Better opioid prescribing in an inpatient oncology unit: quality improvement project.

OBJECTIVES: Unsafe opioid prescribing can lead to significant patient harm and improving standards is a national priority. This report summarises a three-stage process relating to opioid prescribing, which has led to a sustained improvement. METHODS: Opioid prescriptions were reviewed retrospectively over a 4-year period in a tertiary cancer centre. The first audit cycle took place in 2017. When repeated in February 2020 following an opioid education programme implementation, prescribing remained poor. In September 2020, a quality improvement project (QIP) was developed with several interventions including opioid prescribing guidelines. RESULTS: The first audit demonstrated that 76% met safe prescribing and 68% best practice. The second audit showed a deterioration in prescribing, 61% met safe prescribing and 39% best practice despite the implementation of an education programme. The QIP has led to an improvement in prescribing, at 4 months, 87% met safe prescribing and 56% best practice. CONCLUSIONS: Despite implementation of a medical education initiative, a marked deterioration in safe opioid prescribing occurred. A shift towards QI methodology led to a successful pilot of focused interventions and resulted in improved standards of safe prescribing.

Palliative Care for Patients with End-Stage Liver Disease on the Liver Transplant Waiting List: An International Systematic Review.

People with end-stage liver disease on the liver transplant waiting list have high symptom burden, which can successfully be addressed by specialist palliative care. Potential tensions with the perceived curative nature of liver transplant make delivering specialist palliative care challenging. This systematic review seeks to establish what is known on the impact of specialist palliative care for patients on liver transplant waiting lists, healthcare professionals' perspectives of providing specialist palliative care for this population, and uptake of advance care planning (ACP). Medline, Embase, and CINAHL were searched to May 5, 2020. Qualitative and quantitative findings were grouped together according to main relevant themes. Eight studies of mixed quality and mainly quantitative, were identified. Findings suggest early palliative care intervention improve patients' symptoms and prompt ACP conversations, but patients on the waiting list receive limited palliative care input. Liver physicians' lack of clarity on referral criteria and liver transplant patients' concerns of being abandoned, were reasons for reluctance to refer to specialist palliative care. They felt referral to specialist palliative care is appropriate only for patients receiving hospice or end of life care. Uptake and understanding of ACP and goals of care designation by patients is poor. This review found evidence of benefit of specialist palliative care for patients on liver transplant waiting lists, but found in a limited understanding of their role. Evidence is limited to studies from North America. Future research is needed to understand better how palliative care could be provided into this clinical environment.