Trigger-based pathways to increase utilization of palliative care services for cancer patients: A multi-disciplinary approach.
Authors: Singh Vinit , Vyas Charmee , Fichadiya Harshil , Goldberg Shira , Keegan Nicole , Ostrander-Coffey Patricia , Nicolosi Gretchen , Lim Bomina , Lopes Diane , Gebel Kristen , Preston Jessica , Kelly Tia , Johnston Diann , Granet Kenneth 
Published: June 2022

e24007

Background: Palliative care involves services to improve the quality of life for chronically ill patients and their care teams. Use of palliative care has shown to decrease the utilization of resources and increase clarity of goals of care. Although acceptance of palliative care principles has been improving, we conducted a multidisciplinary project to increase the utilization of palliative care consult (PCC) and follow its effect of hospital-based outcome. Methods: IRB approved study involving patients on medical floors and in the ICU were conducted over 3 months with 1-month pre-intervention phase (PIP). We developed PCC triggers based on medical literature for the ICU and Medical floors to identify at risk patients likely to benefit from PCC on admission. Trigger questionnaire included but was not limited to the problem list at admission, comorbidities, requirements and availability of social support, and age > 80 years which were reviewed by the primary Nursing staff at admission assessment. Patients meeting any one of the triggers were eligible for PCC. The RNs would reach out to the primary team to notify them of patient’s eligibility for PCC. We adopted “opt in” model to request approval of the PCC. Outcomes measures included rate of PCC among triggered, code status change, and discharge planning. Triggers for pre-intervention were filled by EHR review. All the categorical variables were compared by chi-square test. Results: 344 (Median age - 69, 50.58% Female) patients were enrolled during the study with 93 (27.03%) cancer patients. 93/121 (76.86%) of PIP patients and 160/223 (71.74%) of intervention phase (IP) patients triggered the PCC. During PIP, proportion of triggered non-cancer and cancer patients referred for PCC were 9/73 (12.33%) and 6/20 (30.00%) respectively. During IP, proportion of triggered patients referred for PCC significantly increased compared to PIP to 28/99 (28.28%, p-value – 0.01) and 38/61 (62.30%, p-value – 0.01) for both non-cancer and cancer patients, respectively. During the IP, PCC was recommended significantly more times (p-value – 0.00) in cancer patients than non-cancer patients. Among all with PCC involved, 4/17 (23.59%) PIP and 8/59 (13.56%, p-value – 0.56) IP full-code cancer patients changed code status to DNR. Among the cancer patients, 10 (6 from ICU and 4 from medical floor) patients were discharged to home hospice compared to none in pre-intervention phase. Conclusions: Application of trigger-based pathways leads to early and increase utilization of palliative care services for all patients by identifying patients to benefit from early PCC. Among cancer patients, we found improvement in utilization of hospice services and clarification of their code status at discharge. Further studies are needed to standardize the procedure for increased integration of PCC into our hospital’s clinical models of care.