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Palliative care interventions in intensive care unit patients. Intensive Care Med 2021; 47:1415-1425. [PMID: 34652465 DOI: 10.1007/s00134-021-06544-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
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Kuchinad K, Sharma R, Isenberg SR, Hamayel NAA, Weaver SJ, Zhu J, Hannum SM, Kamal AH, Walling AM, Lorenz KA, Ailon J, Dy SM. Perceptions of Facilitators and Barriers to Measuring and Improving Quality in Palliative Care Programs. Am J Hosp Palliat Care 2020; 37:1022-1028. [PMID: 32336104 DOI: 10.1177/1049909120916702] [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] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine perceptions of facilitators and barriers to quality measurement and improvement in palliative care programs and differences by professional and leadership roles. METHODS We surveyed team members in diverse US and Canadian palliative care programs using a validated survey addressing teamwork and communication and constructs for educational support and training, leadership, infrastructure, and prioritization for quality measurement and improvement. We defined key facilitators as constructs rated ≥4 (agree) and key barriers as those ≤3 (disagree) on 1 to 5 scales. We conducted multivariable linear regressions for associations between key facilitators and barriers and (1) professional and (2) leadership roles, controlling for key program and respondent factors and clustering by program. RESULTS We surveyed 103 respondents in 11 programs; 45.6% were physicians and 50% had leadership roles. Key facilitators across sites included teamwork, communication, the implementation climate (or environment), and program focus on quality improvement. Key barriers included educational support and incentives, particularly for quality measurement, and quality improvement infrastructure such as strategies, systems, and skilled staff. In multivariable analyses, perceptions did not differ by leadership role, but physicians and nurse practitioners/nurses/physician assistants rated most constructs statistically significantly more negatively than other team members, especially for quality improvement (6 of the 7 key constructs). CONCLUSIONS Although participants rated quality improvement focus and environment highly, key barriers included lack of infrastructure, especially for quality measurement. Building on these facilitators and measuring and addressing these barriers might help programs enhance palliative care quality initiatives' acceptability, particularly for physicians and nurses.
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Affiliation(s)
| | - Ritu Sharma
- Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarina R Isenberg
- Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Temmy Latner Centre for Palliative Care, 518775Sinai Health System, Toronto, Ontario, Canada.,Division of Palliative Care, Department of Family and Community Medicine, 7938University of Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, 7938University of Toronto, Ontario, Canada
| | - Nebras Abu Al Hamayel
- Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Junya Zhu
- 1466Yale University, New Haven, CT, USA
| | - Susan M Hannum
- Department of Health, Behavior and Society, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Arif H Kamal
- Duke Cancer Institute and Duke Fuqua School of Business, 3065Duke University, Durham, NC, USA
| | - Anne M Walling
- 19975VA Greater Los Angeles Health System, Los Angeles, CA, USA.,19975University of California, Los Angeles, CA, USA
| | | | - Jonathan Ailon
- Division of Palliative Care, Department of Medicine, 7938University of Toronto, Ontario, Canada
| | - Sydney M Dy
- 1466Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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A Comparison of Policy Analysis of Palliative Care for Cancer in UK, Malaysia, and South Africa. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2019. [DOI: 10.5812/ijcm.94841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Dy SM, Sharma R, Kuchinad K, Liew ZR, Abu Al Hamayel N, Hannum SM, Zhu J, Kamal AH, Walling AM, Lorenz KA, Isenberg SR. Evaluation of the Measuring and Improving Quality in Palliative Care Survey. J Oncol Pract 2018; 14:e834-e843. [PMID: 30537461 DOI: 10.1200/jop.18.00405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the reliability, content validity, and variation among sites of a survey to assess facilitators and barriers to quality measurement and improvement in palliative care programs. METHODS We surveyed a sample of diverse US and Canadian palliative care programs and conducted postcompletion discussion groups. The survey included constructs addressing educational support and training, communication, teamwork, leadership, and prioritization for quality measurement and improvement. We tested internal consistency reliability, described variation among sites, and reported descriptive feedback on content validity. RESULTS Of 103 respondents in 11 sites, the most common roles were attending physician (38.9%) and nurse practitioner, clinical nurse specialist, or physician assistant (16.5%). Internal consistency reliability was acceptable (Cronbach's α = .70 to .99) for all but one construct. Results varied across sites by more than 1 point on the 1 to 5 scales between the 10th and 90th percentiles of sites for two constructs in recognition and focus on quality measurement (score range by site, 1.7 to 4.8), one construct in teamwork (score range, 3.1 to 4.6), and five constructs in quality improvement (score range, 1.8 to 4.6). In descriptive content validity evaluation, respondents described the survey as an opportunity for assessing quality initiatives and discussing potential improvements, particularly improvements in communication, training, and engagement of team members regarding program quality efforts. CONCLUSION This survey to assess palliative care team perspectives on barriers and facilitators for quality measurement and improvement demonstrated reliability, content validity, and initial evidence of variation among sites. Our findings highlight how palliative care team members' perspectives may be valuable to plan, evaluate, and monitor quality-of-care initiatives.
