Data Type

Operational data (quantitative and qualitative) were used during the pilot phase of implementing a palliative care (PC) screening tool in an MICU to a) improve the screening process for identifying palliative care needs b) increase the number of PC consultations, and c) assess staff reactions gathered via interviews on the effectiveness of the tool

Short Description

After developing a palliative care screening tool (PCST), data gathered during the pilot implementation phase were used to develop an effective process for identifying palliative care needs and increasing referrals resulting in a more than four-fold increase in palliative care consultations over a one year period in the MICU

Goal

To increase the number of palliative care referrals by 50% within one year by implementing a palliative care screening process on all patients admitted to the MICU

Measures

• Patients screened with the PCST
• Patients screened with the PCST who have palliative care needs
• Palliative care team referrals resulting from the screening tool
• Primary screening criteria leading to palliative care referrals

Data Collected

As part of a three-year initiative to increase patient access to palliative care at St. John Hospital, in Detroit, MI, a palliative care screening tool (PCST) was developed and piloted in the MICU. The nurse manager of the MICU was responsible for assuring that each patient was screened with the PCST; social workers and/or case managers completed the tool during rounds. When a patient was found to meet the criteria, the case manager contacted the patient's attending physician to give them the information and suggest a palliative care consult. Quantitative and qualitative data were collected to evaluate the implementation of the tool including: number of PCSTs completed, disposition of the PCST, palliative care consults resulting from the PCST, any reasons that orders for palliative care were not written for patients who met the screening criteria, and staff experience with the PCST. Early findings resulted in refinement of the screening and referral process: 1) the nurse manager took responsibility for completing the tool because she was always present at interdisciplinary rounds and the social worker and/or case manager could not always attend; 2) MICU referral policy was changed, with the support of the MICU nurse manager and an intensivist, the medical executive committee agreed to change the "attending only" referral practice to include MICU residents and intensivists.

Graph or Table of Results

Summary of Results (What Worked and Why)

Use of the PCST and the resulting change to procedures for physician-ordered referrals were followed by an increase in palliative care needs identified and palliative care consults provided to MICU patients. Qualitative data revealed that the tool was a burden to use, primarily because of the length and complexity. Over time this tool may be replaced by a shorter list "palliative care triggers" based on findings that revealed nine primary criteria associated with palliative care referral.

Lessons learned

• Evaluate the tool for burden of completion, education value, and effectiveness in generating appropriate referrals on a weekly basis during the pilot phase and to identify barriers as they appear and revise procedures
• Engage leadership during development and early implementation process so when barriers arise, change can occur.
• Create an environment where MICU residents/intensivists can write the referral for a palliative care consultation
• Incorporate PC screening into routine processes. If it is not part of standard procedures, it will be dropped whenever resources are stretched.