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Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. It is often confused by health care professionals with hospice which is a facility or program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill. Co-morbidities have consistently contributed to 7 and 30-day readmission rates (i.e. HF, COPD) being above the benchmark and nursing has been attempting to identify solutions to help address this issue. This is a population of individuals who would quality for palliative care services, yet are never offered palliative care services. Nurses are the caregivers at the bedside of the patient who can help to identify those individuals needing palliative care services in order to help prevent readmissions and provide for better symptom management in these individuals. With this information in mind, potential solutions to address the barriers that exist to getting the individuals who need palliative care services to them were evaluated. The two most identified barriers were: not identifying individuals early on that would qualify for palliative care services; and the process that exists that requires a nurse to obtain a physician consult prior to consulting with palliative care.

INTRODUCTION

OBJECTIVES

TARGET POPULATION AND SAMPLING: The target population was all patients admitted to the Cardiac Surveillance (CSU) and Progressive Care (PCU) units from April 1st, 2016 to July 31st, 2016. This was a convenience sample with the number of participants determinant on the number of admissions to these two nursing units during the specified timeframe. PROCESS: Criteria that needed to be included on the palliative care screening tool was compiled based on the literature and guidelines. Once the tool was agreed upon by all stakeholders, a trial of screening new admissions was conducted for 30 days to ensure that the tool was efficiently identifying the patients appropriately based on the scoring system. In order to ensure that the nursing staff on the identified units understood the tool and process, education was conducted with them that included what palliative care is, how to complete the palliative care screening tool, what to do with the results of the palliative care screening tool . Those patients that were not directly admitted on the identified nursing units for this study were excluded (i.e. surgical patients admitted through Surgicare/transfers) as the admission process is conducted prior to the patient’s arrival to the unit. While the nurse on either CSU or PCU was completing the individual’s admission they also started to complete a Palliative Care Screening Tool. (see Picture A) Based upon the score of the screening tool, nursing then took one of the two options: 1.  A score of 4-5 on the screening tool prompts for a NURNI order (nurse no interface) to send a notification to the Palliative Care Advanced Practice Nurses that a patient qualifies for a consult (see Picture B). 2.  A score of greater than 6 on the screening tool a message will appear to

“Notify case management for possible hospice eligibility”.

Case management then reassessed the patient every 48 hours to determine if the patient situation has changed and the score is different. Subsequent scores would result in the same actions as above. Picture A Picture B

METHODS

DATA COLLECTION METHODS: Data was collected through an electronic report that tracked readmitted patients, their palliative care screening scores and if a palliative care consult was completed when deemed appropriate based on the score of the screening. Readmission information was obtained from the Quality Resource Department (QRD) who routinely tracks this data for both 7 and 30 day readmissions. DATA & FINDINGS: Upon completion of the first 90 days of data collection, a comparison of data was done to determine if the palliative care screening tool on admission was having an impact. The 30 day overall readmission rate did not show any significant improvement as shown in the graph below (Graph A). Since data for the remainder of the months was not considered complete yet by QRD, any data after April was not able to be included. Graph A In evaluation of the 7 day readmission data the only disease process that had any change was that of heart failure (Graph B). Data was only available from QRD for the first two months which showed a positive decrease, though it cannot be excluded that this is due to normal variation until the remainder of the data is complete. It could be concluded that if heart failure is the only disease process that had a change that it was due to the two units selected for the initial research were both the primary cardiac units at the hospital where the research is being done. Graph B

RESULTS CONCLUSIONS

After completion of the initial parts of this research, it is determined that a longer timeframe is needed to continue to collect the readmission rates in order to conclude if conducting a palliative care screening on admission to an acute care setting can have an impact on readmission rates over an extended period of time. The next steps will be to expand the palliative care screening tool to all adult inpatient units so that a larger population of patients can be included in the data. Having a larger population of patients be included may impact the readmission rates more globally than just the use of the tool on the two specified units. Of note, nurses who were able to use the palliative care screening tool felt more empowered to get the services needed for their patients because they had the ability to initialize the consult nurse-to-nurse verses having to obtain a physician order to have this process started. There was also an increase in palliative care consults by 15.1% when compared to the previous year at the same time.

REFERENCES•  Antonio, C.P., Barretto, A., Del Carlo, C., et al. (2007). Re-hospitalizations

and mortality still at alarming rates in advanced heart failure. J Cardiac Failure, 13, S153.

