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Colleen's First QI Project, Part Five: So What Can We Improve?

By IHI Open School | Tuesday, February 26, 2013
Editor’s Note: Colleen McCormick, a fourth-year medical student from Wright State University in Ohio, is using the IHI Open School Quality Improvement Practicum to conduct her first quality improvement project.
Every Wednesday during February and March, Colleen will write a blog post about her progress as a student trying to make a change in the health care system. You can catch up on last week’s post here.

By Colleen McCormick, fourth-year medical student, Wright State University

After creating our aim statement and defining the project, it was time to really think about how to improve! If you recall, the aim statement for our project is to increase utilization of the palliative care team for patients in the medical ICU from 25% to 50% by April 2013.

We had estimated, after talking with an ICU nurse and referencing the literature, that our baseline palliative care utilization would be 25%. Wow, were we wrong!

After our data expert helped me analyze the electronic medical record (EMR), we found that our baseline utilization was only 3%! We had a lot of work to do.

We started by looking at our baseline data by gender, diagnosis, primary physician, and length of stay (LOS) to see if there were any trends in consult requests. We found that patients who received palliative care consults typically had longer ICU stays than those patients who did not — 5.3 days on average versus 2.7 days on average, respectively. In addition, only 19% of physicians caring for ICU patients had ordered a palliative care consult in the past year. (Other variables such as gender and diagnosis did not vary based on palliative care consults during that initial data analysis.)

Since our goal is to increase palliative care use, we needed some planned changes of how to make that happen.

First, it seems we need better education for providers. While the hospital supports lectures on all sorts of topics, including the importance of palliative care, ICU physicians rarely have time to leave the wards to attend such sessions. Moreover, because less than 20% of physicians were requesting consults, we think that there must be a knowledge, attitude, or skill gap between the physicians who order consults and those who do not. These gaps, we think, can be targeted with education.

Education came up again when we spoke with the ICU nurses. They are in a unique position because they know the patients and families very well, and therefore can often recommend palliative care consults. Like the physicians, time is an issue for them. They told us we needed to bring education to them, as they were also too busy to attend learning sessions.

Fortunately, one member of our team is a palliative care nurse (I’m really happy we got all the stakeholders involved early on) and she volunteered to head up an educational intervention for the physicians and nurses. We really wanted to make the information “stick,” so with help from this book by the Heath Brothers, we decided to appeal to the emotions of our staff. Having a patient or family member, we think, who has seen palliative care first-hand will be very persuasive for the medical providers.

And since our planning team includes both ICU physician and nurse champions for increasing palliative care, they can help us by encouraging their colleagues to participate in the intervention. (Measuring attendance at these in-house educational sessions will be one of our process measures.)

A second intervention we hope to implement to streamline the consult process is a simple screening tool. While physicians must request the consult in the EMR, nurses, residents, and medical students could use a screening tool to help decide if a patient was in need of palliative care. Fortunately, there are many validated tools from which to choose. Along with our nurse champions, Dr. W and I designed a tool that we thought would be simple and effective. We shared this tool with our planning team for their feedback, and passed them out to the ICU nurses for their review. After several email threads and two group discussions, we settled on a final draft. (Utilization of this tool on every patient in the ICU will be another process measure.)

Once the tool was finalized, I applied it retrospectively to patients in the medical ICU (MSICU). First, I looked at patients who had passed away in the ICU, and counted how many had received palliative care consults. Then, I went through the medical records of the ICU patients to see how many consults should have been expected based on the tool criteria. Here is what I found:

5 chart

While hindsight is 20-20, many of these patients who passed away could have benefited from palliative care. In summary, 13.5% of these patients received consults and we estimated that 73% could have benefited from palliative care.

Next, I applied the tool to all patients in the MSICU during a period covering several weeks and again compared expected versus observed. During a three-week period from December to January, there were zero palliative care consults; using the tool, we estimated that 26% of the patients could have benefited from palliative care.

Hopefully, the tool that we developed will guide medical providers in determining when to request a palliative care consult. We would love to see the consult rate increase to 25% or above, but this may be too high of a goal for our first few PDSA cycles. Therefore, we decided to edit our aim statement. Our new aim is to increase utilization of the palliative care team for patients in the medical ICU from 3% to 9%.

While we hope to increase palliative care consults, we do not want to place undue commitments on the primary medical providers. (That’s why having regular feedback and discussions on nurse satisfaction with the tool will be one of our balancing measures.)

I’m excited that we have a plan in place that can potentially improve patient care! To see my full charter, click here.

And, as always, I’d love to hear any feedback you might have.

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