Beth Cotten, RN, BSN, CCRN Lyn Jay, RN, MSN, ACNP, CCRN Travis VanDinh, RN, BSN, CCRN
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2 Beth Cotten, RN, BSN, CCRN Lyn Jay, RN, MSN, ACNP, CCRN Travis VanDinh, RN, BSN, CCRN Phyllis Barron, RN, MSN, MSHP, FNPC, CCRN Coach Frances Simpson, RN, MSN, ACNS Project Lead
3 Bridging the Gap: Improving Care Through Understanding Courtesy of Nancy Granai-Sisk
4 Seton Medical Center Austin Our Hospital: 474-bed hospital in urban area Magnet facility Provides complex care to a diverse patient population Our ICU: 35-bed mixed ICU, expanded to 37 in September 2013
5 Seton Medical Center Austin CSI Team
6 Goals The goals of this project: Implement Care and Communication Bundle from Improving Palliative Care in the ICU (IPAL-ICU) initiative Improve communication with patients and families Improve patient and family satisfaction
7 IPAL-ICU Care and Communication Bundle Day 1 Identify decision maker Address advance directives Address code status Distribute brochure Assess pain regularly Manage pain optimally Day 3 Offer social support Offer spiritual support Day 5 Hold interdisciplinary family meeting
8 Baseline Data Day 1: Identify Decision Maker 25% Address Advance Directive 62.5% Address Code Status 87.5% Distribute Brochure 0.0% Assess Pain Regularly 100% Manage Pain Optimally 87.5%
9 Baseline Data Day 3: Offer Social Support 75% Offer Spiritual Support 50% Day 5: Interdisciplinary Family Meeting 25%
10 Planning for Success Pilot 3 aspects of the IPAL-ICU Care & Communication Bundle: Identify surrogate decision maker by ICU day 1 in at least 75% of cases Present family brochure by ICU day 1 in at least 75% of cases Facilitate and conduct interdisciplinary family meeting by ICU day 5 in at least 75% of patients with 5-day length of stay (LOS)
11 How We Came to Our Topic Started system-wide palliative care initiative Identified communication gaps Needed more accurate identification of legal decision maker Topic supports relationship-based care Seton s professional practice model
12 How We Came to Our Topic Evidence-Based Best Practice 1 Institute of Medicine All 4 major societies representing critical care professionals (ATS, SCCM, ACCP, AACN) National hospital and health care networks, eg, Voluntary Hospital Association Veterans Administration Healthcare System Institute for Healthcare Improvement Commercial insurers
13 Outcomes of the Care and Communication Bundle Outcome Selected Relevant References* ICU/Hospital LOS Campbell, 2003; Campbell, 2004; Norton, 2007; Curtis, 2009 Use of Non-beneficial Treatments Campbell, 2003; O Mahony, 2009 Family Satisfaction/Comprehension Azoulay, 2002 Family Anxiety/Depression, PTSD Lautrette, 2007 Conflict Over Goals of Care Lilly, 2000 Time From Poor Prognosis to Comfort- Campbell, 2003 Focused Goals Symptom Assessment/Patient Comfort Erdek, 2003; Chanques, The IPAL-ICU Project, Center to Advance Palliative Care
14 Project Metrics Meeting With Christine Jesser, SHF Analytics: LOS Multifactorial, no way to isolate effect of project HCAHPS Not representative (live discharges, combined ICU/IMC, low n) Recommendation: Focus on Implementation of Best Practice
15 Budget Grant Allocation Salary 180 Kick Off Promotion Items TV for Education 1205 Video Education 5000 Redosing Promotion Items
16 Project Timeline
17 Kickoff and Ice Cream Social
18 Kickoff and Ice Cream Social
19 Kickoff and Ice Cream Social
20 Kickoff and Ice Cream Social
21 Developed Tools Education Tools: Staff education handout Project/IPAL-ICU/Palliative Care/MPOA/LNOK Kickoff Education Board Project Tools: IPAL-ICU checklist Family meeting progress note Family brochure in collaboration with Palliative Care
22 Documents
23 Family Brochure
24 Process Measures Initial Process Measures (July to September 2013) 144 patients admitted to pilot unit 74.3% of checklist filled out 72.9% of family brochures handed out
25 Process Measures August through February patients admitted to pilot unit 116 patients with LOS who would need a day 5 meeting ~18% of patients meet criteria for day 5 meeting Day 5 family meetings: Completed 55 of 73 day 5 meetings = 75.3%
26 Process Measures July Aug Sept Oct Nov Dec* Jan* Feb* Pt Admited Anticipated Meetings Actual Meetings
