Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study
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《英国医生杂志》
1 Lenox Hill Hospital, 100 East 77th Street, New York, New York 10021, USA
Correspondence to: C Monteleoni cmonteleoni@lenoxhill.net
Abstract
At Lenox Hill Hospital, a 652 bed acute care facility in New York City, a multidisciplinary group of professionals concerned about improving medical care and quality of life for patients with dementia undertook a quality improvement project to address the issue of feeding tube placement in these patients. The project was conducted under the auspices of the New York Palliative Care Quality Improvement Collaborative (PCQuIC), a multisite initiative sponsored by the United Hospital Fund, RAND Corporation, and the Washington Home Center for Palliative Care Studies, with the aim of improving palliative care services in the 23 participating healthcare institutions.13 Faculty at the collaborative supplied training in the "plan-do-studyact" model for improvement14 15 and mentoring for this project over a 10 month period from September 2002 until June 2003. The project's core team included a geriatrician, a speech pathologist, a nurse, and an administrator. The hospital's vice president for medical affairs served as senior leader, acting as an advocate for the project.
Outline of the problem
We established three aims to measure the success of our interventions:
Reduce by 50% the number of feeding tubes placed in patients with dementia
Reduce to zero the number of feeding tubes placed in patients with dementia who are capable of taking food by mouth
Reduce to zero the number of feeding tubes placed in patients with dementia who have advance directives stating the wish to forgo artificial nutrition and hydration.
We hoped to achieve these aims within nine months of initiating quality improvement interventions.
Methods used to identify problems
Beginning in January 2003, the team formed a palliative care consulting team and instituted educational programmes.
The palliative care consulting team was led by the director of geriatrics. Working with medical residents on geriatrics rotation and the existing ethics and pain consult services, the team provided support and guidance for attending physicians (figure). A letter from the hospital's vice president for medical affairs requested attending physicians to call a member of the team whenever a feeding tube was being considered for any patient, demented or otherwise. Primary care physicians, gastroenterologists, nutritionists, nurse managers, and case managers attended in-service training sessions that explained the project and enlisted participation (boxes 1 and 2) The project was publicised at the quarterly medical staff conference and at grand rounds.
Role of palliative care consulting team
Four educational programmes were instituted. Firstly, a nationally recognised geriatrician with expertise in feeding issues in dementia gave a medical grand rounds presentation addressing the issue of feeding tube placement. The other three programmes involved the 24 medical residents in postgraduate year 2: they have a rotation of 12 sessions of pain management consultation; participate in presenting modules of the EPEC (Education for Physicians in End of Life Care) curriculum to the remainder of the medical house staff (attendance is mandatory); and spend one month on geriatrics rotation, which includes answering all palliative care consulting requests.
Box 1: Specialties targeted
Speech pathology
Nutrition
Gastroenterology
Nurse managers
Case managers
Primary care physicians
Hospitalists (physicians specialising in inpatient care)
Ethics committee
Administration
Box 2: Components of in-service training
Review of medical literature on burdens and benefits of tube feeding in patients with dementia
Discussion of advance directives
Linking advanced dementia to palliative care
Explanation of quality improvement project
Assignment of role in project
Effects of change
Use of rapid cycle quality improvement methodology13 14 to change medical practice in this case was successful on many levels. The intensive educational initiative, coupled with implementation of a palliative care consulting service, brought the issue of tube placement in patients with dementia into focus for the hospital community. Medical grand rounds and in-service training sessions were well attended. From January to September 2003, the consult team intervened on 12 feeding tube cases. It is unlikely, however, that the sharp reduction in tube placement is attributable only to the organised quality improvement interventions. During the study period, physicians, nurses, nutritionists, speech pathologists, case managers, social workers, and other clinical staff seemed to talk more, formally and informally, about feeding tubes and the wider issue of medically futile treatment, suggesting a "cultural shift" within the hospital. Staff from many disciplines took pride in the rapid, dramatic results of the project, and this increased morale and belief in the possibility of positive change within the institution. Doctors' response to the project was generally positive, although a few practitioners resented "interference" with their care of patients. More commonly, doctors were grateful for the help the consulting team offered in dealing with difficult cases. Education of house staff, in both didactic sessions and clinical rotations, was a key component in the success of the project.
Key learning points
Despite literature questioning value of this intervention, physicians insert feeding tubes in patients with dementia
Interdisciplinary teamwork and focused educational effort can rapidly produce change in practice
Nutritionists, speech pathologists, gastroenterologists, case managers, social workers, nurses, and house staff can be targeted for education
The palliative care team works with attending physician to address prognosis, the patient's decision making capacity, the patient's wishes, and treatable causes of poor food intake
We wondered if the sharp decline in feeding tube placement in patients with dementia in our hospital had been accompanied by an increase in outpatient tube placements in outpatient settings or at nearby facilities. We have joined a consortium of hospitals in New York City to address the issue on a regional basis.
It became clear from chart review and palliative care consultations that absence of clear goals of care often led to unnecessarily long, complicated stays in hospital, contradictions among recommendations made by various clinicians on a case, and care inconsistent with patients' wishes. The palliative care consultant became a facilitator of communication among medical staff and between doctor and patient or surrogate, to establish goals of care. We have started a new quality improvement activity for early establishment and documentation of goals of care.
