Enhancing Care at the End of Life Through Transition To Hospice 2017-11-16T16:28:29+00:00

Project Description

Enhancing Care at the End of Life Through Transition To Hospice

Background

  • Patients who were at end of life and required planned withdrawal of treatment often had withdrawal take place in the intensive care unit (ICU), which does not offer the family an optimal environment for grieving or allow the patient/family to access the specialized knowledge and support services provided by hospice at the end of life.
  • In an effort to enhance care at the end of life, a hospital developed a process for critical care patients to transfer to the Hospice Inpatient Unit (physically located on the hospital campus) for withdrawal of life sustaining treatments.
  • ICU nursing staff was provided with education about the benefits to patients and families of hospice and processes were put into place that allowed for nursing to be a part of the patient’s transfer to hospice.
  • Improvements resulted in an increase from a baseline of 0% of patients/families agreeing to transfer to hospice for planned withdrawal of life sustaining treatment to 70%+ of patients/families agreeing.

Aim Statement

By January 1, 2015 70% of eligible critical care palliative care patients/families were to accept transfer to inpatient hospice prior to withdrawal of life sustaining measures through on-going staff education and Supportive and Palliative Care (SPC) support. The team was able to reach and sustain the goal of 50% and felt that an increase to 70% was an appropriate stretch goal.

Financial Implications

Utilizing the services offered by a SPC team for appropriate patients has shown to result in a lower average direct cost per day. Update

  • A study published in 2013 estimated the cost of caring for a patient in the ICU setting whose death was imminent was approximately $4,000 a day.*
  • The Center for Medicare and Medicaid Services Hospice Cost Report from 2011 shows the average cost per inpatient hospice day was $1,232.
  • From a cost avoidance perspective, the dollars saved by a dying patient being cared for in the optimal hospice care setting for one day is $2,768 ($4,000 – $1,232 = $2,768).

During the scope of this project a total of 120 patients were transferred from the hospital ICU to the inpatient hospice unit where the patients had an average length of stay of 1.56 days prior to passing away. From a cost avoidance perspective, that represents approximately $518,170 not spent.

*Rachel Champeau, September 2013, Science + Technology UCLA Newsroom, UCLA / RAND Study

Patient and Family Centeredness Implications

A study in the Journal of Clinical Oncology (Wright, 2010) demonstrated that bereaved caregivers of patients who died in an ICU setting are at increased risk for post-traumatic stress disorder (PTSD). Among caregivers, 21% of those whose loved ones died in the ICU or hospital developed PTSD six months later compared to 4.4% of those whose loved ones died at home with hospice.

The inpatient hospice setting allows for a more personal approach to care and a more home-like environment.

  • Monitors are not present, allowing the focus to move away from ‘numbers’ and move towards treating visible / tangible symptoms
  • There are fewer distractions and interruptions – less equipment noise, decreased traffic from physicians and staff, decreased exposure to and distress from unnecessary procedures like blood samples being collected or regular vital signs being taken
  • Staff who are experts in death and dying can better support patients and families during their end-of-life experience
  • Families receive ongoing bereavement services by trained hospice personnel for up to 13 months – including free access to support groups and individual/family counseling
  • There are dedicated social work services to assist with final arrangements
  • Expert comfort care is provided from nurses specifically trained in managing the symptoms associated with the dying patient
  • Child Life Specialists, pediatric health care professionals, with expertise in helping the children involved with the dying patient are also available

Metrics/Measures

Process Measure:

  • Increase in overall SPC referrals

Outcome Measure:

  • The percentage of eligible critical care palliative care patients/families that accept transfer to inpatient hospice prior to withdrawal of life sustaining measures

Balance Measure:

  • The team hopes that the interventions will also have a positive impact on shortening the average days from hospital admission to SPC consult. Said another way – that the SPC team receives referrals for patients earlier in their hospital stay versus later.

The team also hopes the interventions will contribute to a positive change in the staff perception and understanding of SPC and hospice. 

Rapid Cycle Improvement: Cycle 1

Plan- Using the feedback from Survey Monkey, the team organized curriculum for nursing staff focused on the following topics: identifying patients appropriate for hospice, having the hospice conversation and the different levels of hospice and services available for each level.

Do- Approximately 15 Lunch and Learn classes were offered to nursing staff on day and night shifts and during the week and weekends. In addition, an educational module was created for all staff related to SPC. The transfer process was formalized and clear instructional material was developed and posted about the process.

Check- There was excellent attendance at the Lunch and Learn sessions with positive feedback from the staff. There was a slight increase in the process measure (SPC referrals) with noted variation. Feedback was received from the nursing staff that the patient transfer process was improved, but not consistent.

Act- Continued to monitor and hardwire interventions and re-group with the hospice impatient unit team regarding the transfer process.

Rapid Cycle Improvement: Cycle 2

Plan- Revisit communication and process interventions with the SPC team and hospice unit.

Do- A staffing change at the hospice unit took place and this opportunity was used to re-group with the new team member to reassess the current transfer processes. The hospice team implemented a new step by inviting the patient’s critical care nurse to be a part of the actual transport/transfer process with that patient and family. The hospice unit continued to welcome visits by the hospital critical care nursing so they could feel included and maintain those “relationships” that had developed with the patient and family.

Check- Positive staff response to the interventions and both process and outcome measures improved with some stability. Positive feedback from staff regarding the transfer process.

Act- Continued hardwiring interventions and resurvey staff.

Rapid Cycle Improvement: Cycle 3

As more physicians and nursing staff worked with the SPC team, the value of and the satisfaction with the services the team could provide to the patients became more clear. These positive experiences contributed to an increase in SPC referrals (process measure).

Plan: The Social Work & Care Coordination teams identified an opportunity among our severely ill patients with an extended length of stay as there were delays with the SPC team being consulted or not being consulted at all.

Do: The SPC Social Worker started attending the extended length of stay meetings to hear the case presentations and offer feedback.

Check: The change contributed to identifying SPC patient referrals in a more timely manner and also initiated referrals to SPC for patients, as appropriate.

Act: Continue to monitor.

Results

The outcome measure results exceed the target of 70% for the past 8 months.

The increase in SPC referrals (process measure) overall has placed the program into the top quartile of hospitals nationally with regards to the percentage of hospital admissions that receive a SPC consult.

Sustainability

  • Continue to assess nursing’s understanding of SPC services and identify any new barriers to transitioning appropriate patients to hospice with an annual survey.
  • Monthly collaboration meetings with hospice unit to review data and address any process opportunities.
  • Representatives from SPC and Social Work provide ongoing education to staff during Multidisciplinary Critical Care Rounds and nursing unit staff meetings as needed.
  • In May 2014, notifications were created in the patient safety event tracking system to alert the SPC team when a previous SPC patient has been readmitted to the hospital to allow for on-going communication, planning and continuity of care.
  • The SPC program will go through the scheduled formal Joint Commission 2015 recertification survey in December 2015.

Next Steps

  • With the growth and success of the program, the unit had to recruit a second SPC physician.

Lessons Learned

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