Evidence Based Practice Intervention End of Life Care (EOLC) Protocol

1. Evidence Based Practice Intervention End of Life Care (EOLC) Protocol Improves Patient Satisfaction Jamie McGuire, BSN, RN; Angela Robinson BSN, RN; Michelle Lozano BSN, RN; Leslie Norton BSN, RN;& LoicKiza BSN, RN Wright State University – Master’s Program Students

2. Statement of the Problem • Technological advancements allow patients to live longer and survive life threatening situations, making death an option in these situations. • The Center for Disease Control and Prevention (CDC) (2012) reported that 10% of Americans suffer from a chronic disease that affects their daily living, with 18% of Ohioans reporting ‘poor/fair’ health in 2011. • Gaps exist in healthcare delivery when providers should consider end of life care (EOLC) rather than life sustaining efforts. • Studies have found that providers and patients feel that accepting death and EOL care demonstrates hopelessness and failure. • Lack of EOLC leads to poor patient outcomes, unnecessary suffering, provider constraints, soaring healthcare costs, and futile health care. • The Institute of Medicine (IOM) promotes a good death to improve the quality of life when the end of life is near.

3. PICOT • Problem: Lack of utilization of EOLC protocols among terminally ill and chronically debilitated patients in the LTAC population - leads to poor patient outcomes, unnecessary suffering, provider constraints, soaring healthcare costs, and futile health care. • Intervention: Implementation of EOLC protocols improve staff and provider’s awareness of EOLC through nurse-delivered training and provider initiation of EOLC protocols. • Comparison: These findings will be correlated with existing evidence based data used in the Liverpool Care Pathway. • Outcome: The expected outcome in this EBP is improvement of patient satisfaction among those partaking in EOLC protocols. The ripple effects of this intervention include better healthcare resource utilization, decreased futile healthcare costs, improved provider satisfaction, and improved patient and family satisfaction. • Time Frame for intervention: The time for this intervention is one to two hours for the initial training by the clinical educator and case management team. Staff training, led by the clinical educator, would occur in the initial orientation and quarterly during lunch and learn in-services. The interdisciplinary team will spend a few minutes each week discussing the effectiveness of the intervention during grand rounds.

4. Planning the Practice Change • Interdisciplinary Team: Clinical educator, Medical staff, Mid-level providers (PA/CNP’s), Nursing staff, Clergy, Case Management, and Social services. Weekly Team meeting/Grand Rounds to review multidisciplinary feedback. • Key Informants: Hospital Administration given staff resources more appropriately utilized, cost of care reduction, and an associated decreased facility mortality rate. Increased revenue given reduced lengths of patient stays and increased admissions. • Outside Involvement: Press Ganey; Referring hospitals, providers and nursing facilities; Home Care Services; Spiritual support; Clergy; Palliative Care Consultants; Hospice services; Home care agencies; Social services consult; County Elder Service Programs; LTACs; Acute care hospitals; Medicare resources.

5. Critical Appraisal of Evidence • The findings within the organization imply absence of EOL protocols and knowledge of EOL care. • Determining the baseline of EOL knowledge and recommendations of the nurses to improve EOL concerns. • Incorporating and the utilize end-of-life (EOL) protocols to increase patient and family satisfaction during terminal phases of life. • Utilization of EOL protocols will improve nurses expertise, communication, patient/family satisfaction, and patient outcomes. • Protocols allow patients to make decisions, participate in treatment, and to verbalize individualized desires. • Protocols help guide healthcare professionals in the appropriate direction during terminal phases and increases communication among the interdisciplinary team to ensure the patient’s plan of care is adjusted accordingly. • EOL protocols promote patient/family knowledge and improves quality of life during terminal phases of life.

6. Kotter and Cohen’s Model of Change • Core Goal- Create real change by affecting peoples feelings • Very effective management model: used by Dell and Coca-Cola Metre, C. (2009) Kotter and Cohen eight steps. Retrieved from http://newtrendsinmanagement.wikispaces.com/Change+Management

7. Projected Timeline Principal Investigator1 Data transcriptionist2 Consultant 3

8. Planning for Change • Intervention- Implement new End of Life (EOL) protocols • Resisters- Reluctance to accept that EOL is near from staff, fear of change (the way things have always been done, work day interruptions, financial issues, lack of support from management/administrators) • Special accommodations- Sensitive nature of EOL care, readiness of families and patients to accept new course of healthcare, and compassionate/understanding staff is necessary • Persuasion strategies- Support of management/administrators to staff to assist them with change 4

9. Planning for Change • Specific aims- Improve patient satisfaction and outcomes for a population for patients that End of Life Care (EOLC) protocols are applicable to. • Clinical setting- 44 bed long term acute care unit • Support for change- Acquiring the support of administrators, managers, and employees is key to the success of the protocol use and implementation • Population- Staff and providers of the LTAC unit 4

10. Evaluation • Patient and family satisfaction will be measured using a Likart-type survey, previously tested for validity and reliability with 73% of variance accounted for, and a Cronbach’s α = 0.97. • The consultant will mail surveys to patients and families, and the primary investigator will receive data in the form of completed surveys on a weekly basis. • Monitoring will occur on a weekly basis during interdisciplinary grand rounds, monthly during informal staff surveys, monthly via review of resources allocated, and monthly via completed surveys from patients and family member.

11. Evaluation • Success will be determined based on the baseline satisfaction scores as compared to the scores after implementation. • The impact will be maintained patient and family satisfaction, and increased likelihood of referral to the LTAC as evidenced by Press Ganey and HCAPS scoring at or above the benchmarks (~90%). • Human Subjects will be protected through password protected computer files, identifier-absent surveys, and the following of HIPPA protocols by all involved. All demographics represented in the LTAC will be eligible for the study, given an EOL status.

12. Budget • Staff training including two-hour lunch and learn session: ~ $12,000 • Materials including surveys, mailing materials, flyers, pamphlets, and office supplies: ~ $2,000 • Personnel: ~$1,000 • New Record Keeping including data spreadsheets, and the use of password protected software:~ $1,000

13. Acknowledgement of Donors • The cost of this study will be paid for by various grants from The Ohio Alzheimer’s society, The American Cancer Society, The Ohio Hospice Society, and other family and community donations.

14. References • Center for Disease Control and Prevention (2012) Chronic disease prevention and health promotion, Retrieved from http://www.cdc.gov/chronicdisease/index.htm • Reinke, L., Shannon, S., Engelberg, R., Dotolo, D., Silvestri, G., &Curtis, J., (2010). Nurses' identification of important yet under-utilized end-of-life care skills for patients with life-limiting or terminal illnesses. Journal of Palliative Medicine, 13(6):753-9. doi:10.1089/jpm.2009.0423. • Press Ganey (2013) About Us. Retrieved from: http://www.pressganey.com/aboutUs.aspx