ABSTRACT
Background: Patients with terminal diseases frequently undergo procedures and interventions that are futile and maybe detrimental to the patients' quality of life. We conducted a quality improvement project aimed to reduce futile acute care services (ACS) for cancer patients treated with a palliative intent. Methods: A multidisciplinary team retrospectively reviewed the records of terminally ill cancer patients who died during in the hospital at our institution, King Abdulaziz Medical City, Riyadh, Saudi Arabia. We included all patients expired between November 2017 to May 2018. The review aimed to assess the magnitude of improper utilization of acute care services (ACS) such as: Critical care response team (CCRT), cardiopulmonary resuscitations (CPR) and admission to intensive care unit (ICU). A root cause analysis and process mapping were conducted to identify reasons for over utilization of these services. Timely documentation of goals of care was identified as a main reason for this problem. Then interventions were implemented to improve the practice. Post intervention data was captured and compared to the baseline data. Results: After delivery of staff education sessions and implementation of mandatory documentation of goals of care in the electronic healthcare record system, the timely documentation of goal of care for patients with palliative intent had significantly increased from 59% of cases in the baseline to 86% for the post intervention phase. As a result, admission to ICU decreased from 32% of cases in the pre intervention phase to 14% in the post intervention phase reducing monthly cost of admission to the ICU by 40% and estimated to be on average of $48,000 USD monthly ($576,000 USD annually). Conclusions: Our interventions resulted in improved documentation of the goal of care leading to decrease in the utilization of acute care services (ACS) including reduction of intensive care unit (ICU) admissions and cost. This outcome is even more relevant nowadays during COVID-19 pandemic and the pressure on critical care resources. Improvement is sustained by integrating the changes in the work process and electronic medical records.
ABSTRACT
Background: Cancer care is heavily centered in health care facilities due to the requirements of providing complex multidisciplinary care with multiple testing and interventions. We describe our experience in implementing a new model of care to minimize cancer patients visit to health care facilities and to reduce the risk of infections and to decrease the pressure on the health care system. Methods: In response to the COVID-19 pandemic, we reengineered the cancer care process to reduce patients visit to the hospital by the implementation of a Care Near Home (CNH) Model, which comprises offour components: Virtual clinic, laboratory testing near home, shipping medications and supplies, and involving local health care facilities. The effectiveness and acceptance of this new model has been assessed by the delivery of timely care successfully and assessing the satisfaction patients and healthcare providers. Results: On March 18, 2020, we launched the virtual clinics followed by different components of the model. The number of virtual clinic visits has increased significantly from 399 visits in March to 1107 in April 2020. More the 90% of physicians and patients who responded to the survey expressed their acceptance and satisfaction with the virtual clinic services. Medications were shipped to total of 603 patients. Of those, 578 (96%) patients received their medications (378 patients outside city, 200 patients inside city of which, 95% received medications within 24 hours). Only 25 (4%) patients did not receive their medications and we arrange for alternative solutions. Laboratories in various regions were set up to perform the tests for our patients and to communicate the results through our electronic healthcare records system. The process of ordering and performing the test were piloted with success and now we are at the scaling up phase. Conclusions: Although the implementation of CNH Model was driven by COVID-19 pandemic, it will be integrated in our work process and utilized as a long term approach to manage many of our patients because it is more convenient to them and more cost effective to the health care system.