Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.
Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore.
Am J Hosp Palliat Care. 2022 Jun;39(6):667-677. doi: 10.1177/10499091211045616. Epub 2021 Sep 15.
We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients.
The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions.
Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05).
Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.
我们开展了一项试点质量改进（QI）项目，旨在提高危重症神经外科患者获得姑息治疗的机会。
QI 项目在神经外科重症监护病房（NS-ICU）进行。在 QI 项目之前，向姑息治疗团队转诊的比例很低。姑息治疗和重症监护团队组成的 ICU-姑息治疗协作组在 2013 年至 2015 年期间领导了 QI 项目。干预措施包括让主要利益相关者参与，制定正式的筛查和转诊标准，使工作流程标准化，并与 ICU 中的跨学科团队联合召开会议，讨论患者的护理计划。姑息治疗团队将对患者进行症状优化评估，与 ICU 团队一起参加联合家庭会议，并在 ICU 护理后为患者和家庭提供支持。我们还在 QI 项目之后的 2016 年至 2018 年期间收集数据，以审查干预措施的可持续性。
QI 项目和 ICU-姑息治疗协作组的干预措施使转诊人数从 2012 年的 9 人显著增加到 2014 年的 44 人和 2016 年的 47 人。该协作有助于促进 ICU 外转，在接受姑息治疗的患者中，更多的患者在 ICU 外舒适地死亡（96%），而不是未转诊的患者（75.7%，p<0.05）。与未转诊的患者相比（74.2%，p<0.001），转出 ICU 时，更多的患者有复苏禁忌（DNR）医嘱，且在生命的最后 48 小时内进行的检查更少（p<0.001）。转介患者的 ICU 日费用降低（p<0.05）。
多方面的 QI 干预措施提高了向姑息治疗团队的转诊率。接受姑息治疗的患者在生命末期的检查更少，ICU 日费用也更低。
