ASCOs Quality Training Program Project Title: Reducing the percent - - PowerPoint PPT Presentation
ASCOs Quality Training Program Project Title: Reducing the percent of ICU deaths of patients with advanced cancer at Stanford Health Care Presenters Names: Pelin Cinar, MD, MS & Zarrina Bobokalonova, RN, MSN, BEc Institution: Stanford
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Project Title: Reducing the percent of ICU deaths of patients with advanced cancer at Stanford Health Care Presenters’ Names: Pelin Cinar, MD, MS & Zarrina Bobokalonova, RN, MSN, BEc Institution: Stanford Cancer Center Date: 10/08/2015
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ICU mortality in 2014
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Total number of deaths 382 patients Oncology patients 116 patients Solid oncology patients 66 patients Advanced solid cancers 38 patients
Percent of Palliative Care Consultation
Number of days prior to death when Palliative Care Consulted
20 80
10 20 30 40 50 60 70 80 90
No Yes
n=66
65% 20% 15%
10 20 30 40 50 60 70
<7 days 7-14 days >14 days
n= 20
55% of cases had palliative care consultation 0-3 days before dying
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Team Leader:
Team Members:
Project Sponsor:
Improvement Coach:
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Updated figure to be uploaded by Zarrina
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13% 24% 34% 42% 50% 57% 63% 69% 75% 80% 85% 89% 92% 94% 97% 99% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 4 6 8 10 12 14 16 GOC note mostly used in ICU at EOL Pt & family knowledge/acceptance of disease state GOC discussed only in last few days POLST and AD not on file/uploaded/full code instead MD & team disagreement about CP, subjectivity Pt & family new dx and aggressive management Pressors require ICU care PC consult can take 1-3 days No PC consult ordered GOC often addressed in ICU first Failure to better communicate and adequately educate pt/family Hospice/stepdown beds not available patient kept alive/pressor support for family to arrive Conflicting feelings from care team and family about pc Intensivist forced to direct care Primary oncologist not contacted Not a pleasant patient or family area for dying
Causes of patients with advanced stage cancer dying in ICU
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CL 40.4% UCL 89.5%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Rate 2014
Rate Mean Target
30.3%
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tumors by primary oncologist
by primary oncology
admission to join in family meeting
with family meetings every 3 days
EPIC
disease progression and goals of care by primary
with advanced solid cancers admitted to the ICU after approval by the primary oncologist
easily on EPIC
being admitted to the hospital/ICU
consultation within 3 days
medicine in outpatient clinic
present to ED
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Date of PDSA cycle Description of intervention Results Action steps
9/1/2015 – 9/21/2015 Criteria developed to communicate with the primary oncologists and trigger early referral to palliative care
between pre-PDSA and post-PDSA death rates.
consults were requested within
admission and were completed the following day.
with ICU/Oncology
critical care units.
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Criteria for Obtaining Palliative Care Consultation for Oncology Patients admitted to the ICU Any Stage IV disease or Stage III lung or pancreatic cancer AND one or more of the following:
expectancy <6 months or refractory disease (need to confirm with primary oncologist)
nausea, dyspnea, delirium, distress)
Resident/fellow calls the primary
patients If the criteria are met:
primary oncologist and place Palliative Care consult.
to the primary oncologist.
primary oncologist, inpatient
their input.
*If the patient is admitted overnight, may call primary
**Add to your progress note approximate time and date of contact with primary oncologist
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Implementation of Criteria on 9/1/15
Pre-PDSA n=13
Post-PDSA n=10
3 (23.1%)
2+ lines of prior therapy with life expectancy <6 months
4 (40%) 7 (53.8%)
Hospitalization within prior 30 days
3 (30%) 1 (7.7%)
>7 day hospitalization
1 (10%) 1 (7.7%)
Uncontrolled symptoms
1 (7.7%)
2+ lines of therapy + Hospitalization in 30 days
1 (10%)
Hospitalization in 30 days + >7 day hospitalization
1 (10%)
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Rate of ICU deaths of patients with solid tumors did not change after the intervention
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Pelin Cinar, MD, MS, Clinical Assistant Professor of Medicine in Oncology Zarrina Bobokalonova, RN, MSN, BEc, Clinical Quality Specialist Eric Hadhazy, MS, Senior Quality Consultant Sandy Chan, LCSW, ACHP-SW, Manager, Palliative Medicine
Reducing the percent of ICU deaths of patients with advanced cancer at Stanford Health Care
AIM: By October 2015, we will decrease the percentage of advanced solid tumor ICU deaths at Stanford Health Care by 25%. TEAM: Palliative Care ED ICU GI Oncology Thoracic Oncology Internal Medicine (resident) PROJECT SPONSORS: Douglas Blayney, MD QUALITY COACH: Holley Stalling, RN, MPH, CPH,
CPHQ
INTERVENTION: Criteria were developed to assist with triggering consultation with early palliative care consultation. The criteria included: stage IV disease or stage III lung or pancreatic cancers and one or more of the following: 2+ lines of prior therapy with life expectancy <6 months or refractory disease; hospitalization within prior 30 days; >7 day hospitalization; uncontrolled symptoms (pain, nausea, dyspnea, delirium, distress). The primary oncologist was contacted by the ICU team if the patient admitted to the ICU met these criteria. If the primary oncologist agreed, Palliative Care service was consulted. ICU team was asked to document that primary oncologist was contacted and whether Palliative Care service was consulted. CONCLUSIONS:
for pre and post intervention did not change
contacting the primary oncologists and palliative care consultations NEXT STEPS:
within the last 30 days.
Neuro-critical Care). RESULTS:
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% pre-PDSA post-PDSA 32 18 7 4 Rate
Pre and Post Intervention Results
Expired in ICU Admitted to ICU