Preventing Readmissions Through Effective Partnerships—Communication and Palliative Care (PREP-CPC): A Multisite Intervention for Encouraging Goals of Care Conversations for Hospitalized Patients Facing Serious Illness

2019 ◽  
Vol 37 (8) ◽  
pp. 582-588
Author(s):  
Kelsey Gradwohl ◽  
Gordon J. Wood ◽  
Rebecca K. Clepp ◽  
Liza Rivnay ◽  
Eytan Szmuilowicz
Keyword(s):  
Palliative Care ◽  
Quality Improvement ◽  
Health Care Professionals ◽  
Essential Elements ◽  
Hospitalized Patients ◽  
Goals Of Care ◽  
Serious Illness ◽  
Risk Patients ◽  
Life Sustaining Treatment ◽  
Hospital Teams

Background: Despite evidence showing that goals of care (GOC) conversations increase the likelihood that patients facing a serious illness receive care that is concordant with their wishes, only a minority of at-risk patients receive the opportunity to engage in such conversations. Objective: The Preventing Readmissions through Effective Partnerships—Communication and Palliative Care (PREP-CPC) intervention was designed to increase the frequency of GOC conversations for hospitalized patients facing serious illness. Methods: The PREP-CPC employed a sequential, multicohort design using a yearlong mentored implementation approach to support nonpalliative care health-care professionals at participating hospitals to implement quality improvement projects focused on GOC conversations. Results: Over the 3-year study period, 134 clinicians from 29 hospital teams were trained to facilitate GOC conversations. After the kickoff conference, participants reported improvements in their confidence in facilitating GOC conversations. The hospital teams then instituted site-specific pilot interventions to promote GOC conversations, identifying essential elements required for ongoing improvement. Since projects varied by hospital, results did as well, but reported positive outcomes included increased GOC conversations, increased Practitioner Orders for Life-Sustaining Treatment form completion rates, new screening and documentation methods, and increased support from leadership. Conclusions: The PREP-CPC pilot successfully engaged a diverse set of hospitals to participate in quality improvement collaborative promoting primary palliative care and more frequent GOC conversations. This initiative revealed several lessons that should guide future interventions.

Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning

2018 ◽  
Vol 36 (2) ◽  
pp. 97-104 ◽  
Author(s):  
Signe Peterson Flieger ◽  
Erica Spatz ◽  
Emily J. Cherlin ◽  
Leslie A. Curry
Keyword(s):  
Palliative Care ◽  
Quality Improvement ◽  
End Of Life ◽  
Advance Care Planning ◽  
Secondary Analysis ◽  
Care Quality ◽  
Care Planning ◽  
Goals Of Care ◽  
Patient Goals ◽  
Advance Care

Background: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. Objective: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. Methods: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. Results: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. Conclusions: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.

scholarly journals Improving compliance to clinical practice guidelines with a multifaceted quality improvement program for the prevention of venous thromboembolic disease in nonsurgical patients

2020 ◽  
Vol 32 (5) ◽  
pp. 319-324
Author(s):  
Paula Ruiz-Talero ◽  
Daniela Cerón-Perdomo ◽  
Catalina Hernández-Flórez ◽  
Santiago Gutiérrez-gómez ◽  
Oscar Muñoz-Velandia
Keyword(s):  
Quality Improvement ◽  
Hospitalized Patients ◽  
Low Risk ◽  
Assessment Tools ◽  
Bleeding Complications ◽  
Improvement Program ◽  
Vte Prophylaxis ◽  
Before And After ◽  
Venous Thromboembolic ◽  
Risk Patients

Abstract Objective To evaluate the change in compliance to thromboprophylaxis guidelines before and after the implementation of a multifaceted patient safety program. Design Longitudinal before and after study. Setting Teaching hospital, Hospital Universitario San Ignacio, Bogotá (Colombia). Participants Adult nonsurgical hospitalized patients. Intervention A multifaceted program for the prevention of venous thromboembolic (VTE) disease among adult nonsurgical hospitalized patients. The strategies of the program included (i) update and communication of thromboprophylaxis guidelines, (ii) the implementation of risk-assessment tools in electronic medical records, (iii) nursing staff activities and (iv) education to health personnel and patients for maintenance of the program. Main Outcome Measure Appropriate use of thromboprophylaxis. Results 221 and 236 patients were evaluated in the pre- and postimplementation periods, respectively. Global appropriate thromboprophylaxis prescription went from 74.66 to 82.6% (P = 0.064). Adequate thromboprophylaxis in high-risk patients did not increase significantly (77.70 vs 80.62%, P = 0.528), but a significant reduction in inappropriate thromboprophylaxis formulation in low-risk patients was found, decreasing from 20.55 to 5.26% (P = 0.005). Conclusions Implementing a quality improvement multifaceted program improves the formulation of adequate thromboprophylaxis. Reducing the inappropriate prescription of VTE prophylaxis in patients at low risk of thrombosis can lead to a reduction in bleeding complications and a better use of economic and human resources.

