Implementation of NECPAL and Chronic Liver Disease Screening Tools in Transplant Unit

Abstract

Problem & Purpose: Liver disease is often associated with high symptom burden and long hospital course, subsequently leading to decreased quality of life. For patients considered unsuitable for transplantation, the alternative treatment options are supportive management and palliative care (PC). The most significant barrier to early PC is the failure to identify patients who may benefit. Currently, transplant health care professionals have limited PC education, as well as understanding of primary PC and PC service flow. The purpose of this quality improvement (QI) project is to identify non-transplantable liver disease patients’ unidentified unmet PC needs, utilizing two validated tools (Necesidades Paliativas [Palliative. Needs]) (NECPAL) and Chronic Liver Disease Questionnaire (CLDQ), and integrate them within routine nursing care activities in the transplant unit. Method: This DNP project was integrated into a Quality Improvement (QI) project guided by the MAP-IT (Mobilize-Assess-Plan-Implement-Track) QI process model. Over a 12-week period, nurses and nurse practitioners (NPs) completed the tools for every non-transplantable liver disease patient. The NECPAL screening tool was used to identify patients in need of PC, and was completed by the NPs. The CLDQ tool was completed by the bedside nurse and was used to assist with identifying symptoms and quality of life. Results: A total of five nurse practitioners and ten staff nurses received education and training on the NECPAL and CLDQ tools from the DNP student project leader. Sixteen non-transplant liver disease patients ages ranging 29 to 68, median age 52, majority (69%) female participated. Percentage of patients who completed the CLDQ and reported symptoms of unmet needs an average of 80%. The most symptoms reported were abdominal bloating and discomfort, worry, and family impact. The percentage of both screening tools goal 100% average (50%, n=9) were completed by the nurses and NPs. The percentage of patients completing the NECPAL an average of 60%, indicated a need for integration of palliative care. The unintended barriers included change in medical director, nurses completing one of the two screening tools, and patients deeming nontransplantable on the transplant service admitted to other units. Conclusions: Implementation of NECPAL and CLDQ tools identified multiple unmet PC needs in non-transplantable liver disease patients. Nurses and nurse practitioners voiced confidence and ease in use of the tools identifying symptoms and clinical indicators for the identification of unmet palliative care needs and to promote incorporation into routine nursing care in liver disease patients who were deemed non-transplantable.