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Integrated Approach to Palliative Care in Acute Care (iPAC-AC)

Webinar SeriesDecember 4, 2019

Kelli Stajduhar, PhD, RNUniversity of VictoriaNeil Hilliard, MDUniversity of British Columbia

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• Wednesday, January 22, 2020 at 12 noon ETSupporting quality of life assessments of frail older adults and their family caregivers – Richard Sawatzky, Trinity Western University & Kara Schick-Makaroff, University of Alberta

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Presenters

2019-12-04

Integrated Approach to Palliative Care in Acute Care (iPAC-AC)

Neil Hilliard, MDUniversity of British Columbia

• Professor in the School of Nursing and Institute on Aging & Lifelong Health at the University of Victoria

• Research Scientist with Fraser Health

• Palliative Care Consultant Physician in Abbotsford

• Clinical Associate Professor at the University of British Columbia

Kelli Stajduhar, PhD, RNUniversity of Victoria

Integrated Palliative Approach to Care in Acute Care(iPAC-AC)CFN Webinar

December 4, 2019

Objectives

• To understand why we need an integrated palliative approach to care (iPAC) in acute care

• To know what is the difference between iPAC and specialized palliative care

• To learn about how to implement iPAC in acute care

Outline

•Why iPAC?•What is iPAC?

Introduction

The iPAC-AC intervention

•Qualitative•Quantitative

iPAC-AC Results

Conclusions

Discussion

Timely Access: We need to focus on those being missed

Lawand, C., Access to Palliative Care in Canada: Key Findings from CIHI’s Baseline Report, February 1, 2019

Equitable access: We need to include non-cancer patients

Lawand, C., Access to Palliative Care in Canada: Key Findings from CIHI’s Baseline Report, February 1, 2019

For success, we need to identify who they are and how they will benefit

Integration of a Palliative Approach in Home, Acute Medical, and Residential Care Settings: Findings from aProvince-Wide Survey, iPANEL, September 2015

Surprise Question

The Benefits of a Palliative Approach

Applying a palliative approach

Identification

Components of a Palliative Approach to Care

A palliative approach is different than specialized palliative care. It takes the principles of palliative care and ADOPTS, ADAPTS, EMBEDS

10

ADOPT principles EARLY (as soon as diagnosis) in the course of a person’s life-limiting condition

ADAPT strategies to meet patient and family needs, blend principles of palliative care with chronic disease management

EMBED practices into usual care in settings not specialized in palliative care

Sawatzky, R. et al. … & Stajduhar, K. (2016). Conceptual foundations of a palliative approach: A knowledge synthesis. BMC Palliative Care, 15(5). www.ipanel.ca

iPAC-AC: A Combined Quality Improvement Participatory Action Research Intervention

Baseline Data

Collection

Action Cycles

Evaluation Plan

June 1 – Sept. 302016

Oct. 1 – March 312016/2017

Apr. 1 – July 152017

Overall Goal: Enhance quality of care in acute care for people living with life-limiting conditions

• explore their beliefs, assumptions and practices around care in their practice settings to sensitize them to the challenges and opportunities that arise in caring for the dying and their families in acute care settings;

• share information and evidence about a palliative approach, the potential benefits for patients, families, providers and the healthcare system and key ingredients for care delivery;

• develop and implement strategies to integrate a palliative approach into their work that are relevant, sustainable, and realistic for acute care environments; and

• evaluate these strategies and their influence on patient and family outcomes.

Project Phases

PHASE 1: Collection of Baseline Data• 2 focus groups on medical unit (n=10) + 12 key informant interviews• Patient Survey: Canadian Health Care Evaluation Project Questionnaire (CANHELP) Lite patient version;

McGill Quality of Life Questionnaire (MQOL-R), Quality of Life in Life Threatening Illness-Family Carer Version(QOLLTI-F), Edmonton Symptom Assessment System-Revised, Veterans RAND 12-item health survey.

