Improving timely transfers from acute care to the local palliative care unit for patients at the end of life.

BACKGROUND: Despite evidence showing that nearly two thirds of the Canadian population prefer to die at home, the majority die in hospital. Honoring a patient's wish for their preferred location of death is an essential component in end-of-life care. Therefore, for those patients admitted to acute care whose choice is to transfer to a palliative care unit for end-of-life care, it is imperative that this occurs in a safe and timely manner. The General Internal Medicine ward at this local tertiary care academic center, did not have a standardized process for transferring patients at the end-of-life to the local palliative care unit. With bed calls made between Monday to Saturday at 8 am, weekday and weekend transfer times ranged between 1 to 6 hours. The aim of this project was to establish a standardized, safe and efficient patient transfer from acute care to the palliative care unit for a daily standard arrival time. METHODS: A multidisciplinary quality improvement team was formed to analyze the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process and turnaround time. An outcome measure aiming for a turnaround time of two hours was set as the target. RESULTS: A total of fourteen patient transfers were included. Average transfer time during the weekday was reduced from a baseline average of 180.2 to 128.3 min. This change was found to be statistically significant and sustained (P<0.003). The average transfer time on weekends remained stable at 234 min. The outcome target of a 10:00 am arrival time to the palliative care unit was achieved 42% of the time. CONCLUSIONS: This project remains on-going and early data is encouraging as it met the targeted transfer time 42% of the time. Fidelity in the process measures helped to meet the targeted turnaround time of two hours for a safe and efficient transfer to the palliative care unit and ensured patients got to their preferred location for end of life care. The goal is to expand this project to other general internal medicine wards across the organization.

Preliminary results of the generation of a shortened quality-of-life assessment for patients with advanced cancer: the FACIT-Pal-14.

OBJECTIVE: Shortened quality-of-life (QOL) tools are advantageous in palliative care patients. Development of such tools begins with the identification of issues relevant to a population. The purpose of this study was to identify the most important items of the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) to create an abbreviated questionnaire for future palliative care trials. METHODS: A convenience sample of patients and health care professionals (HCPs) assessed the relevance of each item of the FACIT-Pal and whether they would include the item in a final questionnaire. Patients and HCPs identified their top 10 most important issues and were asked whether items were inappropriate, upsetting, or irrelevant; a shortened questionnaire was generated from this input. RESULTS: Sixty patients and 56 HCPs participated. The median score in the Karnofsky Performance Scale (KPS) of patients was 70, and the majority of HCPs were radiation oncologists. The 46-item questionnaire was shortened to 14 questions, retaining several items from the Functional Assessment of Cancer Therapy-General (FACT-G) as well as issues pertaining specifically to palliative care patients. Items within the emotional, physical, and functional well-being subscales were retained along with those for various symptoms including constipation, nausea, dyspnea, and sleep. No new content beyond what is covered by the FACIT-Pal was identified consistently by either HCPs or patients. Similarly, no item was consistently rated as being inappropriate, upsetting, or irrelevant in the 14-item questionnaire. CONCLUSION: The FACIT-Pal-14, a shortened 14-item questionnaire has been generated for the palliative care population. Future studies should complete psychometric validation of this instrument for the assessment of QOL in palliative care patients.

Patients' and Health Care Providers' Evaluation of Quality of Life Issues in Advanced Cancer Using Functional Assessment of Chronic Illness Therapy - Palliative Care Module (FACIT-Pal) Scale.

BACKGROUND: To examine the agreement of Health Care Providers (HCPs) and patients' evaluation of quality of life on the Functional Assessment of Chronic Illness therapy - Palliative care module (FACIT-Pal) scale. METHODS: Sixty advanced cancer patients and fifty-six health care providers involved in their care at Sunnybrook Health Sciences Centre completed a modified version of the FACIT- Pal. In the survey, patients and HCPs indicated the 10 top issues affecting the quality of life of patients with advanced cancer most profoundly. The percentage of participants selecting each item as one of their 10 most relevant items was calculated in HCPs and patients. RESULTS: There were differences in relative rankings of QOL issues among patients and HCPs. Among the top 10 items which were identified from both patients and HCPs, there were differences in the rankings. Patients ranked emotional support from family (40.9%) as most important followed by pain (38.6%), lack of energy (31.8%) and able to enjoy life (29.6%). HCPs ranked in the following order: pain (73.2%), lack of energy (63.4%), nausea (51.2%) and dyspnea (51.2%) whereas patients rated nausea at 18.2 % and dyspnea at 9.09%. CONCLUSION: There is a discrepancy between scores of patients and HCPs as they may prioritize differently. HCPs tended to put more emphasis on physical symptoms, whereas patients had emotional and global issues as priorities.