Department of Medicine, Saint Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.
Division of Nephrology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA.
BMJ Open Qual. 2023 Aug;12(3). doi: 10.1136/bmjoq-2023-002330.
Heart failure is a leading cause of hospitalisations. Integration of palliative care services with medical therapy in the management of hospitalised patients with heart failure is imperative. Unfortunately, there are no standardised criteria for palliative care referrals among hospitalised patients with acute decompensated heart failure. The objective of our quality improvement project was to develop and implement a palliative care consult trigger tool for hospitalised patients with acute decompensated heart failure. We found that among eligible patients, palliative care referrals were underused, likely contributing to misalignment of goals of care and suboptimal advance care planning. We developed a trigger tool and designed and implemented structured multicomponent educational interventions to improve the appropriateness and timeliness of inpatient palliative care consultations in this high-risk population. The educational interventions led to a significant increase in the rate of appropriate inpatient palliative care consultations among hospitalised patients with acute decompensated heart failure (46.3% vs 27.7%; p=0.02). In addition, palliative care referrals resulted in better alignment of goals of care at the time of hospital discharge, as measured by a significant increase in the completion rate of a healthcare proxy form (11.4% vs 47.2%; p<0.001) and a Medical Order for Life-Sustaining Treatment form (2.0% vs 24.1%; p<0.001), as well as the establishment of a Do-Not-Resuscitate order (2.7% vs 29.6%; p<0.001). Furthermore, the intervention resulted in a significant decrease in the hospital readmission rate up to 90 days post-discharge (43.6% vs 8.3%; p<0.001). This quality improvement project calls for the development and adoption of standardised criteria for palliative care referrals to benefit hospitalised patients with heart failure and reduce symptom burden, align goals of care and improve quality of life.
心力衰竭是住院的主要原因。将姑息治疗服务与心力衰竭住院患者的医学治疗相结合是至关重要的。不幸的是，急性失代偿性心力衰竭住院患者的姑息治疗转介没有标准化的标准。我们的质量改进项目的目的是为急性失代偿性心力衰竭住院患者开发和实施姑息治疗咨询触发工具。我们发现，在符合条件的患者中，姑息治疗的转介被低估了，这可能导致治疗目标的不一致和最佳的预先护理计划不足。我们开发了一个触发工具，并设计和实施了结构化的多组分教育干预措施，以改善高危人群中住院患者姑息治疗咨询的适当性和及时性。教育干预措施导致急性失代偿性心力衰竭住院患者适当的住院姑息治疗咨询率显著增加（46.3%对 27.7%；p=0.02）。此外，姑息治疗的转介导致在出院时更好地调整了治疗目标，这体现在医疗代理表格（11.4%对 47.2%；p<0.001）和医疗维持生命治疗表格（2.0%对 24.1%；p<0.001）的完成率显著增加，以及不复苏命令（2.7%对 29.6%；p<0.001）的建立。此外，干预措施还显著降低了出院后 90 天内的医院再入院率（43.6%对 8.3%；p<0.001）。这个质量改进项目呼吁制定和采用姑息治疗转介的标准化标准，以造福心力衰竭住院患者，减轻症状负担，调整治疗目标，提高生活质量。
