Mollo, page 1. Katie Mollo. Abstract

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1 Katie Mollo Abstract Introduction: The benefits of Palliative Care to patients, families, and the economics of health care have been proven in the adult and geriatric populations and Palliative Care is a growing field in the pediatric population. With slightly more than half of childhood deaths occurring in infancy, there is a need for Palliative Care in the NICU. Recent studies and institutions are looking at the benefits of establishing criteria for Palliative Care consults in the NICU. The question this project poses is if establishing Palliative Care criteria in our NICU will increase, the number of Palliative Care consults. Methods: Palliative Care consult criteria for this study were created based on different studies and reviewed by the staff. Data was collected prior to establishing criteria, and after criteria. A mid-point intervention during the study was to determine if ing the criteria to the residents prior to their assignment to the NICU would increase consults. Results: There was no significant difference in the number of Palliative Care consults in the precriteria group when compared to the post-criteria group. There was a slight increase in consults when the criteria was ed to the residents just prior to starting a NICU rotation. Conclusion: This quality improvement projected showed that making criteria for NICU Palliative Care did not statistically increase consults. However, the study was successful in highlighting areas of improvement for further study. Introduction Palliative Care is an increasingly important component in offering quality healthcare to patients and their families. According to US Department of Health and Human Service Centers for Medicare and Medicaid Services and the National Quality Forum Palliative Care is defined as patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering. 1 The need for Palliative Care is becoming more recognized by the medical profession. In 2001, the National Consensus for Palliative Care was organized to help standardize Palliative Care. Since the establishment of this program, there has been an increase in the number of hospice and Palliative Care programs. Looking specifically at the pediatric population, there has also been a significant increase in Palliative Care services. According to an article from Pediatrics, 50% of all pediatric hospitals reported having a Palliative Care program and that the majority of programs were established within the past decade. 2 Most pediatric Palliative Care is utilized in the NICU, PICU, and Oncology. Resulting from the establishment of these new programs, there is an emphasis to educate physicians on Palliative Care. According to a survey of residents who worked at Children s Hospital of Pittsburgh in 2003, residents felt that they needed more education in the principles of Palliative Care. 3 The article shows the importance of residents becoming more knowledgeable in and thus more comfortable with the use Palliative Care. Focusing on Palliative Care in the NICU, according to the facts and figures of the Pediatric Palliative and Hospice Care in America, slightly more than half of childhood deaths occur in infancy. The leading causes of death in infancy include congenital malformations and complications of short gestation/low birth weight (LBW). 4 There is insufficient data regarding the Palliative Care in Pediatrics, specifically in the NICU, and this is an area that needs further research. Palmetto Health Richland has an inpatient Palliative Care service, however, there is currently no standardized criteria for NICU palliative care consults. Palliative Care is consulted based simply on the physician s determination to consult. The Palliative team is available for consults in the NICU, PICU, and Children s hospital. The aim of this study is to see if establishing criteria for Palliative Care consults will increase the number of Palliative Care consults in the NICU We are going to measure the success of the Mollo, page 1

