integrated approach to palliative care in acute care (ipac-ac) · 12/4/2019 · a palliative...
TRANSCRIPT
www.cfn-nce.ca
Integrated Approach to Palliative Care in Acute Care (iPAC-AC)
Webinar SeriesDecember 4, 2019
Kelli Stajduhar, PhD, RNUniversity of VictoriaNeil Hilliard, MDUniversity of British Columbia
www.cfn-nce.ca
Welcome
• Today’s webinar will be hosted by CFN’s Manager of Research & KT: Amanda Lorbergs
• We will answer as many Qs as time permits
2019-12-04
www.cfn-nce.ca
Reminder: Survey & Webinar
2019-12-04
• Survey will pop up on your screen after webinar • Feedback on how to improve webinar series
• Webinar slides & video available for viewing online within 1-2 days at:
• cfn-nce.ca/news-and-events/webinars
www.cfn-nce.ca
Next CFN Webinars
2019-12-04
Register at:http://www.cfn-nce.ca/webinars/
• Wednesday, January 15, 2020 at 12 noon ETElder-friendly Approaches to the Surgical Environment-using Biological samples to Identify & provide Optimized care – Rachel Khadaroo & Amritpal Bhullar, University of Alberta
• Wednesday, January 22, 2020 at 12 noon ETSupporting quality of life assessments of frail older adults and their family caregivers – Richard Sawatzky, Trinity Western University & Kara Schick-Makaroff, University of Alberta
www.cfn-nce.ca
2020 CFN Training Programs
• Application Packages for 2020 Interdisciplinary Fellowship & Summer Student Awards Programs due Monday, December 16, 2019 by 12 noon EST
• Intent to Apply must have been submitted
• Visit: www.cfn-nce.ca/training/ for more details
2019-12-04
www.cfn-nce.ca
Presenters
2019-12-04
Integrated Approach to Palliative Care in Acute Care (iPAC-AC)
Neil Hilliard, MDUniversity of British Columbia
• Professor in the School of Nursing and Institute on Aging & Lifelong Health at the University of Victoria
• Research Scientist with Fraser Health
• Palliative Care Consultant Physician in Abbotsford
• Clinical Associate Professor at the University of British Columbia
Kelli Stajduhar, PhD, RNUniversity of Victoria
Integrated Palliative Approach to Care in Acute Care(iPAC-AC)CFN Webinar
December 4, 2019
Objectives
• To understand why we need an integrated palliative approach to care (iPAC) in acute care
• To know what is the difference between iPAC and specialized palliative care
• To learn about how to implement iPAC in acute care
Outline
•Why iPAC?•What is iPAC?
Introduction
The iPAC-AC intervention
•Qualitative•Quantitative
iPAC-AC Results
Conclusions
Discussion
Timely Access: We need to focus on those being missed
Lawand, C., Access to Palliative Care in Canada: Key Findings from CIHI’s Baseline Report, February 1, 2019
Equitable access: We need to include non-cancer patients
Lawand, C., Access to Palliative Care in Canada: Key Findings from CIHI’s Baseline Report, February 1, 2019
For success, we need to identify who they are and how they will benefit
Integration of a Palliative Approach in Home, Acute Medical, and Residential Care Settings: Findings from aProvince-Wide Survey, iPANEL, September 2015
Surprise Question
The Benefits of a Palliative Approach
Applying a palliative approach
Identification
Components of a Palliative Approach to Care
A palliative approach is different than specialized palliative care. It takes the principles of palliative care and ADOPTS, ADAPTS, EMBEDS
10
ADOPT principles EARLY (as soon as diagnosis) in the course of a person’s life-limiting condition
ADAPT strategies to meet patient and family needs, blend principles of palliative care with chronic disease management
EMBED practices into usual care in settings not specialized in palliative care
Sawatzky, R. et al. … & Stajduhar, K. (2016). Conceptual foundations of a palliative approach: A knowledge synthesis. BMC Palliative Care, 15(5). www.ipanel.ca
iPAC-AC: A Combined Quality Improvement Participatory Action Research Intervention
Baseline Data
Collection
Action Cycles
Evaluation Plan
June 1 – Sept. 302016
Oct. 1 – March 312016/2017
Apr. 1 – July 152017
Overall Goal: Enhance quality of care in acute care for people living with life-limiting conditions
• explore their beliefs, assumptions and practices around care in their practice settings to sensitize them to the challenges and opportunities that arise in caring for the dying and their families in acute care settings;
• share information and evidence about a palliative approach, the potential benefits for patients, families, providers and the healthcare system and key ingredients for care delivery;
• develop and implement strategies to integrate a palliative approach into their work that are relevant, sustainable, and realistic for acute care environments; and
• evaluate these strategies and their influence on patient and family outcomes.
