Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

TY - JOUR

T1 - Establishing Goals of Care for Patients With Stroke and Feeding Problems

T2 - An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

AU - Hwang, Franchesca

AU - Boardingham, Christine

AU - Walther, Susanne

AU - Jacob, Molly

AU - Hidalgo, Andrea

AU - Gandhi, Chirag D.

AU - Mosenthal, Anne C.

AU - Lamba, Sangeeta

AU - Berlin, Ana

N1 - Funding Information: This work was supported by the New Jersey Medical School Hispanic Center of Excellence, Health Resources and Services Administration through grant D34HP26020 (Dr. Ana Berlin), and the Auen Foundation (Dr. Franchesca Hwang). The authors declare no conflicts of interest. Publisher Copyright: © 2018 American Academy of Hospice and Palliative Medicine

PY - 2018/10

Y1 - 2018/10

N2 - Background: Few patients with dysphagia because of stroke receive early palliative care (PC) to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. Measures: To increase documented goals of care (GOC) discussions among acute stroke patients before feeding gastrostomy tube placement. Intervention: We undertook a rapid-cycle continuous quality improvement process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for PC referral prompted by the speech and language pathology evaluation. Outcomes: During a six-month period, 21 patients underwent gastrostomy tube placement; 52% had preprocedure GOC discussions postintervention, with the rate of compliance increasing steadily from 13% (11/87, preintervention) to 100% (2/2) in the final two months. Conclusions/Lessons Learned: We effectively increased documented GOC discussions before feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early PC for stroke patients.

AB - Background: Few patients with dysphagia because of stroke receive early palliative care (PC) to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. Measures: To increase documented goals of care (GOC) discussions among acute stroke patients before feeding gastrostomy tube placement. Intervention: We undertook a rapid-cycle continuous quality improvement process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for PC referral prompted by the speech and language pathology evaluation. Outcomes: During a six-month period, 21 patients underwent gastrostomy tube placement; 52% had preprocedure GOC discussions postintervention, with the rate of compliance increasing steadily from 13% (11/87, preintervention) to 100% (2/2) in the final two months. Conclusions/Lessons Learned: We effectively increased documented GOC discussions before feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early PC for stroke patients.

KW - Stroke

KW - cerebrovascular accident

KW - dysphagia

KW - feeding tube

KW - gastrostomy

KW - goals of care

KW - palliative care

KW - surgical patients

KW - trigger

KW - workflow integration

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U2 - https://doi.org/10.1016/j.jpainsymman.2018.06.010

DO - https://doi.org/10.1016/j.jpainsymman.2018.06.010

M3 - Article

C2 - 29953940

SN - 0885-3924

VL - 56

SP - 588

EP - 593

JO - Journal of Pain and Symptom Management

JF - Journal of Pain and Symptom Management

IS - 4

ER -