Purpose: Our goal was to create an interdisciplinary policy to provide the healthcare team with a framework for caring for patients who are not likely to benefit from ICU admission based on poor prognosis and the unlikely benefit of advanced therapies. This policy became known as the Limited Escalation Bed (LEB) Policy.
Description: We recognized that prior efforts did not involve all the key stakeholders. As a result a.) the criteria were applied inconsistently, b.) the entire health care team did not have a framework for thinking about such patients and thus delivered an inconsistent message to patients, families and each other and c.) low value care was administered to patients at the end of life.
We further recognized that a novel methodology would be mandatory to create a meaningful document. Instead of working independently, we designed a “Service 360”. The goal was to consider and articulate the viewpoint of limited escalation from every perspective. We convened a group of key stakeholders from intensive care, hospital medicine, nursing, palliative care and ethics. We transcribed the salient features of a recent and particularly difficult case involving a terminally ill patient who did not meet criteria for ICU level care because of prognosis. To specifically analyze a situation where expectations varied between stakeholders, this case was identified from a Patient Safety Indicator (PSI) report written by a house officer who felt abandoned when caring for this terminally ill patient. Using this exemplar, we performed a group, iterative exercise to delineate the perceptions and relevant concerns of each of the following perspectives: patient, outpatient oncologist, hospital administration, intensivist, family, nursing manager, ethicist, NY state, hospital oncologist, housestaff, consultants, hospitalist and bedside nurse. A table captured these perspectives to better appreciate when and where tensions occurred. We refined our work by applying other cases involving limited escalation. After fully understanding the perspectives of each of these groups did we start writing. The group met twice monthly to revise the language to ensure that the policy would be philosophical and practical. The policy fully spells out the purpose, definition, scope and collaborative responsibilities around limited escalation.
Conclusions: Service 360 was an effective and novel methodology for creating policy around the sensitive topic of limited escalation.