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Suzanne Emil, Lisa Marr, Jasmeet Paul, Sonlee West, Alex Schevchuck

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Presentation on theme: "Suzanne Emil, Lisa Marr, Jasmeet Paul, Sonlee West, Alex Schevchuck"— Presentation transcript:

1 Nurse-led Triggers for GOC Discussions and Palliative Care Consultations in the TSICU
Suzanne Emil, Lisa Marr, Jasmeet Paul, Sonlee West, Alex Schevchuck (Teri Heynekamp, Ed Alas, MLA) (Deepti Rao, Hospitalist) Medical Leadership Academy

2 Background Palliative Care benefits:
Patient and families: Quality of life, Satisfaction with care, Pain and symptom management, hospice utilization Hospitals: Decreased O/E, cost, 30-day readmission, ED visits, LOS, ICU readmissions, decreased ICU admission at end of life Earlier consults show better outcomes There will never be enough Palliative Care specialists to care for all the patients who need them Need to train physicians and nurses in “Primary Palliative Care”- skills all providers should have (running a family meeting, treating pain, etc.)

3 Why did we choose this project?
Alignment with Health System Goals: Improve Mortality Index (O/E ratio) Better utilization of resources Improve value-based care- lower cost, increased satisfaction Improve inpatient access and through-put Improve CGCAHPs (inpatient satisfaction)

4 How is it done now? (Plan)
End of Life Education: No standardization Done primarily by Palliative Care team in different settings One-on-one with individual provides during consultation Providers have little training in, and often discomfort with, having Goals of Care discussions Ex. SICU: 4 out of 22 patients had a code status note on day checked, despite hospital policy that this is required

5 How is it done now? Clinical
Inpatient: Palliative Care Consultations have to be requested by attending physicians Sometimes, RNs see need for consult, but patients not consulted by team Lack of standardization: Who receives a PC consult Consultations usually occur late in admission (avg. time to consult 8 days) How goals of care discussions are documented No trigger criteria for consultations

6 Introduction to Project: SICU (MICU)
Issues to be Addressed: Trigger Criteria for Goals of Care discussions: Physicians are not routinely trained in how to have Goals of Care discussions and do not routinely do them Trigger Criteria for Palliative Care consultation: Many patients would benefit from Palliative Care consultation but are not being seen by the Palliative Care team Earlier identification of patients who would benefit from palliative care will help both patients and hospitals First trial: All ECMO patients get a Palliative Care consult

7 AIMS Improve learner knowledge and confidence- Retro pre/post survey
Increase Documentation of Code status/Goals of Care by 50% Decrease: Time to Palliative Care consultation by 2 days LOS by 1 day ICU readmissions by 50% Increase number of Palliative Care consultations 50% increase in SICU consultations

8 Palliative Care Leaders (PCLs)- SICU (Do)
Physicians: Sonlee West, MD and Jasmeet Paul, MD Monthly lectures to rotators, faculty Nurses: Lauren Dyer, RN and Crystal Sanchez, RN Training for all ICU RNs about project; posting of the project flow chart at each nursing station PCL = The Pickles “PCL” = The Pickles

9 Outline of steps Admitting nurse screens patient to see if they meet trigger Nurse discusses with attending physician and team on rounds Attending/team has a Goals of Care discussion with patient/family within 72 hours of admission Documents on Code Status note in “Urgent Clinical Documents” Based on outcome of discussion, formal Palliative Care consultation based on team request.

