• Decreasing Time to Palliative Care Consultation in an Intensive Care Unit

      Leath, Marcella E.; Van de Castle, Barbara (2021-05)
      Problem: A significant problem for patients in the intensive care unit (ICU) is that palliative care is not involved early in the patient stay. By implementing a screening tool to identify palliative care needs within 72 hours of admission, patient’s palliative care needs can be addressed early in ICU stay. Purpose: The purpose of this quality improvement (QI) project is to implement and evaluate a screening tool to identify patients with palliative care needs in a community ICU to decrease time to referral to palliative care. Methods: The Palliative Care Screening Tool was developed using verified and validated criteria and implemented into practice in a community ICU over a twelve-week period from September 2020 to December 2020. A distribution and collection center for the completed screening tools was created and education occurred for the nurse practitioners on the implementation team and ICU nursing staff regarding the project. Electronic medical record chart audits were completed weekly; data was collected from completed screening tools as well as electronic chart reviews. Screening tool users were surveyed at the completion of this QI project. Results: A total of 193 patients were admitted to the ICU during the implementation phase. Of the patients admitted with a length of stay greater than 72 hours (n=115), 89.6% (n=103) were screened with the tool, and 10.4% (n=12) were not screened. Fifty-five percent of patients screened (n=57) were identified as having palliative care needs. Of those with needs, 50.9% (n=29) were referred to palliative care. Over a 12-week period, there was a decrease in time from ICU admission to referral to palliative care by 68.9%, from 3.95 days at baseline to 2.72 days with the use of a screening tool. Conclusion: The use of a screening tool to assess patient needs for palliative care early in the ICU admission can standardize the process for patient referral and ensure early referral to palliative care.
    • The Implementation of a Nurse-Driven Palliative Care Trigger Tool

      Spurry, Sawyer E.; Alessandrini, Erica (2022-05)
      Problem: Palliative care (PC) providers at an academic medical center stated medical intensive care unit (MICU) patients are often referred late in their hospital stay, with an average PC consult rate of 65% over the last 6 months. This falls below the hospital quality performance metric of 80% of eligible patients receiving a PC consult within 48 hours of admission. Purpose: The purpose of this quality improvement (QI) project is to increase PC utilization in the MICU by implementing a nurse-driven Palliative Care Trigger Tool to prompt referral for specialty PC consults. Methods: MICU nurses and providers received education regarding underused PC services and the evidence supporting the use of nurse-driven PC trigger tools to increase PC referral. A MICU specific criteria of PC triggers was formulated by the QI implementation team based upon the best available evidence. Nursing staff were asked to screen patients daily using the PC Trigger Tool and present findings during bedside rounds. MICU providers were asked to consult PC for patients meeting trigger criteria. Rates of eligible patients and PC consults were collected via electronic medical record data reports, de-identified, and analyzed for trends via run charts. Results: Over 150 MICU nurses were educated on the PC trigger QI initiative along with 10 MICU providers, and 4 PC providers. During the 15-week project period, more than 220 patients were admitted to the MICU and an average of 91% were screened for PC triggers within 48 hours of admission. Approximately 63% of screened patients were identified as having positive PC triggers and 90% of these received a PC consult. Following implementation, the mean time for admission to consult decreased from 22.39 to 7.28 days; mean PC consultation rate within 48 hours of admission increased from 65% to 90%. Conclusion: PC consultation rates increased through the use of an evidence-based PC trigger tool, exceeding the hospital’s quality benchmark for PC referrals. Provider preference greatly impacted consultation rates and emphasizes the need to change knowledge and perspectives related to PC.
    • Implementation of NECPAL and Chronic Liver Disease Screening Tools in Transplant Unit

      Gaines, Susanne; Satyshur, Rosemarie D. (2020-05)
      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.
    • Palliative Care Consultation in Pediatric Stem Cell Transplant

