Implementation of a palliative care consultation trigger tool for hospitalised patients with acute decompensated heart failure (2024)

Clinical setting and stakeholders

The quality improvement project was conducted at a 308-bed acute care teaching hospital that provides tertiary care for a large integrated healthcare system operating nine hospitals in eastern Massachusetts. During the conduct of the study spanning 2019–2020, the hospital had an average of 13 262 inpatient admissions per year, with 47% on medical services, and a dedicated cardiology service that had an average of 1285 discharges annually, representing 21% of all medical hospitalisations. We used the Standards for Quality Improvement Reporting Excellence revised guidelines 2.0 as our framework for this quality improvement report.¹⁰ Our stakeholders were primarily the internal medicine residents and cardiology fellows, the palliative care consultants, and the hospital-based teaching faculty, including hospitalists and cardiologists.

The institutional review board determined that this quality improvement project was not human subjects research and did not require oversight (No. Q101-23).

Root cause analysis

To elucidate the potential factors contributing to the underusage of palliative care services at our institution among hospitalised patients with acute decompensated heart failure, we conducted a root cause analysis. Using a fishbone diagram (figure 1), we identified several factors contributing to the magnitude of the problem, including a lack of recognition that heart failure is a debilitating serious illness with an undulating clinical course, a lack of appreciation that symptom burden is critical to quality of life, high turnover of hospital-based staff (eg, house staff), suboptimal care coordination efforts and goals of care discussions and lack of trigger tools for requesting palliative care services. After deliberation, the quality improvement team opted to focus on developing and rolling out a trigger tool for the timely request of palliative care services to assist in symptoms management, goals of care discussions and advance care planning.

Literature search

A literature search was performed to identify the most common indications or ‘triggers’ for inpatient palliative care consultations. Three team members searched Ovid, MEDLINE, Ovid Embase and PubMed databases for publications in the English language for indications of inpatient palliative care consultations. Using keywords and subject headings, the following concepts were searched: ‘palliative care’, ‘palliative medicine’, ‘hospice care’, ‘advance care planning’, ‘terminal care’, ‘referral and consultation’, ‘referral’, ‘consultation’, ‘patient transfer’, ‘delivery of health care, integrated’ and ‘heart failure’. The search terms were combined by ‘or’ if they represented similar concepts, and by ‘and’ if they represented different concepts.

All original studies, systematic reviews, editorials, commentaries and letters were included. Case reports and conference abstracts were excluded. After the initial search of 325 citations, 143 articles meeting the inclusion criteria were retrieved. Our team divided the included articles equally, and individual members reviewed the abstract and full text of each article and created a list of most common indications for palliative care consults. The list was reviewed by our hospital palliative care team and heart failure specialists. Box 1 summarises the list of ‘triggers’ or indicators that were identified as appropriate for an inpatient palliative care consultation, and adopted for our quality improvement project, based on team consensus. They included New York Heart Association (NYHA) class IV heart failure,⁴ ACC/AHA stage C–D heart failure,^{4 11} presence of refractory dyspnoea (to all interventions),^{4 11} greater than or equal to one hospitalisation for acute decompensated heart failure in the prior 6 months,^{4 11} intensive care unit (ICU) level of care with requirement for inotropic support in the prior 6 months,^{4 11} end-stage kidney disease (on dialysis),^{4 6 12} chronic respiratory failure (requiring home oxygen),^{4 5 7} eligibility criteria or request for hospice care^{4 5 12 13} and stage III/IV cancer (based on tumour, node, metastasis (TNM) classification of malignant tumours).^{7 14 15}

Baseline assessment of practice pattern

The project was initiated in August 2019. In the first phase, we identified patients hospitalised on medical services with acute decompensated heart failure. An arbitrary ‘index hospitalization period’ of 6 months was defined from 1 August 2019 to 31 January 2020. We queried the electronic health record to identify all consecutive patients hospitalised with acute decompensated heart failure during this 6-month period using ‘heart failure’ as a primary diagnosis code. The primary source for the data was the hospital’s electronic health record (MEDITECH, Westwood, Massachusetts, USA).

The following baseline patient characteristics were collected: age; sex; hospital setting (ie, general medicine service and intensive care unit); comorbidities, including history of hypertension, diabetes mellitus, ischaemic heart disease, peripheral vascular disease, stroke, active cancer and end-stage kidney disease; left ventricular ejection fraction documented at time of hospitalisation (≤ vs > 40%), NYHA heart failure class; ACC/AHA stage of heart failure; and number of hospital admissions for acute decompensated heart failure in the prior 6 months.

Using the prespecified eligibility criteria for a palliative care consultation, we next searched the electronic health record to identify whether these hospitalised patients with acute decompensated heart failure met criteria and received such a consultation. The latter was achieved by looking for a specific provider order for an inpatient palliative care consultation or a consultation note recorded by a member of the palliative care team in the medical record.

