Screening tool streamlines requests for palliative care consultations

A simple screening tool integrated into the admissions process for critically ill patients can streamline requests for palliative care consultations, according to a study published in Critical Care Nurse (CCN).

Support for palliative care screening for patients in critical care and intensive care units (ICUs) has been building throughout health care, but there remains no standardized method to assess which patients may benefit from consultations with a palliative care specialist.

An initiative in the mixed surgical and medical ICU at Bon Secours Mercy Health Anderson, a 230-bed community hospital in Cincinnati, has sought to improve the process of requesting palliative care consultations.

"Integrating Palliative Care Screening in the Intensive Care Unit: A Quality Improvement Project" demonstrates the potential impact of adding a simple screening tool at the point of admission to initiate automatic referrals for palliative care consultations.

Co-author Traci Phillips, DNP, APRN, ACNP-BC, CCRN, is a board-certified adult acute care nurse practitioner and member of pulmonary and critical care services at the hospital. The project was conducted during her doctoral work at University of Cincinnati College of Nursing.

"Delayed access to palliative care can result in untreated symptoms, lack of understanding of a patient's care preferences and preventable admissions," she said. "We designed our screening tool to automatically trigger requests for palliative care consultations for patients whose scores meet the defined criteria."

The hospital has one full-time palliative care nurse and uses the traditional model in place at many facilities in which referrals for palliative care consults are guided by the discretion of the attending provider.

The project team used clinical indicators as the foundation of the screening tool, based on work from the Improving Palliative Care in the ICU Project of the Center to Advance Palliative Care. It was designed as a flow sheet in the electronic health record to be completed by the nurse within 24 hours of admission.

The tool includes 12 comorbidities and seven contributing factors that receive one point for every yes. In addition, previous ICU admission within three months or any hospital readmission within 30 days receives two points each. A total score of four or greater indicates referral to palliative care and triggers an automatic request for a consult.

The screening tool was applied retroactively for all patients admitted to the medical intensive care service between Oct. 1 and Dec. 31, 2019.

Of the 267 patients admitted during the project period, 31 received referrals for palliative care consultations using the traditional process. The mean time from admission until referral was six days, with a consultation occurring within two days after referral.

Further analysis indicated that the patients who received referrals using the traditional process also would have received positive results if the screening tool had been in place when they were admitted.

Applying the screening tool to the documented data available on the day of admission in each patient's electronic health record resulted in 59 patients with positive scores that would have triggered a consultation request earlier in their hospital stays.

Additional analysis looked at discharge disposition, especially for 35 patients who were discharged to skilled nursing facilities. Among these patients, only six had received referrals for palliative care consults during their hospital stays, although 17 would have received one as a result of their scores with the screening tool.

Five of the six patients who met with a palliative care specialist during their hospital stays revised their code status prior to discharge to a skilled nursing facility, demonstrating the effectiveness of the discussion. Of the 11 patients discharged to skilled nursing facilities who did not receive palliative care consults during their hospital stays but whose scores indicated they would have received referrals, nine had poor outcomes. (Four died within six months, and five were readmitted to the hospital within 30 days.)

The analysis also revealed an opportunity for the hospital to increase advance care planning discussions for all patients being discharged to skilled nursing facilities. These voluntary face-to-face conversations help determine goals of care and document the patient's health care preferences while the patient can be involved in the decision-making process.