Cecile Kyuregyan Kokozian, DNP, NP

Abstract:

Background: A 282-bed community-based hospital in Southern California with a newly established palliative care program has experienced low rates of medical orders for palliative care consultations. Many intensive care unit (ICU) patients have elevated mortality risk and nearly 20% of all patients in the United States die in an ICU. New palliative care programs experience underutilization of services and consultations occur late in the course of patients’ hospitalization when the full benefits of palliative care cannot be realized. Various studies have explored introduction of screening tools to help identify patients who could benefit from palliative care services. Objectives: This DNP project examined incorporating a mortality screening tool to determine if mortality risk upon patient admission to the ICU impacts the number and timing of medical orders for palliative care consultations. The project also explored ICU nurses’ knowledge and attitude regarding palliative care and nurses’ self-efficacy of using the SOFA screening and discussing results in ICU multidisciplainary rounds after taking a palliative care learning module. Methods: A pilot project was initiated that included nurses completing a Sequential Organ Failure Assessment (SOFA) score upon patient admission to the ICU and discussion of findings during ICU rounding. The number and timing of palliative care consultation orders were collected for 7-weeks prior to the intervention and for 7-weeks post intervention. ICU nurses took a 51-minute online educational session on the goals and benefits of palliative care and the use of SOFA and completed a demographic questionnaire and a brief survey regarding their attitudes and knowledge about palliative care. Results: Twenty-one nurses took the educational module and had improved attitude about palliative care and gained self-efficacy in performing a SOFA assessment and discussing results in ICU rounds. In the pre-intervention period, there were a total of 199 patient admissions and 224 in the post intervention period. Incorporation of a mortality screening tool did not increase the number of palliative care consultation orders but did improve the timeliness of orders. In the pre-intervention period, the mean medical order for a palliative care consultation was placed 12.8 days after ICU admission and post-intervention, this was reduced to 5.5 days. A random sample of patients received SOFA scoring, 43 patients in the pre-intervention period with average SOFA score of 6, and 54 patients in the post intervention period with average SOFA score of 3.8. Conclusion: Palliative care is often underutilized or employed late in the course of hospitalization resulting in decrease in potential benefits of the service. Incorporation of a mortality screening tool could help clinicians identify patients who have the highest risk of death during the period of hospitalization and shorten the time for patients to receive palliative care consultation. Nurses were competent in using a mortality screening tool and leading discussions of mortality risk in multidisciplinary rounds advocating for palliative care consultation for patients. Mortality screening upon admission to ICU empowered nurses to advocate for high-risk patients. Research on whether improving the timeliness of palliative care can help improve patient care, reduce costs of care and reduce burnout in ICU clinicians (by transitioning patients to more appropriate levels of care) is needed. 

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