Description of the quality improvement plan and educational intervention

The second phase involved the planning and implementation of educational sessions for all stakeholders to use the tool to trigger inpatient palliative care consultations (figure 2). In brief, this phase was divided into two educational periods. The first period was from January to February 2020 and the second period was from May to June 2020. During each period, formal conferences were conducted to introduce the quality improvement project to all stakeholders and provide education on the eligibility criteria for palliative care consultations in hospitalised patients with acute decompensated heart failure. Examples of case scenarios demonstrating the appropriate usage of eligibility criteria for inpatient palliative care consults were conducted during these formal conferences. In addition, during the second period (ie, from May 2020 to June 2020), feedback was provided to all stakeholders on the continuous monitoring of eligibility criteria for palliative care consults among hospitalised patients with acute decompensated heart failure and the request for these consults. Furthermore, educational materials (in the form of visual cues) on the eligibility criteria for palliative care consults were posted at physician and nurse workstations across the hospital as a reminder for all stakeholders to trigger, if patients met any of the prespecified criteria. Attendance rate at all conference sessions was 100% across all stakeholders.

When consulted, the palliative care provider assisted in addressing symptom management, prognostic awareness, establishment of goals of care, including code status and advance care planning with assistance in the completion of the Healthcare Proxy (HCP) form and the Medical Order for Life-Sustaining Treatment (MOLST) form, psychosocial support, communication with family members and conflict resolution, transition planning and end of life care. In brief, as part of end-of-life care discussions with patients suffering from serious illnesses, a MOLST form addresses decisions regarding life-sustaining therapies in the setting of advance care planning. The form specifically focuses on cardiopulmonary resuscitation, ventilation (including, non-invasive ventilation, intubation and mechanical ventilation), dialysis, artificial hydration and nutrition and transfer to hospital. It is based on an individual’s right to accept or refuse medical treatment, even if the treatment is lifesaving. It is completed by a clinician and signed by the patient, based on the patient’s own decisions, and is honoured across all healthcare settings in the state of Massachusetts.

Post-intervention evaluation of practice and outcome measures

Following the intervention, over the ensuing 5 months (1 July 2020 to 30 November 2020), hospitalised patients with acute decompensated heart failure were identified using the same methodology. We extracted the data on those who met eligibility criteria and ascertained whether the palliative care service was consulted.

The main outcome measure of interest was to compare the percentage of hospitalised patients with acute decompensated heart failure eligible for an inpatient palliative care consultation, using our pre-established criteria (box 1), who received such consultation during the post-intervention period compared with the pre-intervention period.

Additional outcomes of interest included hospital length of stay, in-hospital death, advance care planning, including documentation of HCP in the medical record, completion of a MOLST form and change in code status (eg, do not resuscitate (DNR) order), as well as all-cause hospital readmission at 30 days, 60 days and 90 days, during the post-intervention period compared with the pre-intervention period. The project was headed, planned and managed at each stage by the listed authors at our institution. Monitoring progress of the project as well as discussions regarding data collection, planned intervention and evaluation of problems encountered during the project were conducted by the authors at biweekly quality improvement meetings. The data were collected in two separate pre-intervention and post-intervention indexed hospitalisation periods. Our analysis was aimed at examining whether our intervention was successful at increasing the total number of palliative care consults.

Continuous variables are reported as mean (with SD), and binary variables as counts (with percentage). Comparisons between groups were made by the Student’s t-test for continuous variables and by the χ² test for categorical variables. All analyses were performed using the SPSS statistical package V.22 (IBM Corporation, Armonk, New York, USA). Differences were considered statistically significant at a value of less than 0.05.

Patients were not directly involved in the development of the research question, trigger tool development or the design of the quality improvement study. Study results may be shared with patients as we hope to continue to use the trigger tool for palliative care consults in patients hospitalized with heart failure.

Baseline assessment of appropriate use of inpatient palliative care consultations

A total of 149 consecutive patients with acute decompensated heart failure were hospitalised during the baseline pre-intervention period. As shown in table 1, the mean age was 71 years, 72 (48.3%) were men, 135 (90.6%) were hospitalised on the general medicine service and 96 (64.4%) had heart failure with reduced ejection fraction (≤40%). In terms of eligibility criteria for an inpatient palliative care consultation, 14 (9.4%) patients had class IV heart failure (based on the NYHA classification system), and 132 (88.6%) had stage C/D heart failure (based on the AHA/ACC staging system). Twelve (8.1%) patients were hospitalised at least once for acute decompensated heart failure in the prior 6 months. Three (2.0%) patients had end-stage kidney disease, and 4 (2.7%) patients had chronic respiratory failure. There were no patients with stage III/IV cancer (based on the TNM staging system), and no patients met criteria for hospice care.

As shown in table 2, during the pre-intervention period, 72 (48%) patients met at least one criterion for an inpatient palliative care consultation, but only 20 (28%) received a consultation. The mean hospital length of stay was 5.5 days, and there were no in-hospital deaths. In terms of advance care planning, at time of hospital admission, 16 (10.7%) patients had a documented HCP form, 2 (1.3%) patients had a documented MOLST form and 4 (2.7%) patients had a DNR order. At time of hospital discharge, the number of patients with a documented HCP form increased to 17 (11.4%); the number of patients with a documented MOLST form increased to 3 (2.0%) and the same 4 (2.7%) patients maintained a DNR order. The hospital readmission rate for these patients at 30 days, 60 days and 90 days was 36.2%, 38.3% and 43.6%, respectively.