10 Nursing Identified Triggers
Multiple organ failure Anoxic brain injury Terminal condition GCS< 3 Age >75 Metastatic cancer

11 SICU Trigger Criteria Project: Goals of Care Discussions and Palliative Care Consultation

12 Curriculum Outline Goals of Care Curriculum will include:
Decisionality and surrogacy for decision-making in New Mexico Basics of prognostication Outline for Patient and Family Goal Setting discussions Laminated cards for learners Review of appropriate documentation of discussions Note templates Code Status Family Goals Setting Conference Surrogate Decision Maker Note

13 Retro Pre/Post Evaluation

14 Laminated Card for SICU: Family Goal Setting Conference

15 Template: Code Status Note

16 Template: Surrogate Decision Maker Note

17 Template: Family Goal Setting Conference

18 Summary Literature Review-All Screening Preparation Of Curriculum
LM- basic outline of goals of care discussions JP, SW, TH assist with MICU and SICU specific additions; identified “nurse champions” in each area Screening JP- 10 additional consults in 2 weeks TH- 12 additional consults in 2 weeks Literature Review-All Surgical ICU criteria: MSOF, anoxic brain injury, terminal condition, GCS< 3 age >75, met cancer, ECMO Medical ICU criteria: met cancer, MOSF, ESLD with MELD >25, > 2 ICU admit same admission, anoxic brain injury Anoxic Brain Injury- 2 Terminal Condition- 2 GCS< 3 age >75- 1 Metastatic Cancer- 1 MSOF- 4  Anoxic Brain Injury metastatic cancer 2. Multiorgan system failure > 3 organ systems 3. 2 or more ICU admissions in the same hospitalization 4. Anoxic brain injury status post cardiac arrest 5. End-stage liver disease with meld > 25  Monthly meetings of MLA team

19 SICU Pilot Program: September 2017-March 2018 PCL: July-August 2017
SICU Trigger Criteria- GOC discussion and need for formal Palliative Care consult; SW/JP did education monthly PCL: July-August 2017 SICU- JP/SW give talk to faculty; Dyer/Sanchez talks to RNs “Train the Trainers”- Palliative Care Leaders (PCL)- Part 1 LM review Goals of Care discussion with JP, TH, SW Other team members also receive training MSOF- 4  Anoxic Brain Injury- 2 Terminal Condition- 2 GCS< 3 age >75- 1 Metastatic Cancer- 1 Anoxic Brain Injury metastatic cancer 2. Multiorgan system failure > 3 organ systems 3. 2 or more ICU admissions in the same hospitalization 4. Anoxic brain injury status post cardiac arrest 5. End-stage liver disease with meld > 25  Monthly meetings of MLA team

20 Train the Trainers- Part 2 Data Collection (March 2018)
Role out curriculum in additional areas, as well as determination of trigger criteria in these areas, looking for outcomes (site-specific)- MICU planned Fall 2018 Train the Trainers- Part 2 LM, JP, SW trained SE, AS on teaching curriculum for their learners (Rheumatology; Cardiology) Data Collection (March 2018) SICU–learner knowledge and confidence, time to palliative care consult, number of palliative care consults, documentation of code status/GOC, ICU readmission MSOF- 4  Anoxic Brain Injury- 2 Terminal Condition- 2 GCS< 3 age >75- 1 Metastatic Cancer- 1 Anoxic Brain Injury metastatic cancer 2. Multiorgan system failure > 3 organ systems 3. 2 or more ICU admissions in the same hospitalization 4. Anoxic brain injury status post cardiac arrest 5. End-stage liver disease with meld > 25 

21 Results (Study)

22 Education Outcomes

23 Retro Pre/Post Evaluation

24 September 2017-March 2018 Monthly lectures to TSICU team and rotators:
21 subjects were interviewed pre- and post intervention MS4: 5 PGY1: 4 PGY2: 1 Unspecified: 11

25 Statistical analysis Paired two-tailed t-test for means

26 Knowledge All p-values are <0.0001 42% ↑ 38% ↑ 67% ↑ 57% ↑

27 Confidence p-value <0.0001 75% ↑

28 Clinical Outcomes

29 Population Encounter Type: Inpatient Admitted 3/1/2017 to 3/31/2018
Discharged Last patient in population discharge 5/4/2018 Excludes 1 patient still inpatient as of 5/8/2018 Age 18 years and older Trauma-Surgical ICU in location history Dept of Surgery-associated Discharge Service Excludes Cardiothoracic Surgery Data sources Cerner PowerInsight and Midas