•  Bausewein, C., Le Grice, C., Simon, S., & Higginson, I. (2001). The use of two common palliative outcome measures in clinical care and research: A systematic review of POS and STAS. Palliative Medicine, 25(4), 304-313. doi: 10.1177/0269216310395984

•  Bergh, I., Kvalem, I., Aass, N., & Hjermstad, M. (2011). What does the answer mean? A qualitative study of how palliative cancer patients interpret and respond to the Edmonton Symptom Assessment system. Palliative Medicine, 25(7), 716-724. doi: 10.1177/0269216310395985

•  Cao, Z., Ong, K.C., Eng, P., Tan, W.C., & Ng, T.P. (2006). Frequent hospital readmissions for acute exacerbation of COPD and their associated factors. Respirology, 11, 188-195.

•  Ferrell, B.R. (2005). Late referrals to palliative care. Journal of Clinical Oncology, 22(12), 2588-2589.

•  Jacobson, J. (2013). Palliative and end-of-life care: Where are we now? American Journal of Nursing, 113(5), 21-23. doi: 10.1097/01.NAJ0000430226.14445.c8

•  Kallen, M., Yang, D., & Haas, N. (2012). A technical solution to improving palliative and hospice care. Support Care Cancer, 20, 164-174. doi: 10.1007/s00520-011-1086-z

•  Malloy, P., Virani, R., Kelly, K., Jacobs, H., & Ferrell, B. (2008). End-of-life care: Improving communication skills to enhance palliative care. Retrieved from http://www.medscape.com/viewprogram/12632_pnt

•  Rice, E.M., & Betcher, D.K. (2010). Palliative care in an acute care hospital: From pilot to consultation service. MedSurg Nursing, 19(2), 107-112.

•  Schultz, M.J., & Gajic, O. (2010). Mandatory checklists at discharge may have the potential to prevent readmissions. Critical Care Medicine, 38, 1226-1227

•  Stephens, S. (2008). Hospital-based palliative care: Cost effective care for patients with advanced disease. Journal of Nursing Administration, 38(3), 143-145.

•  Waterworth, S., Raphael, D., & Horsburgh, M. (2012). Yes but it’s somewhat difficult-managing end of life care in primary health care. Ageing Int, 37, 459-469. doi: 10.1007/s12126-010-9092-x

•  Weissman, D.E., & Meier, D.E. (2011). Identifying patients in need of a palliative care assessment in the hospital setting. Journal of Palliative Medicine, 14(1). doi: 10:1089/jpm.2010.0347

CONTACTINFORMATION

Teresa S. White DNP RN-BC Phone: (779) 696-6442

Email: twhite@swedishamerican.org

•  Identify diagnosis that are problematic with 7 and 30 day readmission rates. •  Understand the difference between palliative care and hospice services. •  Discuss how using a tool that is nurse driven can help to identify patients

who are appropriate for palliative care sooner than the normal referral process.

SwedishAmericanaDivisionofUWHealthTeresaS.WhiteDNPRN-BC

UsingaNurseDrivenPalliaGveCareScreeningTooltoDecrease7&30-dayReadmissions

HYPOTHESIS

The use of a palliative care nurse driven screening tool upon admission will identify patients sooner who are in need of a palliative care consult to provide them with the resources necessary to prevent additional readmissions to the hospital setting.

Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16CHF7DayReadmissionRate 6.9% 8.8% 9.1% 6.9% 7.3% 21.4% 7.7% 5.4% 2.4% 0.0% 3.2% 2.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

7Da

yRe

admission

Rate

CHF7DayReadmissionRate

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-1630DayReadmissionRate 9.4% 9.5% 11.3% 9.2% 9.2% 9.2% 8.7% 10.1% 7.8% 8.4% 8.2% 8.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

30DayReadm

ission

Rate

30DayOverallReadmissionRate

RESEARCHQUESTION

Does the use of a nurse driven palliative care screening tool on admission identify patients in need of palliative care services sooner, resulting in a decrease in readmissions to the acute care setting?

LIMITATIONS

Only using two units in the hospital, instead of all adult care areas limited the study as well as the staffing limitations of the number of Advanced Practice Nurses in the Palliative Care office and case manager turnover. Thirty day readmission data is not all available yet at the time of this data evaluation