Post-intervention assessment of appropriate use of inpatient palliative care consultations and impact on outcome measures

In the post-intervention period, a total of 108 consecutive patients with acute decompensated heart failure were hospitalised. As shown in table 1, the mean age was 72 years, 52 (48.1%) were men, 100 (92.6%) were admitted to the general medicine service and 62 (57.4%) had heart failure with reduced ejection fraction (≤40%). In terms of eligibility criteria for a palliative care consultation, 10 (9.3%) patients had class IV heart failure, and 66 (61.1%) had stage C/D heart failure. Sixteen (14.8%) patients were hospitalised at least once for acute decompensated heart failure in the prior 6 months. In terms of relevant comorbidities, 2 (1.9%) patients had end-stage kidney disease, and 3 (2.8%) patients had chronic respiratory failure. There were no patients with stage III/IV cancer, and no patients met criteria for hospice care.

As shown in table 2, 41 (38%) patients were found to be eligible for an inpatient palliative care consultation, and 19 (46.3%) patients received such consultation, which was significantly higher, compared with eligible patients in the pre-intervention period (46.3% vs 27.7%; p=0.02). In the post-intervention period, and compared with the pre-intervention period, we observed a significant improvement in the documentation of the HCP form at time of hospital admission (28.7% vs 10.7%; p<0.001), which further increased at time of hospital discharge (47.2% vs 11.4%; p<0.001). Similarly, we observed a significant increase in the completion of a MOLST form at time of both hospital admission (11.1% vs 1.3%; p<0.001) and hospital discharge (24.1% vs 2.0%; p<0.001). As part of addressing code status, in the post-intervention period, and compared with the pre-intervention period, we observed a significant increase in DNR orders at time of hospital admission (11.1% vs 2.7%; p=0.006), which further increased at time of hospital discharge (29.6% vs 2.7%; p<0.001). The average hospital length of stay during the post-intervention period was not significantly different compared with the pre-intervention period (6.2±5.1 vs 5.5±3.9 days; p=0.21). Most importantly, during the post-intervention period, the 30-day hospital readmission rate was significantly lower, compared with the pre-intervention period (4.6% vs 36.2%; p<0.001), and this trend persisted at 60 days (6.5% vs 38.3%; p<0.001), and 90 days (8.3% vs 43.6%; p<0.001), likely reflecting aligned goals of care and improved post-discharge care coordination efforts.

Limitations

The generalisation of our results is limited in part by the small sample size and a single-centre intervention. In addition, the post-intervention period occurred during the COVID-19 pandemic, which may have confounded our findings, as we observed a reduced number of hospitalisations for heart failure, compared with the pre-intervention period. Limited staffing of providers, including nurses, advanced practice practitioners and physicians, due to COVID-19 related illness, might have also resulted in less inpatient palliative care referrals. However, we observed a significant increase in palliative care consultations during the post-intervention period, arguing against this potential concern. In our hospital, palliative care services are not available on weekends. This too could have led to fewer palliative care referrals for patients whose hospital course lasted only a weekend. Although not significant, the hospital length of stay was higher in the post-intervention period compared with the pre-intervention period, likely due in part to challenges with timely hospital discharges amid the pandemic. This might have also increased the opportunity to initiate a palliative care referral, resulting in higher consultation rates. Additionally, exploration of patient-related experiences and outcomes was not factored into this project. As the timeline of this quality improvement project included two separate indexed hospitalisation periods, the project did not extend into follow-up of these patients in the ambulatory setting after hospital discharge to monitor other outcomes, including improvements in quality of life, family caregiver outcomes and patient and caregiver satisfaction with care. Furthermore, this project had only one Plan-Do-Study-Act (PDSA) cycle with two distinct educational session phases. Although there was a significant increase in inpatient palliative care consults, multiple PDSA cycles would have shed light on whether our efforts are sustainable long-term. Finally, some of the literature reviewed by our team to identify triggers for palliative care consults, was based on expert opinion rather than peer-reviewed specific criteria. Further research is clearly needed to identify appropriate and timely triggers for palliative care referral.

Twitter: @b_raj84

Contributors: AB—create outline of the project, obtain institutional review board (IRB) approval, data collection during pre-intervention and post-intervention periods, statistical analysis, manuscript writing. SC—create outline of the project, data collection during pre-intervention and post-intervention periods, manuscript editing. JC—create outline of the project, data collection during pre-intervention and post-intervention periods, manuscript editing. AV—create outline of the project, manuscript editing. JL—create outline of the project, manuscript editing. LT—create outline of the project, manuscript editing. BLJ—corresponding author, guarantor, create outline of the project, obtaining IRB approval, statistical analysis, manuscript editing.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.

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