      Lafond, Deborah A. (2012)
      Purpose: The purpose of this project was to investigate the feasibility of a proposed practice change to integrate early palliative care consultation that would promote transcendent comfort in children and adolescents with advanced or high-risk cancers or other non-malignant diseases undergoing hematopoietic stem cell transplantation (HSCT). Background and Significance: Hematopoietic stem cell transplantation (HSCT), a modality used to treat a variety of advanced cancers and other serious non-malignant diseases in children and adolescents, may have significant symptom distress. The goal of enhanced comfort is the utmost concern of children and adolescents undergoing HSCT and their families (Mayer, Tighouart, Terrin, Stewart, Peterson, Jeruss, & Parsons, 2009). Multiple pediatric professional organizations have set a standard to promote relief of symptom distress and promote quality of life and enhanced comfort (AAP, 2000; Freibert & Huff, 2009). Clinical research on the effectiveness and benefits of interventions to relieve symptom distress is paramount to expanding the evidence base of pediatric palliative care and the science of HSCT in prioritizing comfort. Methods: A single-site, feasibility study was used to examine the primary aims of (1) willingness of patients and families of a vulnerable population to receive the palliative care intervention, (2) willingness of the health care team to refer families, (3) resource allocation, and (4) family and provider satisfaction. Secondary aims included evaluation and concordance of comfort from parent and child perspectives. A convenience sample of 12 families (child undergoing HSCT and their parent) were enrolled on the study. Data collection included referral and enrollment patterns, and time and resources required for palliative care interventions. Additional data included child self-report and parental reports of their child's comfort at baseline, T1 (~14 days following HSCT), and T2 (~ 30 days following HSCT). Family and provider satisfaction were measured at the end of enrollment. Findings: 100% of eligible families were referred and consented to participate (N = 12). Each family received a minimum of one visit per week, however, an average of 3 visits per week were made. Visits ranged from 15 minutes to 2 hours, depending upon individual circumstances. The top interventions requested or required, in addition to standard HSCT care interventions, included supportive care counseling, massage therapy, aromatherapy, play therapy, acupuncture, acupressure, and other integrative medicine techniques. Children and adolescents consistently rated comfort as "very good", however, parents tended to rate their child's level of comfort lower. There were 3 deaths of participants during the study. Families and providers expressed high satisfaction with this approach to care. Conclusion: This intervention is a novel approach to providing early palliative care services with curative intent therapy. Early palliative care intervention was well received by providers and families of children undergoing HSCT. Parents rate their child's level of comfort somewhat lower than child self-report, however, distress of parents impacts the entire family system thus interventions aimed at improving the child's comfort may improve parental distress and support better family functioning. Early palliative care services helped palliative care practitioners better meet the needs of the families who experienced the death of their child. Because of this additional support, end of life was peaceful and coordinated. This approach to care will be integrated as a standard of care for HSCT at the study site.
    • Palliative Care Screening Implementation within the Medical Intensive Care Unit

      Troiani, Nicole; Satyshur, Rosemarie D. (2020-05)
      Problem & Purpose: There are over 5 million intensive care unit (ICU) admissions each year with a mortality rate up to 29% and $108 billion dollar cost of care (SCCM, 2018). Palliative care is an essential part of comprehensive care in the ICU, however, it is underutilized in the medical intensive care unit (MICU) of a large urban academic medical center despite the unit reporting the highest mortality rate in the hospital. The purpose of the quality improvement (QI) project is to increase palliative care utilization in the MICU through the integration of nurse driven screening criteria that, when met, suggests the need for a palliative care consult. Methods: The QI project took place over a 13-week period. All patients admitted to the MICU during the implementation phase received a validated palliative care screening completed by the bedside nurse (George et al., 2015). Positive screenings were then discussed and plan of care documented by the interdisciplinary team on daily rounds. Completed screening tools were reviewed every other day to determine screening completion, documentation of family meeting notes, palliative care consults placed, and reason for not consulting palliative care despite positive screening. Results: Compliance with palliative care screening ranged from 79-100% (average 92%). Percentage of positive screenings ranged 18-50% (average 29%). Percentage of positive screenings with a consult ranged 0-60% (average 20%). The most common reason for lack of palliative consult was a planned “family meeting” (42%), however, less than 50% of these patients had a family meeting note documented. Comparing data 8 months pre-implementation to 13 weeks of implementation: average length of stay (LOS) for patients with palliative care consult decreased from 68.61 to 11.75 days; admission to consult mean decreased from 22.69 to 9.16 days; Palliative care consultation rate decreased from 13.86% to 10.39%. Conclusion: Despite utilization of a validated screening tool, palliative care consultation rates decreased. Physician preference greatly impacted consultation rates and highlighted the need to change knowledge and opinions related to palliative care. Finally, results support that screening leads to earlier palliative care consult, decreased LOS, and likely associated cost.
    • Palliative Care Screening Tool Implementation in a Medical Intensive Care Unit

