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Russell B, Philip J, Phillips J, Smith A, Collins A, Sundararajan V. Pilot Implementation of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool. J Pain Symptom Manage 2024; 67:260-268.e2. [PMID: 38101490 DOI: 10.1016/j.jpainsymman.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
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.
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Affiliation(s)
- Bethany Russell
- Palliative Nexus Research Group (B.R., Je.P., A.C.), University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Palliative Care (B.R., Je.P.), St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - Jennifer Philip
- Palliative Nexus Research Group (B.R., Je.P., A.C.), University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Palliative Care (B.R., Je.P.), St Vincent's Hospital Melbourne, Melbourne, Australia; Victorian Comprehensive Cancer Centre (Je.P.), Melbourne, Australia; Department of Palliative Care (Je.P.), Royal Melbourne Hospital, Melbourne, Australia
| | - Janet Phillips
- Melbourne City Mission Palliative Care (Ja.P.), Fitzroy North, Australia
| | - Amanda Smith
- Safer Care Victoria (A.S.), Melbourne, Australia
| | - Anna Collins
- Palliative Nexus Research Group (B.R., Je.P., A.C.), University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- Department of Medicine (V.S.), University of Melbourne, Melbourne, Australia
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Benson J, Wolfson D, van den Broek-Altenburg E. Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners. Med Decis Making 2023; 43:311-324. [PMID: 36597349 DOI: 10.1177/0272989x221145677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Jamie Benson
- Department of Radiology, Larner College of Medicine at the University of Vermont, Burlington, VT, USA.,Department of Surgery, Division of Acute Care Surgery, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Daniel Wolfson
- Department of Surgery, Division of Emergency Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA.,Vermont Department of Health, Division of Emergency Preparedness, Response & Injury Prevention, Burlington, VT, USA
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Russell B, Philip J, Wawryk O, Vogrin S, Burchell J, Collins A, Le B, Brand C, Hudson P, Sundararajan V. Validation of the responding to urgency of need in palliative care (RUN-PC) triage tool. Palliat Med 2021; 35:759-767. [PMID: 33478366 DOI: 10.1177/0269216320986730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Bethany Russell
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia.,Department of Palliative Care, St Vincent's Hospital Melbourne, VIC, Australia
| | - Jennifer Philip
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia.,Department of Palliative Care, St Vincent's Hospital Melbourne, VIC, Australia.,Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia.,Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Olivia Wawryk
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia.,Department of Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, VIC, Australia
| | - Jodie Burchell
- Department of Medicine, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, VIC, Australia
| | - Anna Collins
- Palliative Nexus Research Group, University of Melbourne and St Vincent's Hospital Melbourne, VIC, Australia
| | - Brian Le
- Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia.,Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Caroline Brand
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, VIC, Australia.,Department of Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia.,End-of-life Care Research Group, Vrije University, Brussels, Belgium.,School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Vijaya Sundararajan
- Department of Public Health, La Trobe University, Melbourne, VIC, Australia.,Department of Medicine, St Vincent's Hospital Melbourne and University of Melbourne, Melbourne, VIC, Australia
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Preferences for life expectancy discussions following diagnosis with a life-threatening illness: a discrete choice experiment. Support Care Cancer 2020; 29:417-425. [PMID: 32383072 DOI: 10.1007/s00520-020-05498-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To explore in a sample of adult cancer patients: (1) the relative influence of initiation source, information format and consultation format on preferred approach to life expectancy disclosure using a discrete choice experiment (DCE); and (2) whether patient age, cancer type and perceived prognosis were associated with preferences within the three attributes. METHODS A DCE survey of adult solid tumour and haematological cancer patients. Participants chose between three hypothetical scenarios about life expectancy disclosure consisting of three attributes: initiation source (i.e. doctor versus patient-initiated discussion), information content (i.e. estimate presented as best-worst-typical length of life case scenario versus median survival time) and consultation format (i.e. two 20-min versus one 40-min consultation). Respondents selected their most preferred scenario within each question. RESULTS Three hundred and two patients completed the DCE (78% consent rate). Initiation source was the most influential predictor of patient choice. More preferred a doctor deliver life expectancy information as soon as it is available rather than waiting for the patient to ask (59% vs 41% z = - 7.396, p < 0.01). More patients preferred the two 20-min rather than the one 40-min consultation format (55% vs 45%, z = 4.284, p < 0.01). Information content did not influence choice. Age, cancer type, and patient-perceived prognosis were not associated with preferences. CONCLUSION Healthcare professionals should assess cancer patients' preferences for engaging in life expectancy discussions as soon as they have this information, and ensure patients have adequate time to consider the information they receive, seek additional information and involve others if they wish.
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Russell B, Vogrin S, Philip J, Hennessy-Anderson N, Collins A, Burchell J, Le B, Brand C, Hudson P, Sundararajan V. Triaging the Terminally Ill-Development of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool. J Pain Symptom Manage 2020; 59:95-104.e11. [PMID: 31419540 DOI: 10.1016/j.jpainsymman.2019.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Evidence-based resource allocation is receiving increasing attention as we strive for equity, transparency, and cost-effectiveness across health care. In the context of finite resources, which of our patients with terminal illness should be prioritized for urgent palliative care? OBJECTIVES To develop the scoring system for the novel Responding to Urgency of Need in Palliative Care triage tool. METHODS Online international discrete choice experiment involving palliative care clinicians to establish the relative importance of seven key attributes of palliative care triage identified during an earlier qualitative study. RESULTS Participants (n = 772) were mainly female (79.9%) with a decade of clinical experience. All attributes contributed significantly (all P-values < 0.001) and independently to clinician assessment of urgency. This study found physical suffering (coefficient 3.45; 95% confidence interval: 3.24 to 3.66) was the most important determinant of urgency, followed by imminent dying (coefficient 1.56; 1.43 to 1.69), psychological suffering (coefficient 1.49; 1.37 to 1.60), caregiver distress (coefficient 1.47; 1.35 to 1.59), discrepancy between care needs and care arrangements (coefficient 1.14; 1.02 to 1.26), mismatch between current and desired site of care (coefficient 0.94; 0.85 to 1.03), and unmet communication needs (coefficient 0.84; 0.76 to 0.92). CONCLUSION Palliative care triage, which is complex and contextual, has been made more transparent through this discrete choice experiment. The Responding to Urgency of Need in Palliative Care triage tool provides an important step toward evidence-based assessment of priority for palliative care. Further research is underway to determine the validity of the tool in clinical practice and its impact on patient and caregiver outcomes.
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Affiliation(s)
- Bethany Russell
- Palliative Medicine Research Group, University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia; Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jennifer Philip
- Palliative Medicine Research Group, University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Victorian Comprehensive Cancer Centre, Melbourne, Australia; Department of Palliative Care, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Anna Collins
- Palliative Medicine Research Group, University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jodie Burchell
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Brian Le
- Victorian Comprehensive Cancer Centre, Melbourne, Australia; Department of Palliative Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Caroline Brand
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia; Department of Preventive Medicine, Monash University, Clayton, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Vrije University Brussels, Brussels, Belgium; School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Department of Public Health, La Trobe University, Bundoora, Australia
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