scholarly journals Changing Culture Around Serious Illness: The VA Life-Sustaining Treatment Decisions Initiative

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 751-752
Author(s):  
Joan Carpenter ◽  
Robert Burke
Keyword(s):  
Treatment Decisions ◽  
Treatment Preferences ◽  
Veterans Health ◽  
Health Administration ◽  
Comfort Care ◽  
Goals Of Care ◽  
Serious Illness ◽  
Wide Range ◽  
Life Sustaining Treatment ◽  
Seriously Ill

Abstract Discussing and documenting goals of care and life-sustaining treatment decisions with seriously ill patients is a widely endorsed practice by healthcare and professional organizations. In 2018, The Veterans Health Administration (VA) initiated a new national policy to standardize such practices, the Life Sustaining Treatment Decisions Initiative (LSTDI), which included a coordinated set of evidence-based strategies and practice standards for conducting, documenting, and supporting high-quality goals of care conversations (GoCCs); staff training to enhance skills in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting patients’ goals and preferences; and monitoring and information technology tools to support implementation and improvement. In this symposium, we will describe the first 20 months of implementing the LSTDI across the VA, the largest integrated healthcare system in the US. The first paper will focus on the factors associated with documentation of a GoCC and treatment preferences. The second paper will present findings describing facilitators and barriers to implementing the LSTDI and identifying factors that promote high rates of LSTDI documentation. The third paper examines patient level outcomes associated with a documented goal of comfort care, specifically the odds of receipt of hospice/palliative care, hospitalization, or ICU admission. This symposium will provide attendees with important information regarding a wide range of individual and system strategies to enhance the care of seriously ill older adults by engaging patients with serious illness in GoCCs and documenting their preferences for treatment in durable, easily accessible notes and orders.

scholarly journals Toward improved goals-of-care documentation in advanced cancer: report on the development of a quality improvement initiative

2017 ◽  
Vol 24 (6) ◽  
pp. 383 ◽  
Author(s):  
I. Harle ◽  
S. Karim ◽  
W. Raskin ◽  
W.M. Hopman ◽  
C.M. Booth
Keyword(s):  
Breast Cancer ◽  
Palliative Care ◽  
Quality Improvement ◽  
Advance Care Planning ◽  
Quality Improvement Initiative ◽  
Care Planning ◽  
Documentation System ◽  
Goals Of Care ◽  
Care Plans ◽  
Advance Care

Background Documentation of advance care planning for patients with terminal cancer is known to be poor. Here, we describe a quality improvement initiative.Methods Patients receiving palliative chemotherapy for metastatic lung, pancreatic, colorectal, and breast cancer during 2010–2015 at the Cancer Centre of Southeastern Ontario were identified from electronic pharmacy records.Clinical notes were reviewed to identify documentation of care plans in the event of acute deterioration. After establishing baseline practice, we sought to improve documentation of goals of care and referral rates to palliative care. Using quality improvement methodology, we developed a guideline, a standardized documentation system, and a process to facilitate early referral to palliative care.Results During 2010–2015, 456 patients were included in the baseline cohort: 63% with lung cancer, 16% with colorectal cancer, 13% with pancreatic cancer, and 7% with breast cancer. Care goals in the event of an acute illness were documented by medical oncologists in 6% of cases (26 of 456). Of the 456 patients, 47% (n = 214) were seen by palliative care; care goals were documented by palliative care in 48% of the patients seen (103 of 214). With those baseline data in hand, a local practice guideline and process was developed to facilitate the identification of patients for whom advance care planning and early palliative care referral should be considered. A system was also established so that goals-of-care documentation will be supported with a written framework and broadly accessible in the electronic medical record.Conclusions Low rates of documentation of advance care planning and referral to palliative care persist and have stimulated a local quality improvement initiative.

