Advanced care planning and palliative care in the heart failure population

Purpose The aim of this Lean Six Sigma project was to identify Heart Failure patients who were appropriate for Palliative Care and to facilitate advanced care planning documentation. Background Heart failure (HF) is a chronic debilitating disease that can lead to high mortality and frequent hospital admissions. The downward trajectory of the disease process frequently results in unpredictable decompensation followed by improvement in symptoms. The waxing and waning of symptoms can create a barrier to timely palliative care (PC) referral that bridges chronic services and end-of-life-care. At Memorial Medical Center PC referrals were 8.2% for HF patients 6/2015 – 5/2016 versus the national median of 14%. Evidence supports the HF team can be instrumental in helping patients and their families discuss symptom management, treatment options and PC services. Methods Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology was used for the project. A literature search was performed to identify best practices, including the 2013 ACCF/AHA Guidelines for Management of HF. A PC screening tool currently utilized in the inpatient setting that is valid, reliable and evidence-based, was implemented in the outpatient clinic. An Advanced Care Plan template was developed in the clinic note to address the advanced planning conversation. A process was also developed for identifying and scanning advanced directives into the patient chart with activation of a red banner that easily identifies the advanced directives. Patients who report not having advanced directives were provided educational material regarding advanced directives. The change strategy involved stakeholders and training for all members of the care team on the use and documentation of the Advanced Care Plan template. Communication on implementation and results occurred through unit-based-council meetings, emails and direct conversations with APNs, RNs and other interdisciplinary HF clinic team members. Ongoing dialog occurred between the HF team, physicians, leadership and other clinicians at the HF Steering Committee meetings and monthly project “tollgate” meetings. The change process was implemented in stages with assessment following each process change. The first phase was assessment of the patient's advanced directives and the process of scanning them into the patient chart with activation of the red banner. The second phase was implementation of the Palliative Care Tool. The final stage was the implementation of the Advanced Care Plan template. Descriptive statistics and t testing were used to analyze the data. Conclusions Advanced Care Planning conversations are an important aspect of the care provided to HF patients. A template that allows for patient individualization, provides consistency of documentation among providers and serves as a trigger is critical to capture conversations and provide transparency for all caregivers. Nurses are in a key position to screen, initiate and facilitate Palliative Care conversations among HF patients and their families. Results Patient charts (N=51) were audited prior intervention which revealed 53% had documentation of Advanced Directives. RN documentation of Advanced Directives improved by (N=101) 81% (p=0.000). Advanced Directive documents scanned into EMR also improved from 24% to 67% (p=0.003). The PC tool was utilized in 30 of 41 (73%) of appropriate patients (1st consult or 1st follow-up visit post hospitalization for all patients seen by all providers). Two patients screened with high scores. Discussions were documented with both patients regarding disease progression and PC. One patient was sent back to their primary care provider for a PC referral. The other patient had multiple recent hospitalizations prior to the HF Clinic appointment, declined a PC referral at the time, but was hospitalized the following week, discharged to hospice care and died one month later without further hospital admissions. After implementation of the Advanced Care Plan template (N=38) 79% of patients seen in the HF clinic had documentation that was transparent to other providers (p=0.000).