2 criteria by looking at Palliative Care consults in the NICU before and after establishing criteria. The post-palliative Care criteria progress will be observed and measured over a six-month period. Methods This quality improvement project took place at Palmetto Health Richland Neonatal Intensive Care unit from October 2016 to April Palmetto Health Richland offers a Level III NICU with 69 beds. The pediatric residents rotate monthly in the NICU. The criteria was established through a literature review and review of other institutions criteria for NICU Palliative Care 5. The criteria is listed in Table 1. The pre intervention data was collected from previous year s that were not using Palliative Care criteria between the same time period (October- April). At the introduction of the study the Palliative Care criteria was discussed with NICU physician, nurse practitioners, nurses, and residents. The next two months I discussed the criteria and location with the new residents rotating in the NICU. The next intervention that occurred over the final three months of this intervention was to the Palliative Care criteria to the resident the night prior to their first day rotating, discussing where it was located, and offering to answer any questions regarding Palliative Care in the NICU. After the intervention was completed a short survey was sent out to the residents to evaluate their use of the criteria, and overall barriers faced when consulting Palliative Care. The data was compared qualitatively. Table 1: Palliative Care Criteria CNS Conditions Holoproencephaly Ancephaly Neurodegenerative Disease Congentinal severe Hydrocephalus with absent or minimal brain Genetic Conditions Trisomy 13 Trisomy 18 Osteogensis Imperfecta Errors of Metabolism Renal Conditions Potter Syndrome/Renal Agensis Renal Failure Requiring Dialysis Neonatal Polycystic Disease Heart Conditions Inoperable Heart Anomalies Hypoplastic Left Heart Syndrome Structural Anomalies Large Omphalocele Severe Congenital Diaphragmatic Hernia Gastrochisis Other Extremely low birth weight < 750g Gestational age of 24 weeks or less Hypoxic Encephalopathy Requiring Cooling Nonresponsive to aggressive resuscitation Multiple rounds of CPR Sever Cases of Leukomalacia or brain hemorrhage NEC or midgut volvulus that results in short gut syndrome or long term TPN Results Mollo, page 2

3 The results of this study were compared qualitatively by looking at pre-intervention and postintervention consults numbers. Figure 1 shows this comparison. After reviewing the consults there was no significant change in the amount of consults after the intervention Figure 1: Pre-intervention Palliative Care results are shown in blue bars compared to the post intervention results demonstrated by the red bar. The other information that was analyzing during this project was to see if sending out the criteria the night prior to residents rotating in the NICU would increase consults. Figure 2 shows the comparison of consults prior to ing out criteria to after ing the criteria Prior to After ing residents Figure 2: Demonstrates the effect of ing residents criteria to the start of the rotation. Mollo, page 3

4 Discussion This quality improvement project was to identify if establishing criteria for Palliative Care consults in the NICU would increase the number of consults. This study found that there were no significant increases in Palliative Care consults after establishing criteria in the NICU. The strength of the study is that the criteria were established from a literature review and other programs that use NICU Palliative Care consults. In addition, the study allowed our program to identify areas of weakness and barriers faced by residents. After surveying the residents the three most common reasons given for not calling for a Palliative Care consult were: 1) family not ready to accept prognosis, 2) uncertain prognosis, and 3) the attending physicians do not feel it is necessary to consult Palliative Care. Some of the limitations of this study were the duration of the study, inconsistent staff support for the project, and lack of education regarding Palliative Care s role in the NICU. The project occurred over a short duration. The Palliative Care criteria was not widely accepted by all staff members. The last limitation was based on feedback from the residents that requested more information on Palliative Care s role in patient care in the NICU, which this project did not include. Conclusion: This project may have not been clinically significant, but it showed areas in which we could do further quality improvement to foster relationship between the primary team and Palliative Care, increase education about Palliative Care s role in pediatrics, and improve care for our patient s and their families. Mollo, page 4

5 References 1. Clinical Practice Guidelines for Quality Palliative Care: Executive Summary. New York, NY: National Consensus Project for Quality Palliative Care, Print. 2. Feudtner, Chris, James Womer, Rachel Augustin, and et al. "Pediatric Palliative Care Programs in Children s Hospitals: A Cross-Sectional National Survey." Pediatrics (2013): Kolarik, R. C. "Pediatric Resident Education in Palliative Care: A Needs Assessment." Pediatrics (2006): Friebert, Sarah. "NHPCO Facts and Figures: Pediatric Palliative and Hospice Care in America." NHPCO Facts and Figures: Pediatric Palliative and Hospice Care in America. National Hospice and Palliative Care Organization, 1 Apr Web. 30 Jan Catlin, Anita, Debra Brandon, Charlotte Wool, and Joana Mendes. "Palliative and End-of-Life Care for Newborns and Infants." Advances in Neonatal Care 15.4 (2010) Mollo, page 5