Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital - an open-label stepped-wedge cluster-randomized trial.

BACKGROUND: The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown. AIM: To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians. DESIGN: An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509. SETTING/PARTICIPANTS: Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore. RESULTS: A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI -0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05-1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63-4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79-1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90-1.58, p = 0.215) were similar between the consult and co-rounding models. CONCLUSIONS: The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.

Facilitating terminal discharge: fulfilling the hospitalised patient's wish for home death in the final hours.

BACKGROUND: Terminal discharge (TD) is the rapid discharge of a hospitalised patient when death is imminent. Its time-limited nature makes it challenging, particularly for ward nurses. AIM: To report the development of a structured TD framework, and determine if the framework can expedite TD processes and improve nurses' experience in conducting TDs. METHODS: A 3-phase audit was carried out in a Singapore hospital. The baseline and post intervention audits evaluated the time taken for TD, incidence of prescription errors, continuity of care, and timeliness of equipment arrangement. Nurse satisfaction was assessed through a written survey. Interventions encompassed the implementation of workflow changes and a TD guide. RESULTS: The mean time taken to complete TDs was shorter in the post-compared to pre-intervention phase (2.9±1.4 vs. 4.6±2.3 hours respectively, p<0.01). Approximately 89% of nurses who used the TD guide were satisfied that it made TDs easier. CONCLUSION: A structured TD framework is effective in expediting TDs and improving nurse satisfaction.