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Affiliation(s)
- Sydney M Dy
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ritu Sharma
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Kamini Kuchinad
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zi-Rou Liew
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nebras Abu Al Hamayel
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Hannum
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Junya Zhu
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Arif H Kamal
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anne M Walling
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Karl A Lorenz
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sarina R Isenberg
- Johns Hopkins Bloomberg School of Public Health; Johns Hopkins School of Medicine, Baltimore, MD; University of Cincinnati College of Medicine, Cincinnati, OH; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC; Veterans Affairs Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles; Stanford School of Medicine, Stanford, CA; Temmy Latner Centre for Palliative Care, Sinai Health System; University of Toronto; and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Ahluwalia SC, Chen C, Raaen L, Motala A, Walling AM, Chamberlin M, O'Hanlon C, Larkin J, Lorenz K, Akinniranye O, Hempel S. A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition. J Pain Symptom Manage 2018; 56:831-870. [PMID: 30391049 DOI: 10.1016/j.jpainsymman.2018.09.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/07/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers. OBJECTIVES The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. METHODS Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel. RESULTS We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews). CONCLUSION A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.
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Affiliation(s)
- Sangeeta C Ahluwalia
- RAND Health, Santa Monica, California, USA; UCLA Fielding School of Public Health, Los Angeles, California, USA.
| | - Christine Chen
- Pardee RAND Graduate School, Santa Monica, California, USA
| | | | - Aneesa Motala
- Evidence based Practice Center, RAND Corp., Santa Monica, California, USA
| | - Anne M Walling
- RAND Health, Santa Monica, California, USA; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA
| | | | | | - Jody Larkin
- Evidence based Practice Center, RAND Corp., Santa Monica, California, USA
| | - Karl Lorenz
- RAND Health, Santa Monica, California, USA; VA Palo Alto Health Care System, Center for Innovation to Implementation, Menlo Park, California, USA; Stanford University School of Medicine, Stanford, California, USA
| | | | - Susanne Hempel
- Evidence based Practice Center, RAND Corp., Santa Monica, California, USA
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Namisango E, Bristowe K, Allsop MJ, Murtagh FEM, Abas M, Higginson IJ, Downing J, Harding R. Symptoms and Concerns Among Children and Young People with Life-Limiting and Life-Threatening Conditions: A Systematic Review Highlighting Meaningful Health Outcomes. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 12:15-55. [DOI: 10.1007/s40271-018-0333-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Dy SM, Al Hamayel NA, Hannum SM, Sharma R, Isenberg SR, Kuchinad K, Zhu J, Smith K, Lorenz KA, Kamal AH, Walling AM, Weaver SJ. A Survey to Evaluate Facilitators and Barriers to Quality Measurement and Improvement: Adapting Tools for Implementation Research in Palliative Care Programs. J Pain Symptom Manage 2017; 54:806-814. [PMID: 28801007 PMCID: PMC5705262 DOI: 10.1016/j.jpainsymman.2017.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/23/2017] [Accepted: 06/07/2017] [Indexed: 11/20/2022]
Abstract
CONTEXT Although critical for improving patient outcomes, palliative care quality indicators are not yet widely used. Better understanding of facilitators and barriers to palliative care quality measurement and improvement might improve their use and program quality. OBJECTIVES Development of a survey tool to assess palliative care team perspectives on facilitators and barriers to quality measurement and improvement in palliative care programs. METHODS We used the adapted Consolidated Framework for Implementation Research to define domains and constructs to select instruments. We assembled a draft survey and assessed content validity through pilot testing and cognitive interviews with experts and frontline practitioners for key items. We analyzed responses using a constant comparative process to assess survey item issues and potential solutions. We developed a final survey using these results. RESULTS The survey includes five published instruments and two additional item sets. Domains include organizational characteristics, individual and team characteristics, intervention characteristics, and process of implementation. Survey modules include Quality Improvement in Palliative Care, Implementing Quality Improvement in the Palliative Care Program, Teamwork and Communication, Measuring the Quality of Palliative Care, and Palliative Care Quality in Your Program. Key refinements from cognitive interviews included item wording on palliative care team members, programs, and quality issues. CONCLUSION This novel, adaptable instrument assesses palliative care team perspectives on barriers and facilitators for quality measurement and improvement in palliative care programs. Next steps include evaluation of the survey's construct validity and how survey results correlate with findings from program quality initiatives.