• Family Survey: Quality of Life in Life Threatening Illness-Family Carer Version (QOLLTI-F); CANHELP Lite Caregiver Questionnaire.

PHASE 2: Collaborative Action Cycles• Project retreat with unit multidisciplinary team• Action team meetings ~every 1-2 weeks x 6 months facilitated by CNS – field notes, structured reports

PHASE 3: Formative and Summative Evaluation• Formative: audio taped action team meetings; fieldnotes; reports• Summative focus groups with action team• Pre-post PAR surveys of patients’ and family (quality of life outcomes and satisfaction with care)• Pre-post Patient Journey Mapping• Pre-post comparison of medical record data (length of stay, referrals to palliative care, etc.)

Findings

PHASE 1:Baseline focus groups and key informant interviews suggest:• Integrating palliative approaches to care is challenging in

acute care settings• Over interventionist focus in acute care along with a general

discomfort in talking with patients and families about end-of-life care often meant patients were being “treated to the last breath”

• Participants expressed deep frustration and moral distress

FindingsParticipant 1: Feeding tubes decrease quality of life. You know, rather than being comfortable and keeping those patients comfortable we’re torturing them, in my opinion ... with further tests and procedures.Participant 2: We are treating people ... to the last breath and then we deem them palliative too late into the processParticipant 3: It’s morally distressing for me.Participant 2: It was horrible it was very sad, I was very thankful at the end that he was able, he got what he wanted he wanted to be.... you know be done.Participant 3: It’s not a way to go, tied down to a hospital bed.

Participatory Action Research• Executive Support• Action Team (Manager, PCC, PT, SW,

RN, LPN, Care Aid, Unit clerks)• Activities

• Weekly or bi-weekly meetings • Huddles• Education (CNSs) – disease trajectory,

prognosis awareness, SIC, pain/symptommanagement

• Tools for identification• Surprise question, SPICT tool• Staff developed iPAC Lanyard

• Registration in Hospital EMR (Meditech)

• Monitoring and feedback to Action Team

Participatory Action Research – Facilitators and Challenges

Facilitators• Strong unit leadership• Skilled facilitation skills and capacity

among team members• Receptivity to change• Adapting and embedding tools into

usual care processes• Partnerships between researchers

and clinicians

Challenges• Promoting ongoing engagement• Engaging physicians• Getting the team “on the same page”• Busyness and task focused

environment• Working in silos and competing

priorities

18

19

20

Patient Journey Mapping

Quantitative Analysis

• Interrupted Timed Series Analysis• Pre and post PAR samples• T-tests and chi-square test were used to compare the two samples on continuous and

categorial variables.• For all analyses, a p-value of less than 0.05 was identified as being statistically significant• Ancova was used to compare baseline and post-PAR means of domains scores and total

scores for the continuously scaled outcome measured.• All analyses were controlled for differences in age, gender, and self-reported diagnosis

between the two groups

• Univariate and Multivariate analysis for significant covariates and confounders• Purposeful covariate selection process (Hosmer and Lemeshow)• Single and Multiple Linear Regression models

• Statistical Process (Shewhart) Control Charts

0

10

20

30

40

50

60

Cancer CHF COPD Dementia Renal Failure Stroke Other

Per c

ent

Diagnosis

Per cent iPAC patients by primary diagnosis

Oct

Nov

Dec

Jan

Feb

Mar

Quality of Life Assessment and Practice Support Systems – QPSS

Innovative, integrated health care information systems for patient- and family-centered care that facilitates:

• use of QOL assessment instruments (including PROMs and PREMs) at point of care

• instantaneous feedback with information about scores, score interpretation, change over time, and targets for improvement

• tracking and assessing whether interventions achieve desired results

• capacity to integrate with other health

• information systems

Demographic Information

Demographic variablesDistributionsPre (N = 45)

DistributionsPost (N = 33)

