Palliative care organization and staffing models in residential hospices: Which makes the difference?

BACKGROUND: The number of patients using palliative care services, particularly residential hospices, is increasing. Policymakers are urging these services to reflect on the most effective organizational strategies for meeting patients' complex care needs. AIM: To analyze the predictive power of staffing, structure and process indicators towards optimal control of patients' clinically significant symptoms over time. DESIGN: Secondary analysis of data from a multicentre prospective longitudinal observational study (PRELUdiHO) collected between November 2017 and September 2018. SETTING/PARTICIPANTS: Adult patients (n = 992) enrolled in 13 Italian residential hospices. METHODS: Two generalized estimating equations logistic models were built, both with number of hospice beds and length of stay as independent variables as well as, in one case, patient-to-healthcare worker ratios, and, in the other, health professionals' qualification levels. Dependent variables were six not clinically significant (score<4) symptoms: pain, nausea, shortness of breath, feeling sad, feeling nervous, and 'how you feel overall', according to the Edmonton Symptom Assessment System revised (ESAS-r) scale. RESULTS: The generalized estimating equations indicators on staff revealed the following 'optimal' model: Patient-to-Physician ratio (5.5:1-6.5:1); Patient-to-Nurse ratio (1.5:1-2.7:1); Patient-to-Nurse-Assistant ratio (4.1:1-6.3:1); with the most balanced staff composition including 19% physicians, 23% nurse assistants, and 58% registered nurses; hospice beds (12-25); length of stay (median = 12 days). This model predicted an up to four times greater likelihood of controlling all six ESAS-r symptoms over time. The generalized estimating equations model on the educational level of physicians and registered nurses showed that it was significantly associated with optimal patients' symptom control during the entire hospice stay. CONCLUSIONS: This study showed the exact skill-mix composition and proportions of palliative care team able to ensure optimal control of patients' symptoms. The added value of physicians and nurses with a qualification in palliative care in terms of better patient outcomes reaffirmed the importance of education in guaranteeing quality care. Hospices with 12-25 beds, and recruitment methods guaranteeing at least 12-day stay ensured the most propitious organizational environment for optimal management of clinically significant symptoms. The transferability of these results mainly depends on whether the skills of health professionals in our `ideal' model are present in other contexts. Our results provide policymakers and hospice managers with specific, evidence-based information to support decision-making processes regarding hospice staffing and organization. Further prospective studies are needed to confirm the positive impact of this 'optimal' organizational framework on patient outcomes.

[The management of pain, delirium and dyspnea at home: a proposal for management algorithms]. / La gestione del dolore, del delirio e della dispnea a domicilio: proposta di algoritmi per il trattamento.

. The management of pain delirium and dyspnea at home: a proposal for management algorithms. The project "E-health, advanced nursing care for the cancer patient at home" includes the implementation of an app (and the evaluation of the feasibility of its use) but the core aspect is the availability of a group of nurses able to prevent and answer the needs of the palliative care patients. The three pillars of the project are: training, organisation and the provision of instruments able to offer a guide to nurses when at home of the patients or when called in case of problems. In this issue 2 of the clinical practice protocols for the management of pain, delirium and dyspnea are presented. Each protocol is the result of a constant dialogue between the medical and nursing staff of the Palliative Care and Oncology units. The algorithms can be used by nurses to orient the patient in the choice of the most appropriate at need drugs.

Prevalence, incidence and associated factors of pressure injuries in hospices: A multicentre prospective longitudinal study.