Project Phases
PHASE 1: Collection of Baseline Data• 2 focus groups on medical unit (n=10) + 12 key informant interviews• Patient Survey: Canadian Health Care Evaluation Project Questionnaire (CANHELP) Lite patient version;
McGill Quality of Life Questionnaire (MQOL-R), Quality of Life in Life Threatening Illness-Family Carer Version(QOLLTI-F), Edmonton Symptom Assessment System-Revised, Veterans RAND 12-item health survey.
• Family Survey: Quality of Life in Life Threatening Illness-Family Carer Version (QOLLTI-F); CANHELP Lite Caregiver Questionnaire.
PHASE 2: Collaborative Action Cycles• Project retreat with unit multidisciplinary team• Action team meetings ~every 1-2 weeks x 6 months facilitated by CNS – field notes, structured reports
PHASE 3: Formative and Summative Evaluation• Formative: audio taped action team meetings; fieldnotes; reports• Summative focus groups with action team• Pre-post PAR surveys of patients’ and family (quality of life outcomes and satisfaction with care)• Pre-post Patient Journey Mapping• Pre-post comparison of medical record data (length of stay, referrals to palliative care, etc.)
Findings
PHASE 1:Baseline focus groups and key informant interviews suggest:• Integrating palliative approaches to care is challenging in
acute care settings• Over interventionist focus in acute care along with a general
discomfort in talking with patients and families about end-of-life care often meant patients were being “treated to the last breath”
• Participants expressed deep frustration and moral distress
FindingsParticipant 1: Feeding tubes decrease quality of life. You know, rather than being comfortable and keeping those patients comfortable we’re torturing them, in my opinion ... with further tests and procedures.Participant 2: We are treating people ... to the last breath and then we deem them palliative too late into the processParticipant 3: It’s morally distressing for me.Participant 2: It was horrible it was very sad, I was very thankful at the end that he was able, he got what he wanted he wanted to be.... you know be done.Participant 3: It’s not a way to go, tied down to a hospital bed.
Participatory Action Research• Executive Support• Action Team (Manager, PCC, PT, SW,
RN, LPN, Care Aid, Unit clerks)• Activities
• Weekly or bi-weekly meetings • Huddles• Education (CNSs) – disease trajectory,
prognosis awareness, SIC, pain/symptommanagement
• Tools for identification• Surprise question, SPICT tool• Staff developed iPAC Lanyard
• Registration in Hospital EMR (Meditech)
• Monitoring and feedback to Action Team
Participatory Action Research – Facilitators and Challenges
Facilitators• Strong unit leadership• Skilled facilitation skills and capacity
among team members• Receptivity to change• Adapting and embedding tools into
usual care processes• Partnerships between researchers
and clinicians
Challenges• Promoting ongoing engagement• Engaging physicians• Getting the team “on the same page”• Busyness and task focused
environment• Working in silos and competing
priorities
18
19
20
Patient Journey Mapping
Quantitative Analysis
• Interrupted Timed Series Analysis• Pre and post PAR samples• T-tests and chi-square test were used to compare the two samples on continuous and
categorial variables.• For all analyses, a p-value of less than 0.05 was identified as being statistically significant• Ancova was used to compare baseline and post-PAR means of domains scores and total
scores for the continuously scaled outcome measured.• All analyses were controlled for differences in age, gender, and self-reported diagnosis
between the two groups
• Univariate and Multivariate analysis for significant covariates and confounders• Purposeful covariate selection process (Hosmer and Lemeshow)• Single and Multiple Linear Regression models
• Statistical Process (Shewhart) Control Charts
0
10
20
30
40
50
60
Cancer CHF COPD Dementia Renal Failure Stroke Other
Per c
ent
Diagnosis
