What Was Done?
Global Problem Addressed
Adults over 55 now account for more than 40 percent of trauma patients.1 Compared with younger patients, these older trauma patients have higher rates of mortality and those that survive have worse long-term functional outcomes.2,3 These potential poor outcomes should be discussed with patients, as many older adults report valuing quality of life over quantity of life.4
Palliative care is specialized medical care that focus on preferences and quality of life in patients with serious illness. Palliative care should not be provided solely at the end of life. Any patient with a serious illness, functional dependency or advanced care needs should have a palliative care assessment while hospitalized.5 A critical aspect of providing palliative care involves having goals of care conversations with patients and providing care in line with their preferences. Although providing goal concordant care is recommended for all seriously injured patients, palliative care is unfortunately underutilized in surgical populations.6,7
Identification of Local Problem
Our center has a strong interest in palliative care that has been integrated into our routine delivery of trauma care. Goals of care conversations are started early in patients that are identified as having a high risk of dying. Although almost all of our patients that died were receiving palliative care prior to death, we hypothesized that there remained gaps in palliative care delivery in our patients that were discharged alive, with poor functional outcomes. We performed a prospective observational study of all trauma patients ≥ 55 years admitted to our institution, and identified that more than two-thirds of our patients discharged with a poor functional outcome did not have a goals of care conversation while in the hospital.8
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
University Hospital is a 500-bed urban safety net hospital located in Newark, NJ. It is the only Level I trauma center in Northern New Jersey with more than 3,000 trauma activations per year.
At our institution from 2016 to 2018, we performed a prospective observational study to evaluate the Palliative Performance Scale (PPS) as predictor of outcomes in elderly trauma patients. The PPS is validated tool for the assessment and prognostication of seriously ill individuals.9 It was initially developed for use in cancer patient, but has since been used in other seriously ill populations.10 The PPS scale consists of five domains: ambulation, activity and evidence of disease, self-care, intake and level of consciousness. Scores range from 0 to 100 in increments of 10, where 0 is death and 100 is healthy without limitations. Prior to initiation of the study a meeting was held and all members of the trauma team were introduced to the PPS and trained how to accurately calculate a patient’s score. During the study period, advance practice nurses, that are members of the trauma team, evaluated all admitted trauma patients ≥ 55 years and calculated their PPS. From this study we found that low PPS (<80) was independently predictive of mortality and poor functional outcomes (defined by Glasgow Outcome Coma Score Extended [GOSE] of 1–4) at discharge and six months.11
Planning and Development Process
The American College of Surgeons Trauma Quality Improvement Program (TQIP) Palliative Care Best Practice Guidelines recommend that all trauma patients be evaluated for palliative care needs within 24 hours of admission. Patients identified as having life-threatening or disabling traumatic injuries, or those with less severe injuries that are frail, or have multiple co-morbidities, should have a goals of care conversation within 72 hours of admission.12 We used these guidelines to create and monitor our quality improvement initiative.
To increase goals of care conversations in patients with a high likelihood of being discharged with a poor functional outcome (GOSE of 2–4), we targeted patients with low PPS (<80) score. This target was based off the findings from the prospective study performed by Hwang et al.11
Prior to initiating the quality improvement project, it was imperative that we obtained buy-in. With support of the trauma medical director and chair of the surgical department, we engaged key stake holders-The head of quality improvement and the trauma nurse manager. In addition, we performed an assessment with the advance practice providers to discuss the barriers they faced. After engaging all these key stake holders, we presented our current data on goals of care conversations and our plan for our project to all members of the trauma team during both trauma section meeting and trauma grand rounds. In addition, flyers were placed in the surgical intensive care unit.
Description of the Quality Improvement Activity
This Quality Improvement project was implemented on April 9, 2019.
The purpose of this project was to increase goals of care conversations in elderly patients with a low pre-injury PPS score by using a score less than 80 as a trigger for the conversation.
Our revised standard practice consisted of all admitted trauma patients ≥ 55 years of age having a PPS calculated on admission. A score less than 80 was an automatic trigger for referral for goals of care conversation to occur within 72 hours. The resident physician or advance practice provider evaluating the patient would initiate the conversation or call a palliative care consult, if they felt the patient had advanced needs they could not handle. Goals of care conversations and palliative care consult for all other patients remained at the discretion of the attending based on degree on injury severity and pre-existing comorbidities.
A flow sheet of patient evaluation can be seen in Figure 1.
Prior to implementation of this quality improvement project, all members of the trauma team including attendings and advance practice providers had been trained in evaluating the PPS and in having goals of care conversations. A palliative care specialist was brought in to host a one day workshop on communication skills that included didactics and role play. Following this workshop, advance practice providers were equipped with the tools to not only evaluate PPS, but also hold goals of care conversations independently.
