The Development and Evaluation of an Inpatient Palliative Care Admission Triage Tool

Evaluating the effectiveness of a clinical nurse specialist triage role in a specialist palliative care community service

BACKGROUND

In 2017, a clinical nurse specialist (CNS) triaging role was created within a specialist palliative care community service (SPCCS) in Ireland to enhance the triage process. The aim of this study is to evaluate the effectiveness of the role regarding data collection and reporting. Structured feedback from healthcare professionals (HCPs) was obtained on the effects, challenges and sustainability of this role.

METHODS

This study used a mixed-methods approach. A quantitative analysis of referrals triaged by the SPCCS CNS over 2 years (2018-2019) was performed. Two focus groups with HCP's within the same service were completed in January 2020 and one-to-one interviews were conducted. The quantitative and qualitative results were merged using a triangulation protocol.

RESULTS

In 2017, new health service executive (HSE) standards to categorise the urgency of patient assessment were introduced. Quantitatively, an improvement within the triage process was seen, with an increase in compliance with national access standards. In 2018, compliance was 89.1%. In 2019, this was 96.8%, an improvement of 7.7%. A data discrepancy of 9.5% of referrals was noted over the first 9 months of 2018. After this, data documentation and congruency were seen to improve for the final 3 months of 2018 to 100% and remained at 100%. Qualitative data highlighted the benefits and challenges of the Triage CNS role. Mixed-methods correlation revealed corroboration between both using a triangulation protocol.

CONCLUSION

The triage CNS role was pivotal as an initial point of referral contact. Increased compliance with national access standards occurred resulting in improvements in case and case-load management, information gathering, documentation, data collection and analysis.

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.

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.

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

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.

The evaluation of A Triage Tool for A Community Palliative Care Service Provider

Introduction: Triage, widely used by the military and emergency departments, has not been reported in community palliative care services. Policy designed to improve equitable provision of this care has led to the development of a triage tool. Methods: Retrospective data were collected (50 percent of referrals, n=204) and analyzed using the Wilcoxon signed-rank test to determine the accuracy of the tool in predicting patient status at the first visit. Semi-structured interviews (n=7) with palliative care service staff added qualitative data. Results: Although significant differences between triage scores compared to outcomes at first visit were observed, issues such as upgrading of triage category compared to priority score occurred in more than 30 percent of cases. When correction for this was made, the tool was found to be an accurate guide to patient needs. Conclusion: This tool, when used as intended, was effective in assessing the urgency of need, and it is potentially useful on a wider scale, subject to further evaluation.

Responding to urgency of need: Initial qualitative stage in the development of a triage tool for use in palliative care services

BACKGROUND

Palliative care services face the challenge of a workload increasing in volume and diversity. An evidence-based triage method to assess urgency of palliative care needs is required to ensure equitable, efficient and transparent allocation of specialist resources when managing waiting lists.

AIM

As the initial stage of a mixed-method sequential design, this study aimed to explore palliative care providers' practices and attitudes towards triaging palliative care needs and their views regarding the implementation of a standardised approach.

DESIGN

A qualitative study was conducted involving focus groups and interviews. Transcripts were subjected to deductive thematic analysis.

SETTING/PARTICIPANTS

A total of 20 palliative care providers were purposively sampled to ensure representation across disciplines (primary, specialist; medicine, nursing and allied health), service types (inpatient, hospital liaison and community) and locations (metropolitan and rural).

RESULTS

A series of markers of urgency were identified, including physical and psychological suffering, caregiver distress, discrepancy between care needs and care arrangements, mismatch between current site of care and desired site of death when in terminal phase and complex communication needs. Performance status and phase of disease were reported to be less informative when considered in isolation. Interpersonal and system-based barriers to the implementation of a palliative care triage tool were highlighted.

CONCLUSION

The process of triage in the palliative care setting is complex but can be conceptualised using a limited number of domains. Further research is required to establish the relative value clinicians attribute to these domains and thus inform the development of an acceptable and useful evidence-based palliative care triage tool.

Pilot Testing of Triage Coding System in Home-based Palliative Care Using Edmonton Symptom Assessment Scale

INTRODUCTION

Home-based palliative care is an essential model of palliative care that aims to provide continuity of care at patient's own home in an effective and timely manner. This study was a pilot test of triage coding system in home-based palliative care using Edmonton Symptom Assessment System (ESAS) scale.

