Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division (J.O.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Section of Palliative Care and Medical Ethics (J.O.S., Y.S., G.P., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Palliative Research Center (J.O.S., Y.S., G.P., S.C.B., E.J.C., R.M.A.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
J Pain Symptom Manage. 2023 Dec;66(6):603-610.e3. doi: 10.1016/j.jpainsymman.2023.07.015. Epub 2023 Jul 31.
Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings.
We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients.
Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation.
Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898).
Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.
目标关怀对话可以促进重病患者的高价值护理，但在医院环境中记录的讨论很少发生。
我们旨在制定一项质量改进计划，以改善住院患者的目标关怀记录。
该实施发生在宾夕法尼亚州匹兹堡的一家学术医疗中心。干预措施包括整合一个 90 天死亡率预测模型，将患者分为低、中、高风险人群；一份集中的目标关怀记录；以及自动通知和针对性的姑息治疗咨询。我们比较了实施前后按风险评分记录的目标关怀讨论情况。
在实施前的 12571 名住院患者和实施后的 10761 名患者中，1%被指定为高风险，11%为中等死亡风险。实施后，高风险（17.6%-70.8%，P<0.0001）和中风险（9.6%-28.0%，P<0.0001）患者的目标关怀记录增加。对于中风险患者，由姑息治疗专家进行的目标关怀记录的百分比从实施前到实施后增加（52.3%-71.2%，P=0.0002）。对于高风险患者，主要服务完成的目标关怀记录的百分比从实施前到实施后增加（36.8%-47.1%，P=0.5898，姑息治疗专家的记录从实施前到实施后略有减少（63.2%-52.9%，P=0.5898）。
实施使用死亡率预测模型的目标关怀计划显著增加了目标关怀记录，特别是在高风险患者中。需要进一步研究评估增加中等风险患者目标关怀记录的策略，特别是由非专业姑息治疗提供。