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Affiliation(s)
- Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA; Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Nebras Abu Al Hamayel
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Susan M Hannum
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ritu Sharma
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sarina R Isenberg
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Junya Zhu
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Katherine Smith
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Karl A Lorenz
- Stanford School of Medicine, Stanford, California, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Anne M Walling
- VA Greater Los Angeles Health System, University of California, Los Angeles, Los Angeles, California, USA
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Individualized Performance Feedback to Surgical Residents Improves Appropriate Venous Thromboembolism Prophylaxis Prescription and Reduces Potentially Preventable VTE: A Prospective Cohort Study. Ann Surg 2017; 264:1181-1187. [PMID: 26649586 DOI: 10.1097/sla.0000000000001512] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the effect of providing personal clinical effectiveness performance feedback to general surgery residents regarding prescription of appropriate venous thromboembolism (VTE) prophylaxis. BACKGROUND Residents are frequently charged with prescribing medications for patients, including VTE prophylaxis, but rarely receive individual performance feedback regarding these practice habits. METHODS This prospective cohort study at the Johns Hopkins Hospital compared outcomes across 3 study periods: (1) baseline, (2) scorecard alone, and (3) scorecard plus coaching. All general surgery residents (n = 49) and surgical patients (n = 2420) for whom residents wrote admission orders during the first 9 months of the 2013-2014 academic year were included. Outcomes included the proportions of patients prescribed appropriate VTE prophylaxis, patients with preventable VTE, and residents prescribing appropriate VTE prophylaxis for every patient, and results from the Accreditation Council for Graduate Medical Education resident survey. RESULTS At baseline, 89.4% of patients were prescribed appropriate VTE prophylaxis and only 45% of residents prescribed appropriate prophylaxis for every patient. During the scorecard period, appropriate VTE prophylaxis prescription significantly increased to 95.4% (P < 0.001). For the scorecard plus coaching period, significantly more residents prescribed appropriate prophylaxis for every patient (78% vs 45%, P = 0.0017). Preventable VTE was eliminated in both intervention periods (0% vs 0.35%, P = 0.046). After providing feedback, significantly more residents reported receiving data about practice habits on the Accreditation Council for Graduate Medical Education resident survey (87% vs 38%, P < 0.001). CONCLUSIONS Providing personal clinical effectiveness feedback including data and peer-to-peer coaching improves resident performance, and results in a significant reduction in harm for patients.
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Goel A, Sanchez J, Paulino L, Feuille C, Arend J, Shah B, Dieterich D, Perumalswami PV. A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care. J Viral Hepat 2017; 24:477-485. [PMID: 28039935 DOI: 10.1111/jvh.12669] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/20/2016] [Indexed: 12/12/2022]
Abstract
Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link-to-care programme with patient navigation in two New York City primary care practices. This was a 2-year prospective study of patients born between 1945-1965 ("baby boomers") with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14 642 primary care baby boomer patients of which 4419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (P<.01) with an HCV seropositive rate of 3.3%. Factors associated with being HCV seropositive included older age (P<.01), male sex (P<.01), African American race (P<.01) and receiving care in the housestaff practice (P<.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV-infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening programme using well-studied principles identifies a large number of undiagnosed baby boomers within hospital-based primary care and improves access to specialty providers in a timely manner.