Contributors: CM and EC participated in project design, data collection, data analysis, palliative care case consultations, in-service instruction, and other staff education in palliative care, and writing of this report. Julie Wityk participated in data collection and served as liaison with the PCQuIC faculty. Nancy Mooney, Tamar Kotz, and Barrie Guise participated in data collection. Walter Ettinger assisted with project design and served as the project's senior advocate within the institution. John Rapoport and Arthur Blank assisted with data analysis. CM is guarantor.
Funding: Participation in the PCQuIC collaborative was supported by grants from Lenox Hill Hospital and the United Hospital Fund. These grants subsidised attendance at learning sessions and access to PCQuIC faculty for guidance throughout the course of the activity.
Competing interests: None declared.
References
Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282: 1365-70.
Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996;348: 1421-4.
Peck A, Cohen CE, Mulvihill MN. Long-term enteral feeding of aged demented nursing home patients. J Am Geriatr Soc 1991;39: 732-3.
Mitchell SL, Kiely DK, Lipsitz LA. Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? J Gerontol A Biol Sci Med Sci 1998;53: M207-13.
Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with dementia. Arch Intern Med 2001;161: 2385-6.
Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med 2003;163: 1351-3.
Kaw M, Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy tubes in nursing home patients. Dig Dis Sci 1995;40: 920-1.
Finucane TE, Malnutrition, tube feeding and pressure sores: data are incomplete. J Am Geriatr Soc 1995;43: 447-51.
Ahronheim JC. Nutrition and hydration in the terminal patient. Clin Geriatr Med 1996;12: 379-91.
Ciocon JO, Silverstone FA, Graver LM, Foley CJ. Tube feedings in elderly patients. Indications, benefits and complications. Arch Intern Med 1988;148: 429-33.
Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Intern Med 1997;127: 225-30.
Cobbs EL, Duthie EH, Murphy JB, eds. Geriatrics review syllabus: a core curriculum in geriatric medicine. 5th ed. Malden, MA: Blackwell, 2002: 117.
United Hospital Fund. Palliative care quality improvement collaborative enters its second year. 3 April 2003. www.uhfnyc.org/press_release3159/press_release_show.htm?doc_id=161122 (accessed 3 Aug 2004).
Langley GJ, Nolan KM, Nolan TW. The foundation of improvement. Silver Spring, MD: API Publishing, 1992.
Berwick DM. A primer on leading the improvement of systems. BMJ 1996;312: 619-22.(Carol Monteleoni, coordin)
Correspondence to: C Monteleoni cmonteleoni@lenoxhill.net
Abstract
At Lenox Hill Hospital, a 652 bed acute care facility in New York City, a multidisciplinary group of professionals concerned about improving medical care and quality of life for patients with dementia undertook a quality improvement project to address the issue of feeding tube placement in these patients. The project was conducted under the auspices of the New York Palliative Care Quality Improvement Collaborative (PCQuIC), a multisite initiative sponsored by the United Hospital Fund, RAND Corporation, and the Washington Home Center for Palliative Care Studies, with the aim of improving palliative care services in the 23 participating healthcare institutions.13 Faculty at the collaborative supplied training in the "plan-do-studyact" model for improvement14 15 and mentoring for this project over a 10 month period from September 2002 until June 2003. The project's core team included a geriatrician, a speech pathologist, a nurse, and an administrator. The hospital's vice president for medical affairs served as senior leader, acting as an advocate for the project.
Outline of the problem
We established three aims to measure the success of our interventions:
Reduce by 50% the number of feeding tubes placed in patients with dementia
Reduce to zero the number of feeding tubes placed in patients with dementia who are capable of taking food by mouth
Reduce to zero the number of feeding tubes placed in patients with dementia who have advance directives stating the wish to forgo artificial nutrition and hydration.
We hoped to achieve these aims within nine months of initiating quality improvement interventions.
Methods used to identify problems
Beginning in January 2003, the team formed a palliative care consulting team and instituted educational programmes.
The palliative care consulting team was led by the director of geriatrics. Working with medical residents on geriatrics rotation and the existing ethics and pain consult services, the team provided support and guidance for attending physicians (figure). A letter from the hospital's vice president for medical affairs requested attending physicians to call a member of the team whenever a feeding tube was being considered for any patient, demented or otherwise. Primary care physicians, gastroenterologists, nutritionists, nurse managers, and case managers attended in-service training sessions that explained the project and enlisted participation (boxes 1 and 2) The project was publicised at the quarterly medical staff conference and at grand rounds.
Role of palliative care consulting team
Four educational programmes were instituted. Firstly, a nationally recognised geriatrician with expertise in feeding issues in dementia gave a medical grand rounds presentation addressing the issue of feeding tube placement. The other three programmes involved the 24 medical residents in postgraduate year 2: they have a rotation of 12 sessions of pain management consultation; participate in presenting modules of the EPEC (Education for Physicians in End of Life Care) curriculum to the remainder of the medical house staff (attendance is mandatory); and spend one month on geriatrics rotation, which includes answering all palliative care consulting requests.