30 Results (Table) Baseline Intervention Time period 3/1/17 to 8/31/17
Encounters 556 538 Mean Age (SD) 54.04 (19.20) 54.06 (20.85) Median Age 58 57 Average Length of Stay (SD) 13.64 (15.51) 11.44 (11.96) -↓16% Median LOS 9 8 - ↓1 day ICU LOS Average 5.26 (7.63) 4.84 (7.53) ICU LOS Median 2.7 2.8 Deaths 47 34 with consult 16 (34%) 14 (41%)

31 Palliative Care Consults in ICU
Baseline (PC consults): Average LOS: 5.26 Standard Deviation: 7.63 Median: 2.7 Intervention (PC consults): Average LOS: 4.84 Standard Deviation: 7.53 Median: 2.8 Change: ↓ 0.42d (average LOS)

32 Code Status Notes Goal: ↑ by 50%
Baseline: 68/556 Code Status Notes: 68 Discharges: 556 Percentage: % Intervention: 86/538 Code Status Notes: 86 Discharges: 538 Percentage: % Change (%): ↑ 30.74%

33 # of Palliative Care consults Goal: ↑ by 50%
Baseline: Consults: 42 Discharges: 556 Percentage: 7.55% Intervention: Consults: 44 Discharges: 538 Percentage: 7.91% Change(%): ↑ 4.77%

34 Time to PC consult Goal: ↓ by 2 days
Time from admission to consult: Prior to intervention: 8.5 days (range 1-28) During intervention: 7.4 days (range 0-22) Time to Palliative Care consult decreased by 1.1 days (13%)

35 ICU readmissions goal: ↓ by 50%
Baseline: Readmissions: 41 Discharges: 556 Percentage: 7.37% Intervention: Readmissions : 30 Discharges: 538 Percentage: 5.58% Change (%): ↓ 24.29%

36 Next steps: (Act) Continue with monthly lecture series (West and Paul) and trigger criteria in TSICU Re-educate about trigger criteria; more RN involvement Follow up data 6 months Part 2: Re-create project in the MICU- Fall 2018 Physician Lead: Teri Heynekamp Nursing Leads: Rhonda Davis and Joan Martinez Part 3: Hospitalist Trigger project- TBD Deepti Rao

37 NO? Possible Reasons for Consult:
MICU Trigger Criteria Project: Goals of Care Discussions and Palliative Care Consultation Admitting RN screens patient with PC Trigger Criteria Meets Criteria? YES  If does not meet criteria, Palliative Care consult as usual Team has GOALS OF CARE discussion with patient/family within 72 hours of admission Document Code Status note in URGENT CLINICAL DOCUMENTS Team/Family satisfied? No  If satisfied, continue with plan of care NO? Possible Reasons for Consult: Prolonged LOS without evidence of progress Assistance needed with complex decision making Team Support needed (family conferences) Advance Care Panning Dispo for seriously ill/dying patients Prognostication Unacceptable pain or symptom distress Frequent/recurrent hospitalizations with functional decline Action Plan: Palliative Care Consult Call Trigger Criteria: MOSF Anoxic Brain Injury Metastatic Cancer Cirrhosis On ECMO > 2 ICU stays same admission

38 Summary Trigger Project in the SICU: Education Outcomes:
Improved knowledge and confidence among learners (p value <0.0001) Clinical Outcomes: Overall Code status notes increased by 30.74% Overall SICU readmissions decreased by 24.29% Overall median ICU LOS decreased by 1 day; avg. LOS by 16% Increased PC involvement for patients who died in SICU (41% vs. 34%) Time to PC consult decreased by 1.1 days Number of Palliative Care Consults increased by 4.77% PC consults pre/during intervention shortened LOS in ICU by 0.42 days ? Change seen secondary to earlier consultation

39 Thank you! Dr. Rick Crowell, mentor
Renee Patton, data abstraction and analysis Debbie Begay, for her patience!!

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