scholarly journals The Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19

2020 ◽  
Vol 34 (9) ◽  
pp. 1228-1234 ◽  
Author(s):  
Michele Fiorentino ◽  
Sri Ram Pentakota ◽  
Anne C Mosenthal ◽  
Nina E Glass
Keyword(s):  
Palliative Care ◽  
Scale Score ◽  
Public Hospital ◽  
The Elderly ◽  
Hospitalized Patients ◽  
Risk Patients ◽  
Observational Cohort ◽  
Retrospective Observational Cohort Study ◽  
Performance Scale ◽  
Overall Mortality

Background: Coronavirus disease 2019 (COVID-19) has a substantial mortality risk with increased rates in the elderly. We hypothesized that age is not sufficient, and that frailty measured by preadmission Palliative Performance Scale would be a predictor of outcomes. Improved ability to identify high-risk patients will improve clinicians’ ability to provide appropriate palliative care, including engaging in shared decision-making about life-sustaining therapies. Aim: To evaluate whether preadmission Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19. Design: Retrospective observational cohort study of patients admitted with COVID-19. Palliative Performance Scale was calculated from the chart. Using logistic regression, Palliative Performance Scale was assessed as a predictor of mortality controlling for demographics, comorbidities, palliative care measures and socioeconomic status. Setting/participants: Patients older than 18 years of age admitted with COVID-19 to a single urban public hospital in New Jersey, USA. Results: Of 443 admitted patients, we determined the Palliative Performance Scale score for 374. Overall mortality was 31% and 81% in intubated patients. In all, 36% (134) of patients had a low Palliative Performance Scale score. Compared with patients with a high score, patients with a low score were more likely to die, have do not intubate orders and be discharged to a facility. Palliative Performance Scale independently predicts mortality (odds ratio 2.89; 95% confidence interval 1.42–5.85). Conclusions: Preadmission Palliative Performance Scale independently predicts mortality in patients hospitalized with COVID-19. Improved predictors of mortality can help clinicians caring for patients with COVID-19 to discuss prognosis and provide appropriate palliative care including decisions about life-sustaining therapy.

scholarly journals F05-A Improving Communication about Goals of Care with Hospitalized Patients Who Have Serious Illness: A Canadian, Multi-Centre Program of Research

2016 ◽  
Vol 52 (6) ◽  
pp. e49-e50
Author(s):  
John You ◽  
Jessica Simon ◽  
Dev Jayaraman ◽  
Nishan Sharma ◽  
Alannah Smrke ◽  
...  
Keyword(s):  
Hospitalized Patients ◽  
Goals Of Care ◽  
Serious Illness

Considerations for Prognosis, Goals of Care, and Specialty Palliative Care for Hospitalized Patients With Acute‐on‐Chronic Liver Failure

Hepatology ◽  
2020 ◽  
Vol 72 (3) ◽  
pp. 1109-1116 ◽  
Author(s):  
Ruben Hernaez ◽  
Arpan Patel ◽  
Leanne K. Jackson ◽  
Ursula K. Braun ◽  
Anne M. Walling ◽  
...  
Keyword(s):  
Palliative Care ◽  
Liver Failure ◽  
Hospitalized Patients ◽  
Chronic Liver ◽  
Chronic Liver Failure ◽  
Goals Of Care

Much Ado About Fried Chicken: Abetting Aspiration or Respecting Autonomy?

2019 ◽  
Vol 28 (3) ◽  
pp. 1356-1362
Author(s):  
Laurence Tan Lean Chin ◽  
Yu Jun Lim ◽  
Wan Ling Choo
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Multidisciplinary Team ◽  
Biopsychosocial Model ◽  
Family Members ◽  
Clinical Decisions ◽  
Goals Of Care ◽  
Complex Needs ◽  
Aspiration Risk ◽  
Patient Centric

Purpose Palliative care is a philosophy of care that encompasses holistic, patient-centric care involving patients and their family members and loved ones. Palliative care patients often have complex needs. A common challenge in managing patients near their end of life is the complexity of navigating clinical decisions and finding achievable and realistic goals of care that are in line with the values and wishes of patients. This often results in differing opinions and conflicts within the multidisciplinary team. Conclusion This article describes a tool derived from the biopsychosocial model and the 4-quadrant ethical model. The authors describe the use of this tool in managing a patient who wishes to have fried chicken despite aspiration risk and how this tool was used to encourage discussions and reduce conflict and distress within the multidisciplinary team.

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