Box 1: Specialties targeted
Speech pathology
Nutrition
Gastroenterology
Nurse managers
Case managers
Primary care physicians
Hospitalists (physicians specialising in inpatient care)
Ethics committee
Administration
Box 2: Components of in-service training
Review of medical literature on burdens and benefits of tube feeding in patients with dementia
Discussion of advance directives
Linking advanced dementia to palliative care
Explanation of quality improvement project
Assignment of role in project
Effects of change
Use of rapid cycle quality improvement methodology13 14 to change medical practice in this case was successful on many levels. The intensive educational initiative, coupled with implementation of a palliative care consulting service, brought the issue of tube placement in patients with dementia into focus for the hospital community. Medical grand rounds and in-service training sessions were well attended. From January to September 2003, the consult team intervened on 12 feeding tube cases. It is unlikely, however, that the sharp reduction in tube placement is attributable only to the organised quality improvement interventions. During the study period, physicians, nurses, nutritionists, speech pathologists, case managers, social workers, and other clinical staff seemed to talk more, formally and informally, about feeding tubes and the wider issue of medically futile treatment, suggesting a "cultural shift" within the hospital. Staff from many disciplines took pride in the rapid, dramatic results of the project, and this increased morale and belief in the possibility of positive change within the institution. Doctors' response to the project was generally positive, although a few practitioners resented "interference" with their care of patients. More commonly, doctors were grateful for the help the consulting team offered in dealing with difficult cases. Education of house staff, in both didactic sessions and clinical rotations, was a key component in the success of the project.
Key learning points
Despite literature questioning value of this intervention, physicians insert feeding tubes in patients with dementia
Interdisciplinary teamwork and focused educational effort can rapidly produce change in practice
Nutritionists, speech pathologists, gastroenterologists, case managers, social workers, nurses, and house staff can be targeted for education
The palliative care team works with attending physician to address prognosis, the patient's decision making capacity, the patient's wishes, and treatable causes of poor food intake
We wondered if the sharp decline in feeding tube placement in patients with dementia in our hospital had been accompanied by an increase in outpatient tube placements in outpatient settings or at nearby facilities. We have joined a consortium of hospitals in New York City to address the issue on a regional basis.
It became clear from chart review and palliative care consultations that absence of clear goals of care often led to unnecessarily long, complicated stays in hospital, contradictions among recommendations made by various clinicians on a case, and care inconsistent with patients' wishes. The palliative care consultant became a facilitator of communication among medical staff and between doctor and patient or surrogate, to establish goals of care. We have started a new quality improvement activity for early establishment and documentation of goals of care.
Contributors: CM and EC participated in project design, data collection, data analysis, palliative care case consultations, in-service instruction, and other staff education in palliative care, and writing of this report. Julie Wityk participated in data collection and served as liaison with the PCQuIC faculty. Nancy Mooney, Tamar Kotz, and Barrie Guise participated in data collection. Walter Ettinger assisted with project design and served as the project's senior advocate within the institution. John Rapoport and Arthur Blank assisted with data analysis. CM is guarantor.
Funding: Participation in the PCQuIC collaborative was supported by grants from Lenox Hill Hospital and the United Hospital Fund. These grants subsidised attendance at learning sessions and access to PCQuIC faculty for guidance throughout the course of the activity.
Competing interests: None declared.
References
Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282: 1365-70.
Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996;348: 1421-4.
Peck A, Cohen CE, Mulvihill MN. Long-term enteral feeding of aged demented nursing home patients. J Am Geriatr Soc 1991;39: 732-3.
Mitchell SL, Kiely DK, Lipsitz LA. Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? J Gerontol A Biol Sci Med Sci 1998;53: M207-13.
Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with dementia. Arch Intern Med 2001;161: 2385-6.
Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med 2003;163: 1351-3.
Kaw M, Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy tubes in nursing home patients. Dig Dis Sci 1995;40: 920-1.
Finucane TE, Malnutrition, tube feeding and pressure sores: data are incomplete. J Am Geriatr Soc 1995;43: 447-51.
Ahronheim JC. Nutrition and hydration in the terminal patient. Clin Geriatr Med 1996;12: 379-91.
Ciocon JO, Silverstone FA, Graver LM, Foley CJ. Tube feedings in elderly patients. Indications, benefits and complications. Arch Intern Med 1988;148: 429-33.
Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Intern Med 1997;127: 225-30.
Cobbs EL, Duthie EH, Murphy JB, eds. Geriatrics review syllabus: a core curriculum in geriatric medicine. 5th ed. Malden, MA: Blackwell, 2002: 117.
United Hospital Fund. Palliative care quality improvement collaborative enters its second year. 3 April 2003. www.uhfnyc.org/press_release3159/press_release_show.htm?doc_id=161122 (accessed 3 Aug 2004).
Langley GJ, Nolan KM, Nolan TW. The foundation of improvement. Silver Spring, MD: API Publishing, 1992.
Berwick DM. A primer on leading the improvement of systems. BMJ 1996;312: 619-22.(Carol Monteleoni, coordin)