Abstract
Background: Early access to palliative care (PC) has been shown in multiple studies to improve quality of life (QOL) for patients and families as well as decrease overall costs of end-of-life care. However, most of these studies have been focused on inpatient/hospital PC with medical conditions such as heart failure, cancer, dementia, or chronic obstructive pulmonary disease (COPD) and not surgical patients.|Objectives: Literature was reviewed discussing the value of PC in patients’ and families’ quality of life, the importance of early referral, and economic benefits, as well as current barriers to implementation of early PC, especially in the surgical patient. This project analyzed provider opinions on PC, educated staff on PC, and assessed the efficacy of screening patients referred for surgery in an outpatient preoperative surgical clinic run by advance practice registered nurses (APRNs) to decrease missed opportunities for PC referral.|Methods: An anonymous online survey of Surgical Evaluation Unit (SEU) staff was conducted to assess knowledge and beliefs about PC, as well as their opinion on screening for and referring to PC in this clinic. An online PC educational module was completed by staff after survey and before the quality improvement (QI) implementation. For eight weeks, the Integrated Palliative Care Outcome Scale (IPOS) screening tool was given to veterans 55 years and older. The APRN reviewed the tool and addressed any noted concerns with the patient. If the score indicated PC should be considered, the APRN discussed this with the patient and/or caregiver. Referral was made if they were in agreement. After the eight weeks the staff completed another online, anonymous survey to assess their opinions after the QI project. The IPOS data and follow up on patients with higher scores was completed with the electronic medical record (EMR) review.|Results: The staff’s opinions after the QI project indicated they did have a change in belief regarding doing PC screening and referral in this clinic and were open to continuing. On review of EMR data, two PC referrals were placed by SEU APRNs, compared to no consults submitted in the eight-week period reviewed prior to the QI project. The APRNs indicated that although the patient may not have needed a PC consult, the screening tool did allow them to discuss issues with the patient that may not have come up during a standard evaluation.|Conclusion: Pre-operative PC screening has been increasingly called for without having an accurate, quick process to do so, or a clinic willing to complete this extra task. Staff in the SEU found it did not add any significant time to their duties or to the appointment itself to complete the tool. The majority of the patients voiced no concerns about the tool. While initially hesitant about the project, the APRNs began to see the benefit of the tool in opening dialogue on difficult topics. An internal medicine doctor who staffs the embedded medical evaluation clinic Tuesday through Thursday was interested in the results of this QI project, and wants to support continuing screening in some form, as well as the possibility of initiating goals of care discussions. The results of this QI project support ongoing PC screening and also further education for staff to increase their PC knowledge.|Keywords: palliative care, early access, surgery and palliative care, barriers to palliative care