      Keadle, Emily C.; Hood, Catherine (2022-05)
      Problem: Palliative care is underutilized and not prioritized in a large metropolitan teaching hospital medical intensive care unit. On average, it takes 6.7 days for a patient to receive a palliative care consultation but can take as long as 49 days. Only 15.74% of patients admitted to the medical intensive care unit will receive a palliative care consult. There is not a consistent method by which palliative care recommendations are made or how patients in need of palliative care services are identified in this medical intensive care unit which contributes to a delay in, or lack of, palliative care. Purpose: The purpose of this quality improvement project is to implement and evaluate the effectiveness of a palliative care screening tool in a medical intensive care unit. Methods: A validated palliative care screening tool was added to the admission documentation in a 19-bed medical intensive care unit to be completed by the nursing staff on each admission. When completed, a total score of 4 or greater creates a task for the nurse via the electronic health record to notify the provider of unmet palliative care needs. Results: Nurses utilized the screening tool 74% of the time. The number of palliative care consults increased from 15.74% to 23.75%. Time from admission to palliative care consult decreased from 6.68 days to 6.25 days. Conclusions: The implementation of a palliative care screening tool was associated with decreased time to palliative care consult and an increase in number of palliative care consults in a medical intensive care unit.
    • Palliative Needs Screening in a Surgical Intensive Care Unit

      Lu, Lauren B.; Wilson, Tracey L. (2022-05)
      Problem: A surgical intensive care unit (SICU) at a large academic medical center did not have a process to identify patients with palliative needs. Published evidence demonstrates that screening criteria can help identify those with unmet palliative care needs and increase the rate of appropriate consultations. Purpose: To implement a screening process for identification of unmet palliative care needs among Acute Care Emergency Surgery (ACES) patients in the SICU. Methods: Once the process was developed using available evidence and a validated screening tool, staff were educated on the protocol. The goal was for all admitted ACES patients to receive palliative needs screening by the bedside nurse within 48 hours of admission. For positively screened patients, a palliative care consult would be placed by the SICU provider following approval from the ACES team. ACES patients were re-screened weekly while they remained in the SICU. Results: There were 34 patients admitted during the project period. The total percentage of patients that received screening within 48 hours of admission was 70.6% (24 out of 34 admitted patients). The total percentage of eligible patients that received weekly re-screening was 82% (23 out of 28 eligible patients). The total percentage of positively screened patients that received consultation was 53.8% (7 consults out of 13 positively screened patients). The overall palliative consult rate was 20.6% (7 consults out of 34 total patients). This is greater than the anecdotal baseline of 10%. Conclusions: Barriers were met during the project that affected screening compliance, but the screening tool identified many patients with palliative care needs. While SICU providers were receptive to hearing positive screening results, consultation was deferred at times. But the project may have prompted earlier discussions regarding palliative involvement. With modifications, future initiatives to screen for unmet palliative needs could be extended to other surgical patients in the SICU.
    • Palliative Needs Screening Tool In A Neurocritical Care Unit

      Kruse, Kristina; Costa, Linda (2019-05)
      Background: A problem for seriously ill-hospitalized patients is that palliative care conversations are not considered early in hospital stays. Early effective provider-patient palliative care discussions are associated with decreased length of stay, earlier hospice referrals, and decreased use of nonbeneficial life sustaining therapies. Despite the prevalence of pilot studies, few studies focus on patients with neurocritical illness. Prediction tools used in the neurocritical care unit are specific to a diagnosis and help identify illness outcomes and mortality risk in patients. When compared to non-neuro units, neuro-patients had similar palliative care triggers. Local Problem: At a large academic medical center palliative care screening is not completed early in the patient’s admission to a neurocritical care unit using a validated palliative needs screening tool. Interventions: This quality-improvement project assessed if the palliative needs screening tool can be used to identify unmet palliative needs in a neurocritical care unit. A five-criteria screening tool has been validated in multiple intensive care units in patients with similar palliative care needs to neurocritical care patients. A palliative needs screening tool can be used to identify patients with unmet palliative care needs early in a hospital stay. All patients admitted to the 10-bed east side of the neurocritical care unit will be screened within 48 hours of admission. Results: The sample size was 62 patients over the six-week implementation period. Few patients were identified with unmet palliative care needs using the palliative needs screening tool. Data indicates that this screening tool does not identify patients within a neuro-population that would benefit from a palliative care consultation. Advance practice providers completed a palliative needs questionnaire on admitted patients to evaluate for anticipated palliative care needs for this population. Advance practice providers identified that in 69% of cases goals of care were not identified and 54% of the time there were specific social and support needs that the families or patients needed. Distressing physical and/or psychological symptoms were an identified need in 57% of patients screened with the anticipated palliative need questionnaire. Conclusions: The palliative needs screening tool does not identify neurocritical patients who are at risk of unmet palliative care needs. It is unclear if all neuro-intensive care units from previous studies were also patients admitted to trauma-neurocritical care unit similar to the unit used in this project. Despite a lack of positive screening with the palliative needs screening tool, providers were thinking about palliative care needs their patients may have, though no screening or data collection was done for this specifically. This project highlights the need for a specific palliative needs screening tool for the neuro-critical population. A screening tool specific to neurocritical patients will need to be developed that focuses on common palliative needs in a neuro-critical intensive care unit.
    • Treating Chronic Pain: Therapeutic Music in Adult Palliative Care