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Affiliation(s)
- A Goel
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - J Sanchez
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - L Paulino
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - C Feuille
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - J Arend
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - B Shah
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - D Dieterich
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - P V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine Mount Sinai, New York, NY, USA
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Garner KK, Dubbert P, Lensing S, Sullivan DH. Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement. J Pain Symptom Manage 2017; 53:1-4. [PMID: 27876636 DOI: 10.1016/j.jpainsymman.2016.10.356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/06/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT The Measuring What Matters initiative of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association identified documentation of a surrogate decision maker as one of the top 10 quality indicators in the acute hospital and hospice settings. OBJECTIVES To better understand the potential implementation of this Measuring What Matters quality measure #8, Documentation of Surrogate in outpatient primary care settings by describing primary care patients' self-reported identification and documentation of a surrogate decision maker. METHODS Examination of patient responses to self-assessment questions from advance health care planning educational groups conducted in one medical center primary care clinic and seven community-based outpatient primary care clinics. We assessed the concordance between patient reports of identifying and naming a surrogate decision maker and having completed an advance directive (AD) with presence of an AD in the electronic medical record. RESULTS Of veterans without a documented AD on file, more than half (66%) reported that they had talked with someone they trusted and nearly half (52%) reported that they had named someone to communicate their preferences. CONCLUSIONS Our clinical project data suggest that many more veterans may have initiated communications with surrogate decision makers than is evident in the electronic medical record. System changes are needed to close the gap between veterans' plans for a surrogate decision maker and the documentation available to acute care health care providers.
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Affiliation(s)
- Kimberly K Garner
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; VISN 16/CAVHS Geriatric Research Education and Clinical Center, Little Rock, Arkansas, USA.
| | - Patricia Dubbert
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; VISN 16/CAVHS Geriatric Research Education and Clinical Center, Little Rock, Arkansas, USA
| | - Shelly Lensing
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; VISN 16/CAVHS Geriatric Research Education and Clinical Center, Little Rock, Arkansas, USA
| | - Dennis H Sullivan
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; VISN 16/CAVHS Geriatric Research Education and Clinical Center, Little Rock, Arkansas, USA
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Abstract
The current state of the science in the fields of patient safety and palliative and end-of-life care have many issues in common. This article synthesizes recent systematic reviews and additional research on improving patient safety and end-of-life care and compares each field’s perspective on common issues, both in traditional patient safety frameworks and in other areas, and how current approaches in each field can inform the other. The article then applies these overlapping concepts to a key example area: improving documentation of patient preferences for life-sustaining treatment. The synthesis demonstrates how end-of-life issues should be incorporated into patient safety initiatives. In addition, evaluating overlap and comparable issues between patient safety and end-of-life care and comparing different perspectives and improvement strategies can benefit both fields.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy & Management, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
- Harry J. Duffey Family Pain and Palliative Care Program, Baltimore, MD, USA
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12
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Braus N, Campbell TC, Kwekkeboom KL, Ferguson S, Harvey C, Krupp AE, Lohmeier T, Repplinger MD, Westergaard RP, Jacobs EA, Roberts KF, Ehlenbach WJ. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med 2016; 42:54-62. [PMID: 26556622 PMCID: PMC4945103 DOI: 10.1007/s00134-015-4098-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/08/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the effects of a palliative care intervention on clinical and family outcomes, and palliative care processes. METHODS Prospective, before-and-after interventional study enrolling patients with high risk of mortality, morbidity, or unmet palliative care needs in a 24-bed academic intensive care unit (ICU). The intervention involved a palliative care clinician interacting with the ICU physicians on daily rounds for high-risk patients. RESULTS One hundred patients were enrolled in the usual care phase, and 103 patients were enrolled during the intervention phase. The adjusted likelihood of a family meeting in ICU was 63% higher (RR 1.63, 95% CI 1.14-2.07, p = 0.01), and time to family meeting was 41% shorter (95% CI 52-28% shorter, p < 0.001). Adjusted ICU length of stay (LOS) was not significantly different between the two groups (6% shorter, 95% CI 16% shorter to 4% longer, p = 0.22). Among those who died in the hospital, ICU LOS was 19% shorter in the intervention (95% CI 33-1% shorter, p = 0.043). Adjusted hospital LOS was 26% shorter (95% CI 31-20% shorter, p < 0.001) with the intervention. Post-traumatic stress disorder (PTSD) symptoms were present in 9.1% of family respondents during the intervention versus 20.7% prior to the intervention (p = 0.09). Mortality, family depressive symptoms, family satisfaction and quality of death and dying did not significantly differ between groups. CONCLUSIONS Proactive palliative care involvement on ICU rounds for high-risk patients was associated with more and earlier ICU family meetings and shorter hospital LOS. We did not identify differences in family satisfaction, family psychological symptoms, or family-rated quality of dying, but had limited power to detect such differences.
