Time-limited trials may decrease the length of stay of critically ill patients in the intensive care unit

1. Time-limited trial interventions in patients with poor prognoses decreased length of stay in ICU, reduced minimally beneficial treatments, and increased communication between clinicians and patients/ patients’ families.

2. Time-limited trials did not alter hospital mortality rates of critically ill patients.

Evidence Rating Level: 2 (Good)

Study Rundown: There is growing evidence to suggest that many critically ill patients in the intensive care unit (ICU) may receive treatment of minimal benefit during their stay. Time-limited trials (TLTs) are discussions between clinicians and patients or their surrogate decision-makers; they include examining patients’ preferences, making decisions to use certain medical therapies, and scheduling follow-up meetings to assess progress and next steps. This prospective quality improvement study investigated whether the utilization of TLTs with critically ill patients led to a reduction in intensity and duration of ICU interventions with minimal benefit. Family meetings, which included discussions of patients’ values, prognosis, risk/benefit of procedures, and identifying clinical markers of improvement, were significantly increased postintervention. Median ICU length of stay was significantly decreased in the postintervention period compared to preintervention and many ICU treatments were also used less frequently postintervention. Nevertheless, hospital mortality was similar between the two time periods. Overall, TLTs decreased unnecessary treatments in the ICU and time spent there without affecting mortality in patients suffering from advanced medical illness and poor prognoses. A limitation of this study was that the definition of a patient deemed to have a low likelihood of benefit from ICU procedures was subjective and varied between hospitals; nonetheless, this was believed to be the most practical and realistic approach.

Click to read the study in JAMA 

Click to read an accompanying editorial in JAMA

Relevant Reading: Effect of a quality-improvement intervention on end-of-life care in the intensive care unit

In-Depth [prospective cohort]: Between June 1, 2017 and December 31, 2019, all patients in ICUs from three hospitals in the Los Angeles County Department of Health Services were eligible for this study. 113 patients (725 eligible) preintervention and 96 patients (704 eligible) postintervention were included if they were critically ill and would likely not receive benefit from ICU treatments (category 3 in Society of Critical Care Medicine guidelines). Quality improvement interventions were 4-6 weeks in length and taught physicians how to initiate time-limited trials (TLTs); data were collected for four months preintervention and postintervention. The primary outcomes were the changes in the quality of family meetings and ICU length of stay after TLT interventions. Formal family meetings were significantly increased (68/113 [95.8%] patients vs. 92/96 [60.2%] patients; p<0.001), and median ICU days to the first family meeting was significantly reduced (1.0 days [IQR: 1.0-2.0] vs. 5.5 days [IQR: 2.0-9.0]; p<0.001) postintervention compared to preintervention. Median ICU length of stay significantly reduced (p= 0.02) from 8.7 days (IQR: 5.7-18.3) to 7.4 days (IQR: 5.2-11.5), and various ICU procedures were used less often postintervention. Hospital mortality demonstrated no significant difference postintervention (58.3%) compared to preintervention (58.4%) (p= 0.99).

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