      Goode, Julie P.; Rowe, Gina C. (2020-05)
      Problem and Purpose: Palliative care aims to provide maximum comfort to individuals suffering from life threatening illness. The chronic pain often seen in this population is multifocal, with physical, emotional, and psychosocial symptoms. Pain management in palliative care is often challenging due to medication side effects and frequently affects those with primary cancers as well as non-malignant terminal illness. Therapeutic music (TM) has been shown to reduce chronic pain in palliative care patients. Multiple studies and systematic reviews have demonstrated use of TM leads to significant reductions in chronic pain. The purpose of this doctoral project is to improve the quality of pain management for palliative care residents suffering from chronic pain by adding TM to the list of activities available to residents on the palliative care unit. Methods: This quality improvement project introduced nonpharmacologic pain management by initiating a TM program in the adult palliative care unit of an 88-bed rehabilitation and nursing home. Nursing and ancillary staff attended a 20-minute education session on the benefits and efficacy of TM in the reduction of chronic pain, and four members of the Activities Department were trained to conduct the TM sessions. The palliative care nurse practitioner identified 10 residents most likely to benefit from TM and enrolled them in the program. TM sessions were held for 30-60 minutes twice a week for seven weeks. Residents’ chronic pain scores were assessed before and after each TM session. Residents were also asked to rank their enjoyment of the intervention on a 4-point Likert scale after each session. During week four of the program residents requested an extension of TM sessions and all future sessions were scheduled for 60 minutes. However, all post session assessments were completed after 30-minutes. Results: While resident participation increased from 33% to 69% over the seven-week implementation period, the average weekly participation rate was 50% (n=5). All residents reported a significant decrease in chronic pain levels (mean 44.3%; p<0.01) after TM sessions and resident enjoyment scores averaged 3.5 on a 4-point Likert scale. Conclusion: The implementation of a therapeutic music program improved the quality of pain management for palliative care residents suffering from chronic pain.
    • Use and assessment of a Palliative Care Nurse Practitioner on a Pancreatic Cancer Web Site

      Grant, Marian (2010)
      Patients with pancreatic cancer and their families struggle with physical and emotional issues. They could benefit from palliative care services, but may not have access to them. The Internet has become an important source of health information and a link between patients, families and health care providers. The purpose of this capstone project was to 1) determine if patients and their families would use a Web page where they could access a palliative care nurse practitioner (PCNP); 2) to identify the palliative care needs of the patients and families who accessed the PCNP; and 3) to determine the helpfulness of the Web page. Participants were recruited to the PCNP Web page from the Johns Hopkins Pancreatic Cancer Research Center’s (JHPCRC) Web site. A mixed method design was used to determine 1) the volume of participation with the PCNP Web page, 2) patient and family member needs, and 3) the usefulness of the Web page. Participants could post their questions to the public comments section of the PCNP Web or send the PCNP a private email. There also was a link to an online survey to gather demographic and evaluative information. The PCNP Web page was visited 650 times by 395 unique individuals over an 8-week period. Participants spent an average of 4 minutes and 4 seconds on the PCNP Web page. Half, 49%, came from a link posted on the discussion board of the JHPCRC Web site. Forty-eight participants posted a total of 55 questions or sent individual emails to the PCNP. The majority were from female family members of patients with pancreatic cancer. The majority of questions (66%) fell into one of the eight domains of palliative care. Of these, most of the questions, 42%, asked about physical aspects of pancreatic cancer with the next largest domain, 11%, being psychological concerns about the illness and the risks of developing it. The other third of questions had to do with non-palliative aspects of pancreatic cancer and its treatment. Twenty participants (5% of total visitors) completed the online survey. Most survey respondents were female, family members, middle-aged, white, and college-educated. Although statistical significance was not achieved, most survey respondents found the PCNP website helpful. It was considered easy to use and participants found information and support there and recommended that the PCNP page should be an on-going resource. Access to a PCNP is an important resource for patients with pancreatic cancer and their family members. The Internet can be used to offer information, support and advice to patients and families dealing with a life-threatening illness.