Palliative medicine consultation triggers on the general practice unit
Robbins-Ong M, Chasteen KA, and Cerasale MT. Palliative medicine consultation triggers on the general practice unit. J Gen Intern Med 2017; 32(2):S780-S781.
J Gen Intern Med
STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Identifying patients on general practice units who could benefit from a palliativemedicine consultation can be difficult and there is little available literature to help guide selection. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): 1. Develop evidence-based criteria for identification of patients who would benefit from a palliative medicine consultation. 2. Integrate the criteria into a sustainable workflow, such that the volume of triggered consultations is manageable to be seen daily. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The development of criteria to trigger a palliative medicine consultation began with a review of the available literature. Multiple studies have created consultation criteria for the intensive care unit. Features of these studies were selected that could be applied on general practice units. An initial list of patient characteristics was developed and included potentially life-threatening condition plus positive “surprise” question, ≥2 hospitalizations for the same condition in 3 months, admission for difficult to control physical or psychological symptoms, metastatic or incurable cancer, advanced dementia, failure to thrive, or admission from advanced care facility, which was to be applied upon admission. Secondary criteria were developed to increase specificity of patients who would benefit from consultation. These criteria included ongoing distressing physical or psychological symptoms, social or spiritual concerns affecting daily life, lack of understanding of current illness, goals or care unidentified, uncertainly of decision maker, or treatment options do not match patientcentered goals, which would be applied on the second day of hospitalization and only to patients who met the initial criteria. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): The primary outcomemeasure of the project is the number of consultations that would be generated daily. Initial process measures include the number of patients triaged and the number of patients whomeet the first set of criteria. Qualitative feedback from the general practice unit teams on the aid from the completed consultations would also be reviewed. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): Two PDSA cycles using consultation trigger criteria were completed on a single general practice unit with largely qualitative data collection. The first cycle found the single-step criteria was easily applied in daily rounds, but there was initially discrepancy amongst the providers regarding criteria definitions. Nearly 50% of new admissions met the initial criteria. During the second PDSA cycle, fewer patients met the initial trigger criteria and even fewer met the second step. The volume of potential new consultations averaged less than one per day. The project lead felt the criteria were easy to apply, but had to help guide the other members of the team on criteria application. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY?): A two-step, evidence-based, criteria for recommendation of a palliative medicine consultation was able to generate a sustainable volume of potential new patients on general practice units who would be highly likely to see benefit from a consultation.