• 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.
    • 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 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.