Adults ages 55 and older account for more than 40 percent of trauma patients.1 Compared with younger patients, these older trauma patients have higher rates of mortality, and those who survive have worse long-term functional outcomes.2,3 These potential poor outcomes should be discussed with patients, as many older adults report valuing quality of life more than longevity.4
Palliative care is specialized medical care that focuses on preferences and quality of life in patients with serious illness. Palliative care should not be provided solely at the end of life. Any patient with a serious illness, functional dependency, or advanced care needs should have a palliative care assessment while hospitalized.5 A critical aspect of providing palliative care involves having goals of care conversations with patients and providing care in line with their preferences. Although providing goal-concordant care is recommended for all seriously injured patients, palliative care, unfortunately, is underused in surgical populations.6,7
Rutgers-New Jersey School of Medicine, Newark, has a strong interest in palliative care and has integrated it into the routine delivery of trauma care. Goals of care conversations are started early with patients who are identified as having a high risk of dying. Although almost all of our patients who died were receiving palliative care before death, we hypothesized that gaps remained in palliative care delivery to our patients who were discharged alive with poor functional outcomes. We performed a prospective observational study of all trauma patients 55 years and older admitted to our institution and identified that more than two-thirds of our patients discharged with a poor functional outcome did not have a goals of care conversation while in the hospital.8
Putting the QI activity in place
Rutgers-New Jersey University Hospital, Newark, is a 500-bed urban safety net hospital. It is the only Level I trauma center in northern New Jersey, with more than 3,000 trauma activations per year.
Any patient with a serious illness, functional dependency, or advanced care needs should have a palliative care assessment while hospitalized.
At our institution, in 2016−2018, we performed a prospective observational study to evaluate the palliative performance scale (PPS) as a predictor of outcomes in older trauma patients. The PPS is a validated tool for the assessment and prognostication of seriously ill individuals.9 Initially it was developed for use in cancer patients but has since been used in other seriously ill populations.10
The PPS scale consists of five domains:
- Activity and evidence of disease
- Level of consciousness
Scores range from 0 to 100 in increments of 10, where 0 is death and 100 is healthy without limitations.
Before initiation of the study, a meeting was convened, and all members of the trauma team were introduced to the PPS and trained to accurately calculate a patient’s score. During the study period, advance practice nurses, who are members of the trauma team, evaluated all admitted trauma patients ages 55 years and older and calculated their PPS. From this study, we found that low PPS (< 80) was independently predictive of mortality and poor functional outcomes (defined by Glasgow Outcome Coma Score Extended [GOSE] of 1–4) at discharge and six months.11
FIGURE 1. PALLIATIVE CARE NEEDS FLOW CHART FOR TRAUMA PATIENTS
ADMITTED TRAUMA PATIENT ≥ 55 YEARS OF AGE
The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) Palliative Care Best Practice Guidelines recommend that all trauma patients be evaluated for palliative care needs within 24 hours of admission. Patients identified as having life-threatening or disabling traumatic injuries or those with less severe injuries but who are frail or have multiple comorbidities should have a goals of care conversation within 72 hours of admission.12 We used these guidelines to create and monitor our quality improvement (QI) initiative.
To increase goals of care conversations in patients with a high likelihood of being discharged with a poor functional outcome (GOSE of 2–4), we targeted patients with low PPS (< 80) scores. This target was based on the findings from the prospective study performed by Hwang and colleagues.11
By increasing goals of care conversations in patients with low PPS, we also were able to increase conversations among patients discharged alive with poor functional outcomes by 25 percent.
Before initiating the QI project, it was imperative that we obtain buy-in. With support of the trauma medical director and chair of the surgical department, we engaged key stakeholders, including the head of QI and the trauma nurse manager. In addition, we performed an assessment with the advance practice providers to discuss the barriers they faced. After engaging all these individuals, we presented our data on goals of care conversations and our plan for our project to all members of the trauma team during both a trauma section meeting and trauma grand rounds. In addition, flyers were placed in the surgical intensive care unit (ICU).
Carrying out the QI activity
This QI project was implemented April 9, 2019. The purpose of the project was to increase goals of care conversations in older patients with a low pre-injury PPS score by using a score of less than 80 as a trigger for the conversation.
Our revised standard practice consisted of all admitted trauma patients 55 years and older who had a PPS calculated on admission. A score of less than 80 was an automatic trigger for referral for a goals of care conversation to occur within 72 hours. The resident physician or advance practice provider evaluating the patient would initiate the discussion or call a palliative care consult if they felt the patient had advanced needs they could not manage. Goals of care conversations and palliative care consult for all other patients remained at the discretion of the attending based on degree of injury severity and preexisting comorbidities. A flow chart for patient evaluation is depicted in Figure 1.
Prior to implementation of this QI project, all members of the trauma team, including attendings and advance practice providers, had been trained in evaluating the PPS and in engaging in goals of care conversations. A palliative care specialist was brought in to host a one-day workshop on communication skills that included didactics and role play. Following this workshop, advance practice providers were equipped with the tools not only to evaluate PPS but also to hold goals of care conversations independently.
No additional staff was required for the implementation of this project. Buy-in and participation were necessary from the trauma team, including the trauma medical director, trauma faculty, advance practice providers, and residents. In addition, support from the palliative care team was needed. This project was led by a surgical research fellow working in the trauma department.
There were no additional costs to implement this project, and no funding sources were directly related to this project. The surgical research fellow received salary support from the Auen Foundation for research in palliative care.