Per cent iPAC patients by primary diagnosis
Oct
Nov
Dec
Jan
Feb
Mar
Quality of Life Assessment and Practice Support Systems – QPSS
Innovative, integrated health care information systems for patient- and family-centered care that facilitates:
• use of QOL assessment instruments (including PROMs and PREMs) at point of care
• instantaneous feedback with information about scores, score interpretation, change over time, and targets for improvement
• tracking and assessing whether interventions achieve desired results
• capacity to integrate with other health
• information systems
Demographic Information
Demographic variablesDistributionsPre (N = 45)
DistributionsPost (N = 33)
P-value
Age in years (mean, SD) 76.56(13.37) 71.18(16.25) .114
Sex (% Female) 47.6% 51.5% .738
Marital Status .494
Married or common law 38.6% 27.3%
Single, never married 11.4% 18.2%
No longer married 50.0% 54.5%
Born in Canada 81.0% 69.7% .257
Education .176Less than high school diploma or its equivalent 15.9% 30.3%High school diploma or a high school equivalency certificate 25.0% 33.3%Other certificate or diploma (trade school, College, CEGEP, university) 40.9% 30.3%
University Degree 18.2% 6.1%
Demographic variablesDistributions Pre (N = 30)
DistributionsPost (N = 33)
P-value
Age in years (mean, SD) 56.97(15.18) 61.85(14.83) .202
Sex (% female) 68.8% 45.5% .058
Marital Status .089Married 81.3% 66.7%Living common-law 9.4% 6.1%Single, never married 9.4% 9.1%No longer married 18.2%
Recipient .304Spouse or common-law partner 37.5% 42.4%Other immediate family (e.g., parent, child, sibling) 62.5% 51.5%Extended (e.g., grandparent, grandchild, in law) and not family 6.1%
Living Arrangement (% lives with patient) 51.6% 69.7% .157
Patients Family caregivers
Pre/Post Patient Symptoms
Post-IPAC (N = 31)
Pre-IPAC (N = 38)0
2
4
6
8
10Worst Possible
No symptom
Pain Drowsy Nausea AnxietyTired Lack ofappetite
De-pressed
Shortnessof breath
0
20
40
60
80
100
Communication Decision making
Feeling atpeace
Illness management
Relationships with doctors
Completelysatisfied
Not al allsatisfied
0
2
4
6
8
10
Bestpossible
Worst possible Existential Physical Psychological Relationships
Pre/Post Patient Quality of Life and Care Experience
Quality of life Satisfaction with care
Pre-IPAC (N = 40) Post-IPAC (N = 31) Pre-IPAC (N = 38) Post-IPAC (N = 31)
0
20
40
60
80
100Completelysatisfied
Not al allsatisfied
Providercharacteristics
Communication& decision
making
Illnessmanagement
Relationshipwith doctors
Family involvement
0
2
4
6
8
10Bestpossible
Worst possible
Careroutlook
Carer quality of life
Environ-ment
Financialworries
Patientcondition
Quality of care
Relation-ships
Pre/Post Family QOL and Experience
Quality of life Satisfaction with care
Pre-IPAC (N = 27) Post-IPAC (N = 31) Pre-IPAC (N = 25) Post-IPAC (N = 31)
Per cent of medical unit iPAC patients identified
Pre/Post intervention iPAC flagged patients (n=641)
iPAC Flagged (n=641)Pre-IPAC(n=189)
Post- IPAC (n=432)
VariablesDistributions Mean (SD) / %
DistributionsMean (SD) / %
P-value
Age in years (mean, SD) 77.01 (10.33) 81.13 (0.04) 0.00
Sex (% female) 43.39 51.39 0.06
MEDICAL CONDITIONSMalignant 16.93 14.12 0.37
CHF 12.17 14.81 0.38COPD 11.11 12.96 0.52
Dementia 15.34 13.43 0.53Renal Failure 52.91 52.31 0.89
Stroke 0.00 0.23 0.51Palliative 24.34 18.52 0.10
Average Length of Stay (ALOS) (n = 641, t(619) = 2.63, p = 0.01)(pre PAR: 24.12 days, n=189; Post PAR: 19.4 days, n= 432; ALOS reduced by 4.72 days)
Median Length of Stay (MLOS) (n = 1806) iPAC patient MLOS = 14 days (n = 641); Post iPAC MLOS reduced by 9% = 1.26 days
Variables GM Ratio 95% confidence intervalPre/Post iPAC (n=189 / n= 432) 0.91 0.84 0.98iPAC/not iPAC flagged 1.86 1.72 2.02Cancer/not Cancer 1.42 1.26 1.59CHF/not CHF 1.32 1.17 1.49Dementia/not D. 1.36 1.21 1.54Renal Failure/ not RF 1.14 1.06 1.23
Multivariable regression results: There continues to be a difference in pre- and post-IPAC length of stay after adjusting for confounding variables.
