Discussion
The trajectory of heart failure includes an initial relatively stable phase requiring routine medical management, followed by phases of decline and frequent hospitalisations, and ultimately a terminal phase of unavoidable deterioration lasting for days and weeks.16 Moreover, ageing among patients with heart failure per se, is associated with development of multiple comorbidities, including frailty, thus adding onto the downward spiral of the disease.14 Despite the use of evidence-based guideline directed therapy, quality of life becomes progressively poor, with feelings of fear, hopelessness, vulnerability and sense of burden to family members. Hospitalisations due to heart failure are on the rise. In the USA, compared to 2014, hospitalisation rates related to heart failure increased from 4.2 to 4.9 per 1000 adults in 2017, highlighting the burden of the disease for patients and healthcare systems.17 To tackle this global problem, the WHO has recommended developing guidelines and tools to integrate palliative care into global disease control and health systems.18 Palliative care uses a multidisciplinary approach and seeks to improve quality of life and address the physical, psychological and social needs of the patient. Therefore, along with medical management, an equal focus should be placed on improving quality of life and treating patients with heart failure holistically. In addition, several organisations, including the ACC/AHA, the International Society of Heart and Lung Transplantation and the European Society of Cardiology, have recognised the early integration of palliative care among patients with heart failure.19
Although implementation of palliative care services is a class-1 indication in the ACC/AHA guidelines, palliative care consultations, especially in the hospital setting, remain suboptimal.20 This is attributed in part to lack of standardised triggers, along with other factors such as an unpredictable trajectory, attitudes and beliefs of palliative care from both patients and providers, and lack of inpatient palliative care resources.21 The identification of patients with heart failure in need of palliative care services remains a vexing issue. The 2013 ACC/AHA guidelines state that palliative care or hospice care should be considered ‘throughout the hospital stay, before discharge, at the first visit after discharge, and during follow-up in selected patients’, and that ‘palliative and supportive care are effective for patients with symptomatic advanced heart failure to improve quality of life’.22 The latest 2022 ACC/AHA guidelines recommend implementing palliative care consults in specific instances, including patients with refractory heart failure symptoms and those with multiple comorbidities and frailty, and to assist in major medical decisions, such as placement of left ventricular assist device, which in and of itself requires a palliative care consult for Medicare coverage.11 One study advocated for the administration of standardised symptom assessment scores to identify patients with heart failure who may be eligible for palliative care.12 There is a lack of consensus regarding referral criteria for palliative care services in hospitalised patients with heart failure. Our goal was to formulate a list of common-sense indications that would act as a trigger tool for inpatient palliative care consults.
We initially conducted a root cause analysis to identify reasons for decreased palliative care consults in our hospital; this was highlighted by the fishbone diagram in figure 1. Thereafter, a review of the existing literature was performed to identify the most common indications for palliative care consults, outlined in box 1. These criteria were ultimately used as a trigger tool for inpatient palliative care consults. Most of these criteria had been summarised in a systematic review that advocated for the use of disease-based triggers, including progression of heart failure despite optimal medical therapy, ACC/AHA stage C–D heart failure, multiple hospitalisations for heart failure exacerbations and ICU level of care and/or ionotropic support.11 Due to the level of subjectivity, physical and psychological symptoms were not included. Other narrative reviews have advocated for palliative care referrals among hospitalised patients with acute decompensated heart failure when there are other comorbidities, such as chronic lung disease, end-stage kidney disease, and cancer.12 13 15
During our pre-intervention period, we found that only 28% of eligible patients with acute decompensated heart failure received a palliative care consultation. We introduced our trigger tool through multipronged educational sessions aimed at engaging all our stakeholders involved in this project. During the post-intervention phase, multiple cycles of education and re-education on the use of the trigger tool were implemented to increase yield of palliative care consultations. As a result, in the post-intervention period, palliative care consultations increased to 46% among our eligible patients, almost doubling from the baseline period, making our intervention a success. Additionally, unlike other quality improvement projects on palliative care consults in heart failure, our project included trending process-related variables such as completion of HCP and MOLST forms as well as addressing code status and documenting DNR orders. We observed a significant increase in the documentation of these surrogate process measures in the post-intervention period. Furthermore, during the post-intervention period, all-cause hospital readmission rates decreased significantly up to 90 days post discharge, compared with the pre-intervention period, likely resulting in lower healthcare costs.
Limitations
The generalisation of our results is limited in part by the small sample size and a single-centre intervention. In addition, the post-intervention period occurred during the COVID-19 pandemic, which may have confounded our findings, as we observed a reduced number of hospitalisations for heart failure, compared with the pre-intervention period. Limited staffing of providers, including nurses, advanced practice practitioners and physicians, due to COVID-19 related illness, might have also resulted in less inpatient palliative care referrals. However, we observed a significant increase in palliative care consultations during the post-intervention period, arguing against this potential concern. In our hospital, palliative care services are not available on weekends. This too could have led to fewer palliative care referrals for patients whose hospital course lasted only a weekend. Although not significant, the hospital length of stay was higher in the post-intervention period compared with the pre-intervention period, likely due in part to challenges with timely hospital discharges amid the pandemic. This might have also increased the opportunity to initiate a palliative care referral, resulting in higher consultation rates. Additionally, exploration of patient-related experiences and outcomes was not factored into this project. As the timeline of this quality improvement project included two separate indexed hospitalisation periods, the project did not extend into follow-up of these patients in the ambulatory setting after hospital discharge to monitor other outcomes, including improvements in quality of life, family caregiver outcomes and patient and caregiver satisfaction with care. Furthermore, this project had only one Plan-Do-Study-Act (PDSA) cycle with two distinct educational session phases. Although there was a significant increase in inpatient palliative care consults, multiple PDSA cycles would have shed light on whether our efforts are sustainable long-term. Finally, some of the literature reviewed by our team to identify triggers for palliative care consults, was based on expert opinion rather than peer-reviewed specific criteria. Further research is clearly needed to identify appropriate and timely triggers for palliative care referral.