Over a six-month period, 147 of 172 (85 percent) admitted trauma patients age 55 years and older had a PPS documented, with 43 percent completed within 24 hours of admission. Goals of care conversations took place with 93 percent of patients with a low pre-injury PPS, which was a 55 percent increase from pre-intervention. By increasing goals of care conversations in patients with low PPS, we also were able to increase conversations among patients discharged with poor functional outcomes by 25 percent (see Figure 2). Nearly two-thirds (64 percent) of all goals of care conversations occurred within 72 hours of admission. Of patients who had a goals of care conversation, 14 percent met independently with advance practice providers. The remainder of the conversations took place with the palliative care team or surgical attendings.
FIGURE 2. PROPORTION OF GOALS OF CARE CONVERSATION: PRE- AND POST-IMPLEMENTATION OF PPS AS TRIGGER IN PATIENTS WITH LOW PPS, POOR FUNCTIONAL OUTCOME AT DISCHARGE, AND INHOSPITAL MORTALITY
Evaluating patients and calculating a PPS is an additional task that must be completed in an already busy trauma center. Consequently, some patients did not have a PPS evaluation or documentation. This scenario occurred most often during the high-volume months or on holidays. Patients who arrived without families and were unable to participate in a meaningful way could not have their PPS evaluated within 24 hours of admission or at all.
The PPS was evaluated by advance practice providers who are not always present in the surgical ICU. Hence, many patients admitted directly to the ICU were missed. To avoid any missed patients, especially those pending family input for completion, the surgical research fellow kept an active run sheet of all admitted trauma patients and whether a PPS had been documented. The research fellow would then send out biweekly e-mails of pending patients.
With regard to barriers to having the goals of care conversations, the palliative care team is a busy service that may not be able to see all patients in an expeditious time frame or on the weekends. Furthermore, surgical attendings do not always have time to conduct goals of care conversations. Hence, all members of the trauma team, including advance practice providers, were trained in conducting goals of care conversations.
This project did not focus on cost savings; it was purely focused on increasing goals of care conversations. Although we did not focus on or measure costs, palliative care has been shown to decrease the use of health care resources and reduce costs.13
Tips for others
We have a few suggestions for other health care centers interested in launching a similar QI program. They are as follows:
- Increase buy-in: Buy-in from key stakeholders, such as the trauma medical director, trauma faculty, and advance practice providers, is essential. When introducing the project, stress why it needs to be done. No one wants to perform additional work, but emphasizing how this project is affecting patient care can increase engagement.
- Develop the skill set: For institutions without a palliative care team or trauma teams that are uncomfortable discussing goals of care, we would recommend faculty training in palliative care.
- Sustain the project: Appoint a team leader who can oversee the project and maintain a database. We chose to focus our initiatives on the advance practice providers, as they are constant members of the trauma team. Surgical residents rotate on and off service every month and are less consistent members of the team.
- Share successes: Update team members regularly with progress to keep them engaged.
- American College of Surgeons. NTDB Annual Report 2016. Available at: www.facs.org/-/media/files/quality-programs/trauma/ntdb/ntdb-annual-report-2016.ashx. Accessed June 16, 2020.
- Clark DE, DeLorenzo MA, Lucas FL, Wennberg DE. Epidemiology and short-term outcomes of injured Medicare patients. J Am Geriatr Soc. 2004;52(12):2023-2030.
- LeBlanc J, de Guise E, Gosselin N, Feyz M. Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury. Brain Inj. 2006;20(8):779-790.
- Fried TR, Bradley EH, Towle VR. Valuing the outcomes of treatment: Do patients and their caregivers agree? Arch Intern Med. 2003;163(17):2073-2078.
- Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: A consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
- Lilley EJ, Scott JW, Weissman JS, et al. End-of-life care in older patients after serious or severe traumatic brain injury in low-mortality hospitals compared with all other hospitals. JAMA Surg. 2018;153(1):44-50.
- Rodriguez R, Marr L, Rajput A, Fahy BN. Utilization of palliative care consultation service by surgical services. Ann Palliat Med. 2015;4(4):194-199.
- Fiorentino M, Hwang F, Pentakota SR, Livingston DH, Mosenthal AC. Palliative care in trauma: Not just for the dying. J Trauma Acute Care Surg. 2019;87(5):1156-1163.
- Ho F, Lau F, Downing MG, Lesperance M. A reliability and validity study of the Palliative Performance Scale. BMC Palliat Care. 2008;7:10.
- Baik D, Russell D, Jordan L, Dooley F, Bowles KH, Masterson Creber RM. Using the palliative performance scale to estimate survival for patients at the end of life: A systematic review of the literature. J Palliat Med. 2018;21(11):1651-1661.
- Hwang F, Pentakota SR, McGreevy CM, Glass NE, Livingston DH, Mosenthal AC. Preinjury Palliative Performance Scale predicts functional outcomes at 6 months in older trauma patients. J Trauma Acute Care Surg. 2019;87(3):541-551.
- American College of Surgeons. Trauma Quality Improvement Program Palliative Care best practice guidelines. Available at: www.facs.org/~/ media/files/quality%20programs/trauma/tqip/palliative_care.ashx. Accessed October 9th, 2018.
- Lilley EJ, Khan KT, Johnston FM, et al. Palliative care interventions for surgical patients: A systematic review. JAMA Surg. 2016;151(2):172-183.