Introduction of triggers for palliative care consultation improve utilization and and satisfaction within a level 4 NICU

Introduction of triggers for palliative care consultation improve utilization and and satisfaction within a level 4 NICU

Nguyen L T; Spear M L

Pediatrics

2018

awareness; conference abstract; controlled study; human; infant; leadership; medical record review; needs assessment; nurse; palliative therapy; patient referral; physician; practice guideline; satisfaction

The use of a palliative care guideline in infants remains controversial in the NICU community. Triggers are only intermittently utilized within the NICU setting. Most NICUs implement strategies for near-death care, but few have guidelines for those with medically complex conditions that have potential in progressing towards death. It may be helpful to utilize written criteria for palliative care consultation (PCC) for patients who can benefit from early referral. Thus, our specific aim is to increase the number of PCCs within our level 4 NICU by 20% by the end of December 2016. Our global aim is to improve the care of the medically complex infant in need of multidisciplinary management, which includes palliative care services provided by our palliative care team (named CORE team). The need for a list of triggers was found after distributing a needs assessment survey amongst bedside nurses, nurse practioners, fellows, and attendings. The list was adapted from Caitlin and Carter (2002), and development included input from NICU leadership. The list was posted in the physician workrooms (Figure 1). Bi-monthly reminders were sent out to the NICU fellows on service to review their team's census, identify those who met criteria for PCC, and were encouraged to discuss these patients and their indications for PCC during daily multidisciplinary rounds. After 6 months, a post implementation survey was distributed. Medical chart review of each NICU admission since January 2014 was done to assess which patients met criteria for PCC, how many received a PCC, and the number of days between date of admission and the initial consultation. Prior to implementation, of those who qualified for PCC, 26% received consultation. After implementation, the percentage increased to 46%. The post implementation survey found an increase in understanding the CORE team's role in the NICU, knowing when to consult, and awareness of a positive difference within the NICU since utilizing their services more frequently (Figure 2a). Lastly, the time until initial consultation decreased from approximately two months to one week (Figure 2b). We achieved our goal of increasing the number of PCC. The listed triggers helped establish prompt and proactive referral to the palliative care team at our institution. Not only can a written guideline increase awareness of a palliative care team's role within a NICU, but it also enhances the satisfaction amongst providers of the care they are giving. Next steps include involving the CORE team during weekly multidisciplinary rounds, as well as developing a strategy for those who can benefit from CORE team within 24 hours or overnight. We speculate that utilization of palliative care within the NICU can help guide revision of treatment goals, and provide continuity of care and support to families in need of resources.

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