Promoting timely goals of care conversations between gynecologic cancer patients at high-risk of death and their providers.

OBJECTIVE: We designed a multi-faceted intervention to increase the rate of outpatient goals of care (GOC) conversations in women with gynecologic cancers who are at high-risk of death. METHODS AND MATERIALS: A multidisciplinary team developed an educational program around GOC conversations at end-of-life and chose criteria to prospectively identify patients at high-risk of death who might benefit from timely GOC conversations: recurrent or metastatic endometrial, cervical or vulvar cancer or platinum-resistant ovarian cancer. Gynecologic oncology provider consensus was built regarding the need to improve the quality and timing of GOC conversations. Eligible outpatients were prospectively identified and providers alerted pre-encounter; timely GOC documentation within 3 visits of high-risk identification was tracked. Our institution concurrently and subsequently tracked GOC documentation during the last 6 months of life among all established oncology patients. RESULTS: Of 220 pilot period high-risk patients (96 pre- and 124 during pilot period 2017-2018), timely GOC discussion documentation increased from 30.2% to 88.7% (p < 0.001) and this increase was sustained over time. In the post-pilot period (2019-2020), among patients seen by oncologists during last 6 months of life, compared to other cancer types, gynecologic cancer patients had a higher rate of GOC documentation (81% versus 9%; p < 0.001), a lower rate of receiving chemotherapy during the last 14 days of life (2% vs 5%; p = 0.051), and no difference in end-of-life admissions (29% vs 31%; p = NS). CONCLUSIONS: Implementation of systematic outpatient identification of high-risk gynecologic oncology patients is feasible, sustainable, and increases the timely conduct of GOC conversations.

Combining Multiple Decedent Data Sources for a Population-Based Picture of End-of-Life Healthcare Utilization.

CONTEXT: Although health systems need to track utilization and mortality, it can be difficult to obtain reliable information on patients who die outside of the health system. This leads to missing data and introduces the potential for bias. OBJECTIVES: To evaluate the linkage of patient death data sources with a tertiary health system electronic health record (EHR) to increase the accuracy of health system end-of-life healthcare utilization data in the last month and six months of life. METHODS: The federal Death Master File (DMF) and North Carolina Department of Health and Human Services (NC DHHS) decedent files from 2017 and 2018 were linked to a health system EHR. Descriptive statistics and chi-square tests were utilized to define impact of additional data sources with demographic data and end-of-life utilization. RESULTS: A total of 65,935 patient deaths were identified through our multi-step data integration process. Approximately a quarter of patients (28.3%) had at least one inpatient or outpatient health system encounter in the last six months of life. Of these, patient deaths identified only in the NC DHHS file were less likely (OR 0.45 [95%CI 0.39-0.52]) to be hospitalized in the last month of life. CONCLUSION: We describe a method to supplement EHR data with decedent information across data sources. While additional decedent data improves the accuracy of death data in the health system, patient healthcare utilization is biased towards those who use the health system at the end of life.

Impact of a Real-Time, Pharmacist-Led, Intensive Care Unit-Based Feedback Intervention on Analgesia and Sedation Quality Among Mechanically Ventilated Patients.

BACKGROUND: Consensus guidelines for pain, agitation, and delirium (PAD) in mechanically ventilated patients recommend maintaining a light level of sedation. LOCAL PROBLEM: Consistent attainment of target PAD assessments in mechanically ventilated ICU patients is often challenging. METHODS: This is a single-center, prospective study. INTERVENTIONS: In the intervention group, a pharmacist provided weekly feedback to nurses on their success in achieving target PAD assessments compared with a historical cohort without feedback. RESULTS: Overall, 478 patients and 205 nurses were included. The odds of having weekly Richmond Agitation-Sedation Scale (RASS) score, pain score goals, and Confusion Assessment Method for the ICU (CAM-ICU) negative assessments at goal between the intervention and control groups fluctuated over time without a discernible trend. CONCLUSION: The provision of weekly feedback to nurses on PAD nursing assessments by a pharmacist did not impact the achievement of PAD goals among critically ill mechanically ventilated patients.