P-value

Age in years (mean, SD) 76.56(13.37) 71.18(16.25) .114

Sex (% Female) 47.6% 51.5% .738

Marital Status .494

Married or common law 38.6% 27.3%

Single, never married 11.4% 18.2%

No longer married 50.0% 54.5%

Born in Canada 81.0% 69.7% .257

Education .176Less than high school diploma or its equivalent 15.9% 30.3%High school diploma or a high school equivalency certificate 25.0% 33.3%Other certificate or diploma (trade school, College, CEGEP, university) 40.9% 30.3%

University Degree 18.2% 6.1%

Demographic variablesDistributions Pre (N = 30)

DistributionsPost (N = 33)

P-value

Age in years (mean, SD) 56.97(15.18) 61.85(14.83) .202

Sex (% female) 68.8% 45.5% .058

Marital Status .089Married 81.3% 66.7%Living common-law 9.4% 6.1%Single, never married 9.4% 9.1%No longer married 18.2%

Recipient .304Spouse or common-law partner 37.5% 42.4%Other immediate family (e.g., parent, child, sibling) 62.5% 51.5%Extended (e.g., grandparent, grandchild, in law) and not family 6.1%

Living Arrangement (% lives with patient) 51.6% 69.7% .157

Patients Family caregivers

Pre/Post Patient Symptoms

Post-IPAC (N = 31)

Pre-IPAC (N = 38)0

2

4

6

8

10Worst Possible

No symptom

Pain Drowsy Nausea AnxietyTired Lack ofappetite

De-pressed

Shortnessof breath

0

20

40

60

80

100

Communication Decision making

Feeling atpeace

Illness management

Relationships with doctors

Completelysatisfied

Not al allsatisfied

0

2

4

6

8

10

Bestpossible

Worst possible Existential Physical Psychological Relationships

Pre/Post Patient Quality of Life and Care Experience

Quality of life Satisfaction with care

Pre-IPAC (N = 40) Post-IPAC (N = 31) Pre-IPAC (N = 38) Post-IPAC (N = 31)

0

20

40

60

80

100Completelysatisfied

Not al allsatisfied

Providercharacteristics

Communication& decision

making

Illnessmanagement

Relationshipwith doctors

Family involvement

0

2

4

6

8

10Bestpossible

Worst possible

Careroutlook

Carer quality of life

Environ-ment

Financialworries

Patientcondition

Quality of care

Relation-ships

Pre/Post Family QOL and Experience

Quality of life Satisfaction with care

Pre-IPAC (N = 27) Post-IPAC (N = 31) Pre-IPAC (N = 25) Post-IPAC (N = 31)

Per cent of medical unit iPAC patients identified

Pre/Post intervention iPAC flagged patients (n=641)

iPAC Flagged (n=641)Pre-IPAC(n=189)

Post- IPAC (n=432)

VariablesDistributions Mean (SD) / %

DistributionsMean (SD) / %

P-value

Age in years (mean, SD) 77.01 (10.33) 81.13 (0.04) 0.00

Sex (% female) 43.39 51.39 0.06

MEDICAL CONDITIONSMalignant 16.93 14.12 0.37

CHF 12.17 14.81 0.38COPD 11.11 12.96 0.52

Dementia 15.34 13.43 0.53Renal Failure 52.91 52.31 0.89

Stroke 0.00 0.23 0.51Palliative 24.34 18.52 0.10

Average Length of Stay (ALOS) (n = 641, t(619) = 2.63, p = 0.01)(pre PAR: 24.12 days, n=189; Post PAR: 19.4 days, n= 432; ALOS reduced by 4.72 days)

Median Length of Stay (MLOS) (n = 1806) iPAC patient MLOS = 14 days (n = 641); Post iPAC MLOS reduced by 9% = 1.26 days

Variables GM Ratio 95% confidence intervalPre/Post iPAC (n=189 / n= 432) 0.91 0.84 0.98iPAC/not iPAC flagged 1.86 1.72 2.02Cancer/not Cancer 1.42 1.26 1.59CHF/not CHF 1.32 1.17 1.49Dementia/not D. 1.36 1.21 1.54Renal Failure/ not RF 1.14 1.06 1.23

Multivariable regression results: There continues to be a difference in pre- and post-IPAC length of stay after adjusting for confounding variables.