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Affiliation(s)
- Nicholas Braus
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Toby C Campbell
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Susan Ferguson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Carrie Harvey
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Anna E Krupp
- School of Nursing, University of Wisconsin, Madison, WI, USA
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Tara Lohmeier
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael D Repplinger
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Ryan P Westergaard
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Elizabeth A Jacobs
- Division of General Internal Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | | | - William J Ehlenbach
- Divisions of Pulmonary and Critical Care Medicine, Allergy and Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 5230 Medical Foundation Centennial Building, 1685 Highland Avenue, mail code 2281, Madison, WI, 53705-2281, USA.
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Abstract
PURPOSE OF REVIEW Although providing palliative care in the ICU has become a priority, the success of different methods to integrate palliative care into the ICU has varied. This review examines the current evidence supporting the different models of palliative care delivery and highlights areas for future study. RECENT FINDINGS The need for palliative care for ICU patients is substantial. A large percentage of patients meet criteria for palliative care consultation and there is frequent use of intensive care and other nonbeneficial care at the end of life. Overall, the consultative model of palliative care appears to have more of an impact on patient care. However, given the current workforce shortage of palliative care providers, a sustainable model of delivering palliative care requires both an effective integrative model, in which palliative care is delivered by ICU clinicians, and appropriate use of the consultative model, in which palliative care consultation is reserved for patients at highest risk of having unmet or long-term palliative care needs. SUMMARY Developing a mixed model of palliative care delivery is necessary to meet the palliative care needs of critically ill patients. Efforts focused on improving integrative models and appropriately targeting the use of palliative care consultants are needed.
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Rebecca A. Aslakson, M.D., Ph.D., Recipient of the 2014 Presidential Scholar Award. Anesthesiology 2014; 121:692-4. [DOI: 10.1097/aln.0000000000000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Tieman J, Rawlings D, Taylor J, Adams A, Mills S, Vaz H, Banfield M. Supporting service change in palliative care: a framework approach. Int J Palliat Nurs 2014; 20:349-56. [PMID: 25062381 DOI: 10.12968/ijpn.2014.20.7.349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Palliative care services are increasingly identifying areas for improvement, then trying to create appropriate changes in response. Nurses in particular are often expected to take leading roles in quality improvement (QI) but are not necessarily trained or supported in these processes. METHODS A framework approach to change was developed to guide services through a change cycle and delivered via workshops by representatives of three Australian national projects. Participants were predominantly nurses (80%), with the majority (63.7%) over the age of 50. FINDINGS The workshops and the framework were positively evaluated, with participants feeling confident in a number of QI-related activities following workshop training. CONCLUSION Recognising and addressing problems in clinical practice and service delivery is an important way for nurses to ensure quality care for patients; however, they need support in developing the skills and knowledge that are essential to successful QI activities.
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McLeod-Sordjan R. Death preparedness: a concept analysis. J Adv Nurs 2013; 70:1008-19. [DOI: 10.1111/jan.12252] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Renee McLeod-Sordjan
- Pace University; College of Health Professions; New York New York USA
- Attending Division of Medical Ethics, North Shore-Long Island Jewish, University Hospital System; Great Neck, New York USA
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