Triaging the Terminally Ill-Development of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool

Pilot Implementation of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool

CONTEXT

Specialist palliative care services must balance provision of needs-based care within resource restraints. The Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool is a novel, evidence-based, 7-item prioritization tool, with recommended response times for any given score.

OBJECTIVES

To investigate the acceptability and appropriateness of the RUN-PC Triage Tool implemented into clinical practice.

METHODS

A single-arm, multisite, prospective implementation pilot conducted at 12 community/inpatient palliative care services, using Quality Improvement methodology with Plan-Do-Study-Act cycles. Data collected for each triage episode included demographics, scoring, user feedback and clinical outcomes. Group differences were tested by chi-squared, Wilcoxon Rank Sum or Kruskal Wallis tests.

RESULTS

A total of 5418 triage episodes were captured, 1509 with outcome data. Referrals to inpatient services were of higher acuity than those to community (median score 24 vs. 14). Whilst high numerical scores were unusual, a significant proportion of cases were clinically urgent. Admissions occurred within recommended response times in over 80% of triage episodes; 5.8% of referred patients died before being admitted. Users reported the tool was easy to complete (99.3% of applications), rarely requiring additional time (0.07%), and appropriate in its triage determination (96.0% of applications).

CONCLUSION

The RUN-PC Triage Tool is feasible to implement, with high clinician acceptability and virtually no additional time required. The recommended response times are feasible and highlight target areas for improvement. Implementation of the tool enables palliative care services to better characterize their referral population and, in turn, improve transparency around access to care.

Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners

PURPOSE

Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes.

METHODS

Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models.

RESULTS

High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability.

CONCLUSIONS

Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions.

HIGHLIGHTS

Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.

Using a validated case mix tool for use in the telephone-assisted triage of patients in a specialist palliative care community setting: a consecutive case series

OBJECTIVES

Allocating resources in palliative care is challenging due to the nature of life-limiting illness coupled with the propensity for significant physical symptoms and psychological distress. At present, there is no established system for triaging referrals and prioritising resource allocation.This study aimed to evaluate the feasibility of using a case mix assessment tool for telephone-assisted triaging of referrals to a specialist palliative care service. This assessed a patient's phase of illness, Problem Severity Score (PSS) for complexity of symptom burden and psychological distress, and functional status.

METHODS

Using a prospective consecutive case series approach, 450 referrals to community palliative care over a 6-month period were assessed. Scores for phase of illness, PSS and functional status were assessed at triage, as was the triage category of urgency of response.

RESULTS

Analysis demonstrated that phase of illness corresponds with triage category, with terminal or unstable phase patients significantly associated with urgent (category 1) referrals and highest priority for review. Decreased functional status and high PSS were useful predictors for increased urgency of referral.

CONCLUSIONS

These results demonstrate that this case mix tool could assist in the telephone assessment and triage of referrals to community palliative care.

Winners and Losers in Palliative Care Service Delivery: Time for a Public Health Approach to Palliative and End of Life Care

Background: Consumer experience of palliative care has been inconsistently and selectively investigated. Methods: People in Western Australia who had experienced a life limiting illness in the past five years were recruited via social media and care organisations (2020) and invited to complete a cross sectional consumer survey on their experiences of the care they received. Results: 353 bereaved carers, current carers and patients responded. The winners, those who received the best quality end-of-life care, were those who were aware of palliative care as an end-of-life care (EOLC) option, qualified for admission to and were able to access a specialist palliative care program, and with mainly a cancer diagnosis. The losers, those who received end-of-life care that was adequate rather than best practice, were those who were unaware of palliative care as an EOLC option or did not qualify for or were unable to access specialist palliative care and had mainly a non-cancer diagnosis. Both groups were well supported throughout their illness by family and a wider social network. However, their family carers were not adequately supported by health services during caregiving and bereavement. Conclusions: A public health approach to palliative and end of life care is proposed to integrate tertiary, primary, and community services through active consumer engagement in the design and delivery of care. Therefore, suggested strategies may also have relevance in many other international settings.

Palliative and End-of-Life Care Service Models: To What Extent Are Consumer Perspectives Considered?

This article presents evidence found in a search of national and international literature for patient preferences concerning settings in which to receive palliative care and the appropriateness of different models of palliative care. The purpose was to inform end-of-life care policy and service development of the Western Australian Department of Health through a rapid review of the literature. It was found that consumer experience of palliative care is investigated poorly, and consumer contribution to service and policy design is limited and selective. Most patients experience a mix of settings during their illness, and evidence found by the review has more to do with qualities and values that will contribute to good end-of-life care in any location. Models of care do not make systematic use of the consumer data that are available to them, although an increasingly common theme is the need for integration of the various sources of care supporting dying people. It is equally clear that most integration models limit their attention to end-of-life care provided by health services. Transitions between settings merit further attention. We argue that models of care should take account of consumer experience not by incorporating generalised evidence but by co-creating services with local communities using a public health approach.

Validation of the responding to urgency of need in palliative care (RUN-PC) triage tool

BACKGROUND

The Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool is a novel, evidence-based tool by which specialist palliative care services can manage waiting lists and workflow by prioritising access to care for those patients with the most pressing needs in an equitable, efficient and transparent manner.

AIM

This study aimed to establish the intra- and inter-rater reliability, and convergent validity of the RUN-PC Triage Tool and generate recommended response times.

DESIGN

An online survey of palliative care intake officers applying the RUN-PC Triage Tool to a series of 49 real clinical vignettes was assessed against a reference standard: a postal survey of expert palliative care clinicians ranking the same vignettes in order of urgency.

SETTING/PARTICIPANTS

Intake officers (n = 28) with a minimum of 2 years palliative care experience and expert clinicians (n = 32) with a minimum of 10 years palliative care experience were recruited from inpatient, hospital consultation and community palliative care services across metropolitan and regional Victoria, Australia.

RESULTS

The RUN-PC Triage Tool has good intra- and inter-rater reliability in inpatient, hospital consultation and community palliative care settings (Intraclass Correlation Coefficients ranged from 0.61 to 0.74), and moderate to good correlation to expert opinion used as a reference standard (Kendall's Tau rank correlation coefficients ranged from 0.68 to 0.83).

CONCLUSION

The RUN-PC Triage Tool appears to be a reliable and valid tool for the prioritisation of patients referred to specialist inpatient, hospital consultation and community palliative care services.