METHODS

Objective of the study was to evaluate if the triage coding system in home-based palliative care: (a) Facilitated timely intervention, (b) improved symptom control, and (c) avoided hospital deaths. Homecare services were coded as high (Group 1 - ESAS scores ≥7), medium (Group 2 - ESAS scores 4-6), and low (Group 3 - ESAS scores 0-3) priority based on ESAS scores. In high priority group, patients received home visit in 0-3 working days; medium priority group, patients received home visit in 0-10 working days; and low priority group, patients received home visit in 0-15 working days. The triage duration of home visit was arbitrarily decided based on the previous retrospective audit and consensus of the experts involved in prioritization and triaging in home care.

RESULTS

"High priority" patients were visited in 2.63 ± 0.75 days; "medium priority" patients were visited in 7.00 ± 1.5 days, and "low priority" patients were visited in 10.54 ± 2.7 days. High and medium priority groups had a statistically significant improvement in most of the ESAS symptoms following palliative home care intervention. Intergroup comparison showed that improvement in symptoms was the highest in high priority group compared to medium and low priority group. There was an 8.5% increase in home and hospice deaths following the introduction of triage coding system. There was a significant decrease in deaths in the hospital in Group 1 (6.3%) (χ (2) = 27.3, P < 0.001) compared to Group 2 (28.6%) and Group 3 (15.4%). Group 2 had more hospital deaths. Interval duration from triaging to first intervention was a significant predictor of survival with odds ratio 0.75 indicating that time taken for intervention from triaging was more significantly affecting survival than group triaging.

CONCLUSION

Pilot study of testing triaging coding system in home-based palliative care showed, triage coding system: (a) Facilitated early palliative home care intervention, (b) improved symptom control, (c) decreased hospital deaths, predominantly in high priority group, and (d) time taken for intervention from triaging was a significant predictor of survival.

The development of an instrument that can identify children with palliative care needs: the Paediatric Palliative Screening Scale (PaPaS Scale): a qualitative study approach

BACKGROUND

The introduction of paediatric palliative care and referral to specialised teams still occurs late in the illness trajectory of children with life-limiting diseases. The aim of this ongoing multipart study was to develop a screening instrument for paediatricians that would improve the timely identification of children who could benefit from a palliative care approach.

METHODS

We used a qualitative study approach with semi-structured interviews (Part 1) and a focus group discussion (Part 2) to define the domains and items of the screening instrument. Seven international paediatric palliative care experts from the UK, France, USA, and Canada took part in face-to-face interviews, and eleven paediatric health professionals from the University Children's Hospital, Zurich, participated in a subsequent focus group discussion.

RESULTS

This preliminary phase of development and validation of the instrument revealed five domains relevant to identifying children with life-limiting diseases, who could benefit from palliative care: 1) trajectory of disease and impact on daily activities of the child; 2) expected outcome of disease-directed treatment and burden of treatment; 3) symptom and problem burden; 4) preferences of patient, parents or healthcare professional; and 5) estimated life expectancy. Where palliative care seems to be necessary, it would be introduced in a stepwise or graduated manner.

CONCLUSIONS

This study is a preliminary report of the development of an instrument to facilitate timely introduction of palliative care in the illness trajectory of a severely ill child. The instrument demonstrated early validity and was evaluated as being a valuable approach towards effective paediatric palliative care.

Factors influencing survival after discharge from an Australian palliative care unit to residential aged care facilities: a retrospective audit

BACKGROUND

Increasing demand for palliative care unit (PCU) beds has led to shorter inpatient stays and a requirement to transfer some patients from a PCU to a residential aged care facility (RACF). Concerns have been raised regarding this move with suggestion that patients often die shortly after transfer. Published data investigating this patient group are limited. The aim of the current study was to audit discharges from a PCU to RACFs specifically looking at predictive factors for survival following discharge.

METHODS

A retrospective audit was undertaken of all discharges from the Barwon Health PCU to RACFs between July 2007 and July 2010. Data on patient demographics, clinical and functional status, admission and discharge details, and survival times were examined. Factors influencing survival were evaluated by Cox proportional-hazards regression analysis.

RESULTS

Sixty-two discharges from a PCU to an RACF were included in the analysis. The mean age at discharge was 76 and the majority of patients had malignant disease. Mean and median survival times post-transfer were 106 and 42.5 days, respectively, and 16% of subjects survived more than 100 days. From univariate analyses age, PCU length of stay, admission Resource Utilization Groups-Activities of Daily Living (RUG-ADL) score, dependent mobility, having lung cancer or cancer of unknown primary, and living alone or in an RACF pre PCU admission affected survival. Multivariate analyses showed age, PCU length of stay, RUG-ADL score, and living situation prior to PCU admission together were associated with postdischarge survival times.

CONCLUSIONS

This study is one of the largest investigating this cohort and suggests a number of factors that may predict survival for patients after discharge from a PCU to an RACF.