Fellow Icahn School of Medicine at Mount Sinai Long Island City, New York
Objective/Aim: The aim of this project is to increase the percentage of palliative care consults placed for the patients who screen positive to 33% by 01/31/2025.
Background: With an aging population, Post Acute Care (PAC) facilities are caring for increasing sick and frail populations at high risk for re-hospitalization and adverse outcomes. It is more important than ever for PAC facilities to be able to provide end of life care, document advanced directives, and identify decision makers for these patients as this could lead to more appropriate and goal-concordant care.
This is the 3rd year of this project. A summary of past years: Year 1: Improve the process of palliative care consults placed after a positive screen (done on admission) -100% success with reminder emails by the department secretary Year 2: Refining the palliative care screen for the PALTC setting- highly praised by admissions and palliative care consultant team, 70% concordance with existing clinical screen found in literature (PACT) Year 3: Audit of process reveals very few positive screen consults are now being placed
Quality Improvement Methods: This project takes place at The New Jewish Home (TNJH), a 500-bed skilled nursing facility with approximately 100 PAC beds. There are 6 full time physicians and 5 full time nurse practitioners on site.
Providers completed a survey about barriers to placing palliative care consults.
PDSA 1: Providers re-educated about the purpose of the screening tool, the expected workflow, and where to see a positive result.
Results : Graph
Conclusions: Although the importance of palliative care involvement for patients admitted to PAC is understood by the providers, consults orders based on the screening process are often not placed. Many factors, such as the number of providers involved in one patient's care; provider turnover; competing interests and multiple tasks required of providers to complete on admission; and the diverse level of training of each provider affect the systematization of palliative care screening in the PAC setting. Prior iterations of the palliative care screening process- particularly the placement of consults by providers- were successful due to a third party performing weekly audits and sending email reminders. Unfortunately, the balancing factor was that this placed too much burden on this member of the administrative team. While there may be room to improve upon the existing palliative care screen, we felt that it was most important to establish a clear workflow for consult placement following a positive screen as failing to place consults would render any screen useless. The proposed next PDSA cycle will involve a new member to this process- a role not present at the initiation of this project 3 years ago- an admission nurse whose sole task is completing admissions orders. The task of placing the consult order (for co-signing by a provider) for a positive screen will be given to this nurse, thus removing the above obstacles and streamlining the process.