Discharge Disposition of iPAC patients (per cent)
N = 641 Pre-intervention (n=189) Post-intervention (n=432) Per Cent Change
Died on ward 20.11 11.57 42% reduction Discharged home 43.92 54.4 24% improvementTransferred 34.39 33.56Other 1.59 0.46
Unadjusted chi-square analysis: χ2(3) 11.37, p = 0.01Pre-intervention: Before October 1, 2016Post-intervention: After September 31, 2016
Per cent ICU/HAU/CCU utilization (Revised Limits)
Reduced 25%
Palliative Care Program Referrals
Death chart audits (N=40)First 20 deaths all patients on acute care unit
23
33
37
0
5
10
15
20
25
30
35
40
2016 2017 2018
Per C
ent I
dent
ified
Year
Total per cent iPAC patients Baker 2
Identification of iPAC patients continued to improve and was sustained past the end of the action cycle period ending March 31, 2017. For years prior to 2016, zero per cent iPAC patients were identified.
Conclusions
• Patients who can benefit from a palliative approach to care alongside usual care can be identified by primary care providers on an acute care medical unit.
• A change in culture to a person and family centered team-based integrated palliative approach to care is possible and sustainable on an acute care medical unit through a participatory action approach.
• The Institute of Health Care Improvement (IHI) quadruple aim of improved quality of care, improved patient and family experience, improved provider experience, and at reduced cost is possible through introducing an integrated palliative approach to care.
AcknowledgementsiPAC-AC
iPAC-AC Innovation CommunityPrincipal InvestigatorsNeil Hilliard: [email protected] Sawatzky [email protected] Stajduhar (project leader) [email protected]
Co-investigatorsGweneth DoaneLesli Matheson JenningsClaudia MeyermanSheryl Reimer-KirkhanDella Roberts
HQPs/Group FacilitatorsNicole WikjordPatty Roy
Steering committeeDoris Barwich, Kim Crooks, Carren Dujela, Jerry Gosling, Neil Hilliard, Cari Hoffmann, Jay Lambert, Joyce Lee, Lesli Matheson Jennings, Claudia Meyerman, Della Roberts, Patty Roy, Skanthan Sithamparanthan, Rick Sawatzky, Kelli Stajduhar, Annie Smith, Nicole Wikjord, Connie Wong
Operations committeeTrena Canning, Neil Hilliard, Leslie Matheson Jennings, Nicole Wikjord, Patty Roy, Cornelia Vera
Strategic Transformation TeamJay LambertAnnie Smith
Baker 2 TeamTrena Canning, Iona Wray, Margaret Chafe, Crystal Andrew, Sukhwinder Brar, Karen Griffiths-Hawrylko, Cornelia Vera, Roselyn Beukens, Circe Codio, Maryna Koechlin, Sandra Nechwediuk, Jocelyn Klemes
Patient Journey MappingKevin HareKathrin EiblKaren SymmesHamze Jomaa
Data CollectionDawson McCann, Nicole Wikjord, Patty Roy
Key informant interviewsMelissa Giesbrecht
Health Business AnalyticsYurik Sandino AlarconChong Chen
Health InformaticsNoel Francisco
Individual Level Data AnalysisErin Krieter, Angela Tescon
Industry PartnerJames Voth, CEO, Intogrey
Admin SupportCarren Dujela
www.cfn-nce.ca
Post-webinar surveySurvey will pop up on your screen after webinar • Feedback on how to improve webinar series
Wednesday, January 15, 2020 at 12 noon ETElder-friendly Approaches to the Surgical Environment-using Biological samples to Identify & provide Optimized care – Rachel Khadaroo & Amritpal Bhullar, University of Alberta
Kelli Stajduhar: [email protected] Hilliard: [email protected]
2019-12-04
Project contacts
Next webinar