Document Type
DNP Project
Publication Date
9-2023
Degree Name
Doctor of Nursing Practice
Faculty Advisor
Kerry A. Milner, DNSc, APRN, FNP-BC, EBP-C
Practice Mentor
Simone O'Donovan, DNP, FNP-BC
Abstract
Significance and Background: Palliative care (PC) services are often underutilized in the ICU. There is a lack of understanding of PC by providers, staff, patients, and families which then leads to difficulty obtaining appropriate and adequate referrals to the PC team. In the ICU practice setting, the current process for palliative care referrals (PCRs) has the attending physician as the only individual to initiate a PCR referral. Another element missing from the current process is a criteria trigger tool that other disciplines, including nursing, can use to assess the patient’s need for PCR in the first 48 hours of admission. Recommended hospital standards include having a standardized process in place at the time of admission to identify which patients should receive a PCR.
Purpose: To increase the number of admitted ICU patients screened for PCR by 75% from baseline, within a three-month period. To increase the number of PCRs ordered for ICU patients admitted within 48 hours, within a three-month period.
Methods: The project implementation and evaluation were guided by the Model for Healthcare Improvement set forth by the Institute for Healthcare Improvement. A total of three plan, do, study, and act cycles were completed. The PC criteria trigger tool was part of the patient’s admission data collection for the nursing staff to complete. Patients admitted were screened within a maximum of 48 hours. Based on the PC criteria trigger tool, nurses discussed the need for a PCR with the intensivist, and a referral was placed with 48 hours of admission.
Outcome:Over a 12-week period, there were 278 patient admissions. Of the admissions, 210 (75.5%) nurse PC screenings were performed. Average time for PC referrals in months 1, 2 and 3 of project was 16 hours, 17 hours, and 9 hours respectively. Forty-four patients were screened
high risk for unmet PC needs and 30 (66.6%) PC referrals were placed. Fourteen patients declined PC (n, %), were readmitted during same hospitalization (n, %), or nurse failed to identify (n, %). After PC consultation, 14 (46.6%) patients had DNR/DNI status established, 3 (10%) transferred to hospice care facilities, 3 (10%) transitioned to comfort care and expired in the facility, and 1 (3.33%) received symptomatic management with no escalation in care.
Discussion: Immediate practice implications of this highly effective nurse-led PC screening process using a PC trigger screening tool in the ICU were early identification of patients who could benefit from PC services, improved communication, timely intervention to ensure patient needs are met, reduced burden on physicians, enhanced patient center care, and better resource allocation by identifying patients who need PC most. Next steps are to implement this process in the other ICUs within the health system.
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Recommended Citation
Fiore, S. (2023). Improving timeliness of palliative care referrals within the intensive care unit: A quality improvement project [Unpublished DNP project]. Sacred Heart University.
Included in
Critical Care Commons, Critical Care Nursing Commons, Palliative Care Commons, Palliative Nursing Commons, Quality Improvement Commons
Comments
A DNP project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice, Sacred Heart University Davis & Henley College of Nursing.