BACKGROUND: Patients in palliative care are the population cohort that most frequently develop pressure injuries, severely impacting their quality of life. Data from prospective studies on the prevalence and incidence of pressure injuries in hospices are lacking. AIM: To describe the point prevalence and cumulative incidence of pressure injuries in patients admitted to residential hospices, and to analyze their predictive factors over time. DESIGN: Multicentre prospective longitudinal observational study. SETTING/PARTICIPANTS: Adult patients (n = 992) enrolled in 13 Italian residential hospices, with a minimum sample of 280 for each macro-region (North, center, South/Islands). METHODS: Assessments including the Karnofsky Performance Status, Braden, Edmonton Symptom Assessment System Revised scales and pressure injury staging according to National Pressure Ulcer Advisory Panel were conducted at least every four days, from admission to patients' death/discharge. RESULTS: The 7,967 observations recorded provided prevalence and incidence rates of 34.1% and 26.5%, respectively. The logistic regression model showed non-cancer disease (OR = 2.39, 95%CI = 1.65-3.47), age >80 (OR = 2.01, 95%CI = 1.49-2.71), Braden score 'at risk' (OR = 1.92, 95%CI = 1.17-3.14), urinary catheter (OR = 1.96, 95%CI = 1.40-2.75), drowsiness (OR = 1.41, 95%CI = 1.02-1.95) and artificial nutrition (OR = 1.47, 95%CI = 1.01-2.14) as the variables associated with pressure injury at admission. The generalized estimating equations models, built on the timeframes for observation groups, revealed male gender (OR = 1.68, 95%CI = 1.01-2.79) and Braden score 'at risk' (OR = 4.45, 95%CI = 1.74-11.34) as predictive factors of a new pressure injury developed up to three weeks before a patient's death, while in the last ten days of life these predictors were replaced by diagnosis of cancer (OR = 1.80, 95%CI = 1.11-2.91), worsening pain (OR = 1.65, 95%CI = 1.10-2.49), drowsiness (OR = 1.79, 95%CI = 1.25-2.57) and dyspnea (OR = 1.48, 95%CI = 1.01-2.18). CONCLUSIONS: The high incidence and prevalence of pressure injuries confirm the importance of palliative care nurses continuously focusing on prevention and management strategies. In the last three weeks of a patient's life, the predictive power of the Braden scale for a new pressure injury is not confirmed, throwing doubt on the effectiveness of aimed interventions at modifying risk factors. Along the different disease trajectories, pressure injuries developed during the instability/worsening phases of illness, occurring before hospice admission for non-cancer patients and in the end-of-life phase for cancer patients. Despite continuous provision of appropriate interventions, most of the new pressure injuries were detected during the last ten days of a patient's' life and assessed as 'unavoidable'. These results are crucial to guiding palliative care nursing plans during the different phases of illness, and to predicting care needs, possible management strategies ('wound management' vs. 'wound palliation'), and resource utilization.

Intensity of Integrated Primary and Specialist Home-Based Palliative Care for Chronic Diseases in Northeast Italy and Its Impact on End-of-Life Hospital Access.

BACKGROUND: Hospital admissions at the end of life (EOL) represent an established indicator of poor quality of care. OBJECTIVE: To examine the impact of intensity of integrated primary and specialist home-based palliative care for chronic diseases (HPCCD) plans of care on EOL hospital access. METHODS: Retrospective population-based study using linked mortality, hospitalization, and home care data. Intensity of HPCCD was measured 90-31 days before death; outcomes were hospital death and prolonged hospital stay for medical reasons in the last month of life. Outcomes were modeled through Poisson and quartile regressions. Adults aged 65-84 years with at least an ordinary hospitalization and a drug treatment in the year before death, who died from nononcological chronic diseases in the Veneto Region, January 2012-December 2013, were included. RESULTS: Among 2087 patients, 1016 (48.7%) did not receive any HPCCD homecare visit; 860 (41.2%), 152 (7.3%), and 59 (2.8%) had <2, 2-4, and 4-7 homecare visits/week, respectively. Hospital death occurred for 1310 patients (62.8%) and the median hospital stay in the last month of life was five days (interquartile range 0-14). In multivariate analysis, a higher intensity of HPCCD was associated with lower rates of prolonged (≥14 days) EOL hospitalization and hospital death with a dose-response relationship. When no access to HPCCD was compared with 2-4 visits/week, adjusted percentage of hospital death decreased by -18.4% (95% confidence interval [CI] -5.4% to -29.7%) and the length of hospital stay decreased by 37.9% (95% CI 16.7%-56.0%). CONCLUSIONS: The intensity of integrated HPCCD plans of care was associated with a reduction in EOL hospital stay and in hospital death.