Discharge Disposition of iPAC patients (per cent)

N = 641 Pre-intervention (n=189) Post-intervention (n=432) Per Cent Change

Died on ward 20.11 11.57 42% reduction Discharged home 43.92 54.4 24% improvementTransferred 34.39 33.56Other 1.59 0.46

Unadjusted chi-square analysis: χ2(3) 11.37, p = 0.01Pre-intervention: Before October 1, 2016Post-intervention: After September 31, 2016

Per cent ICU/HAU/CCU utilization (Revised Limits)

Reduced 25%

Palliative Care Program Referrals

Death chart audits (N=40)First 20 deaths all patients on acute care unit

23

33

37

0

5

10

15

20

25

30

35

40

2016 2017 2018

Per C

ent I

dent

ified

Year

Total per cent iPAC patients Baker 2

Identification of iPAC patients continued to improve and was sustained past the end of the action cycle period ending March 31, 2017. For years prior to 2016, zero per cent iPAC patients were identified.

Conclusions

• Patients who can benefit from a palliative approach to care alongside usual care can be identified by primary care providers on an acute care medical unit.

• A change in culture to a person and family centered team-based integrated palliative approach to care is possible and sustainable on an acute care medical unit through a participatory action approach.

• The Institute of Health Care Improvement (IHI) quadruple aim of improved quality of care, improved patient and family experience, improved provider experience, and at reduced cost is possible through introducing an integrated palliative approach to care.

AcknowledgementsiPAC-AC

iPAC-AC Innovation CommunityPrincipal InvestigatorsNeil Hilliard: Neil.Hilliard@fraserhealth.caRichard Sawatzky Rick.Sawatzky@twu.caKelli Stajduhar (project leader) kis@uvic.ca

Co-investigatorsGweneth DoaneLesli Matheson JenningsClaudia MeyermanSheryl Reimer-KirkhanDella Roberts

HQPs/Group FacilitatorsNicole WikjordPatty Roy

Steering committeeDoris Barwich, Kim Crooks, Carren Dujela, Jerry Gosling, Neil Hilliard, Cari Hoffmann, Jay Lambert, Joyce Lee, Lesli Matheson Jennings, Claudia Meyerman, Della Roberts, Patty Roy, Skanthan Sithamparanthan, Rick Sawatzky, Kelli Stajduhar, Annie Smith, Nicole Wikjord, Connie Wong

Operations committeeTrena Canning, Neil Hilliard, Leslie Matheson Jennings, Nicole Wikjord, Patty Roy, Cornelia Vera

Strategic Transformation TeamJay LambertAnnie Smith

Baker 2 TeamTrena Canning, Iona Wray, Margaret Chafe, Crystal Andrew, Sukhwinder Brar, Karen Griffiths-Hawrylko, Cornelia Vera, Roselyn Beukens, Circe Codio, Maryna Koechlin, Sandra Nechwediuk, Jocelyn Klemes

Patient Journey MappingKevin HareKathrin EiblKaren SymmesHamze Jomaa

Data CollectionDawson McCann, Nicole Wikjord, Patty Roy

Key informant interviewsMelissa Giesbrecht

Health Business AnalyticsYurik Sandino AlarconChong Chen

Health InformaticsNoel Francisco

Individual Level Data AnalysisErin Krieter, Angela Tescon

Industry PartnerJames Voth, CEO, Intogrey

Admin SupportCarren Dujela

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Post-webinar surveySurvey will pop up on your screen after webinar • Feedback on how to improve webinar series

Wednesday, January 15, 2020 at 12 noon ETElder-friendly Approaches to the Surgical Environment-using Biological samples to Identify & provide Optimized care – Rachel Khadaroo & Amritpal Bhullar, University of Alberta

Kelli Stajduhar: kis@uvic.caNeil Hilliard: Neil.Hilliard@fraserhealth.ca

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