27 Day 5 Meeting Findings Communication Feedback: Physicians update families inconsistently Physicians sometimes update whoever is present, not surrogate decision maker Meetings very well received: Good idea. Thank you for asking for feedback. Care Feedback: Nurses do a good job keeping family up-to-date Difficult having a different nurse every day Care boards well received, but at times inconsistently updated
28 Day 5 Meeting Findings Care Feedback: Family request for ordering on-demand menu for patient undergoing chemotherapy Family request for shuttle service from Austin to Luling Follow-ups: Physician updates requested/completed Palliative consults Chaplain revisits Social worker revisits Advance directives (missing paperwork, chaplain consult)
29 Day 5 Meeting Findings Equipment: Took 2 days to receive bariatric bed Chairs in waiting room uncomfortable System: No dedicated field for legal next of kin/surrogate decision maker No documented deliberate notification/rescreen for a chaplain needs when patient admitted to floor then transferred to unit
30 Project Impacts Increased collaboration with Palliative Care More staff conversations to identify surrogate decision maker Identified a need to clarify terminology (medical power of attorney vs legal next of kin) and incorporated into project
31 Unanticipated Positive Outcomes Immediate staff buy-in and satisfaction Increased staff awareness of ICU LOS Positive feedback from patients/ families regarding care boards
32 Maintaining Momentum Educate staff on communication strategies in the unit with video education by Dr. Stephen Bekanich, Palliative Care Department Provide video education to network/new hires Strategize/resolve process for weekend meetings Share project through publication or presentations
33 Key Challenges to the Project Census fluctuations Staffing model changes Staff RNs less able to participate in day 5 meetings than anticipated; not currently feasible for RN to facilitate Significant amount of time collecting data Physical unit changes New unit/construction - opening and closing units Logistical difficulty for meeting facilitators Day 5 meetings on weekend resulted in delay
34 Recommendations With our findings, we recommend: Dedicated RN to coordinate and conduct day 5 meetings Expand project to all ICU units (September 2014: 43 beds) Dedicated place in EMR for legal next of kin as surrogate decision maker Submitted as enhancement to EMR/COMPASS team
35 What We Learned Culture change is challenging Timing is critical Logistics can impede best intentions Back to basics Staff education regarding definitions of MPOA/LNOK Palliative care overview/education video Communication strategies
36 Acknowledgements Heather de la Paz, Critical Care Administrative Assistant Nancy Granai-Sisk, RN, BSN Dr. Stephen Bekanich Holly Cross, Palliative Care APN Christine Celio, Palliative Care APN Anne Hulzing, ICU Clinical Manager Ashley Ruiz, LCSW Mollie Gabel, RN, MSN, CCRN, Clinical Educator Michelle Hill, RN, Case Manager Kevin Sheehan, Chaplain Whitney Power, Senior Project Coordinator, Research and EBP Christine Jesser, Analytics Cynthia Gallegos, Palliative Care Manager Seton Medical Center Austin ICU Staff
37 References 1. Center to Advance Palliative Care and the National Institute of Health. Making the case for ICU palliative care integration Accessed October 7, Mosenthal AC, Weissman DE, Curtis JR, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2012;40(4): Nelson JE, Bassett R, Boss RD, et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project. Crit Care Med. 2010;38(9): Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force Crit Care Med. 2007;35(2):
38 References 5. Nelson JE, Mulkerin CM, Adams LL, Pronovost PJ. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006;15(4): Agency for Healthcare Research and Quality. Care and Communication Quality Measures at the National Quality Measures Clearinghouse. Accessed June 10, Treece PD, Engelberg RA, Shannon SE, et al. Integrating palliative and critical care: description of an intervention. Crit Care Med. 2006;34(11 Suppl):S380-S387.
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