2021 Annual Conference

CNS Improving Outcomes
Quality Initiatives
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Background/Significance: At the end of life, most individuals would prefer to pass at home or in hospice. Many hospitals are unaware of individual patient preferences and admit patients expected to pass in <48 hours via the Emergency Department (ED), thus disabling their terminal wishes. The aims of the project were to better honor patient preferences by ascertaining end-of-life wishes, develop a process for implementation, and to reduce overall inpatient mortality.

 

Evaluation Methods: Using Lean methodology, this interdisciplinary group used a structured process to define the problem, review patient trends, design an approach, and develop key drivers and indicators of success. Facilitated by a Value Improvement Consultant, the seven-member core team included Unit-Based Medical Directors (UBMDs), Patient Care Managers, and Clinical Nurse Specialists (CNSs) from two Medicine units, and a Manager of Care Coordination (MCC). Additional support included providers from Hospital, Palliative, and Emergency Medicine teams. Chart reviews by UBMDs illuminated opportunities to better anticipate patient outcomes and identify future imminent cases. The interdisciplinary group collaborated to develop a “Code Goals of Care” process that included CM patient screening on arrival to the ED, refined hospice transfer pathway, and chart flag to alert Providers of patient wishes for any future admissions. A secondary aspect of the pathway was a unit-based CNS screen of inpatient admissions and collaboration with the MCC for chart flag inclusion of patient wishes prior to future admissions. Patients were included in the project if they were in the ED with estimated survival <48-hours, or inpatients with Comfort Care/Do Not Resuscitate orders or expressed desire for hospice care. During the early months of implementation, a weekly huddle was setup to review cases and pathway activations to ensure the process was working well.

 

Outcomes: In the initial four-month project time, 59 patients were transferred to hospice, better supporting their care wishes. A 41% reduction in Inpatient mortality was seen, reducing from 3.0% to 1.73% in the same timeframe. By the end of data collection at 8 months post-implementation, 116 hospice transfers had been initiated, and inpatient mortality reduction was sustained at 1.9%.

 

Implications: Most people would rather pass at home or in hospice, not in the hospital. By ascertaining patient end-of-life wishes, collaborating with ED Providers and CMs, and screening inpatients for care goals, this interdisciplinary team was able to effectively enact and sustain patient preferences and reduce inpatient mortality rates. Comprehensive care maps involving Providers, Nurses, Case Managers, and Care Coordinators are critical to ensuring adherence to patient wishes and limiting unnecessary inpatient admissions. Future projects would include increased involvement of Primary Care Providers, earlier conversations with patients regarding end-of-life preferences before the need arises, and having an enactment plan in place.