, some will recover and some will die. The proliferation of life-sustaining technologies has resulted in important challenges at the intersection of aging and critical care. In direct response, we propose to develop, and evaluate a family-partnered care pathway for critically ill older patients (>70 years of age) admitted to the intensive care unit (ICU). Our proposal is directly aligned with the competition objectives to build research and knowledge translation capacity and develop novel multi-disciplinary and patient and family centered approaches to optimize the care and recovery of critically ill older patients across the continuum of care. 

Approach: Engaging patients and family members as partners in care and research increases the relevance of study findings, avoids waste in research, and enhances patient-centered care. For critically ill patients, frequently too ill to participate in care, this means partnering with patients’ families (partners, children, siblings, friends). Building on our experiences, background work and established partnerships, we will transform the care of older patients with life-threatening illness by developing the evidentiary basis for a family-partnered care pathway. A community of stakeholders jointly developed the program organized across three interconnected themes of work: 

1. Develop a family-partnered care pathway for critically ill older patients admitted to the ICU. 

2. Conduct novel research projects to inform strategies for partnering with patients’ families and address knowledge gaps within the pathway 

3. Perform a pilot implementation and evaluation of the family-partnered care pathway. 

Development: The ICU Liberation ABCDEF bundle (www.iculiberation.org) will serve as the initial building blocks for pathway development. We will establish a standardized evidence-informed approach to: (1) assess, prevent and manage pain; (2) conduct spontaneous awakening and breathing trials; (3) optimize analgesia and sedation; (4) assess, prevent and manage delirium; (5) encourage mobility and exercise; (6) engage and empower families of patients to participate in and advocate for their care; and (7) adapt all of the above to older critically ill patients.

Research: Based on stakeholder consultations we will focus on increasing the evidentiary basis for partnering with families in the care. Projects will include amongst others:

1) Clinical evaluation of a decision support tool to improve shared decision-making for family members – the IMPACT Trial.

2) Development of a patient/family handover tool to educate, engage and empower patients and families in facilitating continuity of care – the INFORM Study. 

3) Development of a tool to screen the family members of critically ill older patients for spiritual distress – the INPIRE Study. 

Implementation & Evaluation: After incorporating novel elements from our research projects, we will conduct a pilot implementation and evaluation of the pathway for older patients admitted to 4 medical-surgical ICUs in Alberta (our clinical laboratory). Implementation strategies will be developed using the theoretical domains framework, MRC framework for complex interventions and NHS sustainability model, will be multi-component and will target multiple stakeholders. The primary outcomes will include the feasibility and acceptability of implementing the pathway. 

Significance: We will reengineer the care of critically ill older patients by developing and evaluating a pathway that partners family members with healthcare providers to enhance care. The pathway will be an evidence informed applied innovation, designed to standardize and improve the care of critically ill older patients, customizable to individual hospital settings and scalable to different healthcare jurisdictions. The time is right to invest in evidence-informed solutions that provide critically ill older patients with better care and better health during ‘late-life’.

 

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