Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project

Abstract

Objectives:

We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients.

Methods:

The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients’ care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions.

Results:

Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05).

Conclusions:

Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.

Keywords

ICU-palliative care collaboration palliative care critical care intensive care neurosurgical ICU

Introduction

Admissions into the neurosurgical ICU (NS-ICU) are often sudden and unexpected for patients and their families. They are often caused by intracranial hemorrhage or traumatic brain injuries. These patients face high mortality and suffer from severe physical and cognitive damage that often impairs their capacity to make decisions.^1,2 Despite advancements in medical technology, many patients never regain their functional independence and suffer from permanent disability and have a poor quality of life.³ These patients and families have high palliative care needs.⁴

Palliative care is an integral component of high-quality care for critically ill patients and families.^5
-7 Timely palliative care involvement in a critically ill neurosurgical patient allows management of distressing physical symptoms and facilitates communication to align goals of care. Several ICU consensus reports have recommended the use of tools and checklists to trigger a palliative care consult in the ICU.^8
-10

We conducted a pilot Quality Improvement (QI) project with the aim of integrating palliative care into the NS-ICU in our tertiary teaching hospital. We described our project’s development, implementation and outcomes of our interventions using the SQUIRE guidelines.

Methods

Setting

This QI project took place in Tan Tock Seng Hospital which is a 1500-bed tertiary hospital in Singapore from 2013 to 2015. It has 4 intensive care units (ICU) with the Medical ICU (MICU), Surgical ICU (SICU), Neurosurgical ICU (NS-ICU) and Coronary Care Unit (CCU). The NS-ICU has 12 ICU and 6 High-Dependency Unit (HDU) beds admitting more than 1500 patients per year from neurology and neurosurgical specialities. The established Palliative care department in the hospital not only manages inpatients, but also provides consult services to the emergency room and intensive care units reviewing more than 2000 patients per year.

For the purpose of our QI project, the focus was on patients admitted under the neurosurgical team in ICU from 2013 to 2015. The NS-ICU is staffed by intensivists certified in critical care medicine working with neurosurgeons, neurosurgery residents supported by a dedicated ICU nursing team trained in neurocritical care. It generally admits patients with extensive intra-cerebral hemorrhage and traumatic brain injuries.

Prior to the QI project, critically ill neurosurgical patients with palliative care needs were referred infrequently. Referral rates were low with only 9 referrals in 2012. There were no standardized criteria for referral and absence of a screening process in place to identify neurosurgical patients with palliative care needs.

As there was no established ICU-Palliative collaborative before 2013, referrals rates were low, with 11 (CCU), 17 (MICU) and 9 (SICU) patients referred from their respective ICUs in 2012. This prompted the palliative care and intensive care team to form the ICU-Palliative Care collaborative which led to the start of this QI project from 2013 to 2015 in NS-ICU.

Quality Improvement Interventions

In response to the low palliative care referral rates which did not reflect the unmet needs of patients in the NS-ICU, a workgroup came together (ICU-Palliative Care Collaborative) to foster closer collaboration between the relevant teams. They included the NS-ICU director, senior palliative care physician, neurosurgeon, ICU and palliative care advance nurse practitioners and medical social worker.

A palliative care team comprising a palliative care physician and advance nurse practitioner with ICU experience focused on symptom control, goals of care discussions during family meetings and post-ICU care for the patients referred (Appendix A).

Establishing referral criteria

After joint discussions between the various members of the workgroup, the ICU-Palliative Care Collaborative established a new screening criteria adapted from the IPAL-ICU recommendations.⁹ The new screening criteria included patients with i) hypoxic ischemic encephalopathy ii) traumatic brain injury (TBI) with poor neurological prognosis iii) extensive intra-cranial hemorrhage/subarachnoid hemorrhage with no further surgical interventions iv) low presenting Glasgow Coma Scale (GCS) of ≤6. Patients were referred once they met any one of the above criteria. Asymptomatic patients who were imminently dying or brain-dead patients waiting for organ donations were excluded.

The GCS was selected as one criteria as it was used globally in neurological assessment and was a reliable predictor of in-hospital mortality.¹¹ Prognostication for TBI patients were based on International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) recommendations.¹² TBI patients were deemed to have poor prognosis should they had raised intra-cranial pressure despite life-saving intra-cranial surgery, persistently poor GCS, poor pupillary response, hypoxia and hypotension and were recommended for referral.^13,14

Establishing a screening process and referral workflow to palliative care

The palliative care team would initially join the NS-ICU rounds weekly, using the screening checklist to identify suitable patients for referral. The process slowly evolved with the ICU Nurse Practitioner taking over this task. However, this led to “missed referrals” whenever this nurse was away from work. The responsibility to trigger the referral was finally taken up by the ICU-Nurse-in charge on duty. A workflow was also established to trigger referral to Palliative Care (Figure 1). This led to a more consistent pattern of referrals.

Combined weekly interprofessional meetings

Weekly interprofessional meetings with palliative care and ICU teams were conducted. This platform allowed the palliative care team, intensivists and social workers to discuss patients’ medical condition, symptom burden and families’ expectations. Discussions were also held regularly between the palliative care and ICU teams throughout the week should there be changes in the patients’ condition and management plans.

Orientation for intensivists

As intensivists rotated out of the NS-ICU on a weekly basis, many were not familiar with the referral processes. To improve understanding of the referral process, intensivists were also updated of the QI project at the beginning of their weekly changeover.

Education and engagement of NS-ICU nurses

Lastly, there was a low level of confidence from the NS-ICU nursing team in communicating with families at the bedside. The palliative care team helped to design a communication course for the NS-ICU nurses to better equip them in communicating with families at the end-of-life. This course was led by an interprofessional team comprising of palliative care physicians, nurse practitioners and social workers. NS-ICU nurses were also taught to assess distressing symptoms by the palliative care team during their reviews.

Palliative Care Interventions in ICU

The palliative care team would review the patients on the same day of referral. Joint family conferences with intensivists and social worker were conducted to establish realistic goals of care based on a patient- and family–centered approach.

As part of new interventions from the collaboration, an extubation protocol was established which was published in our earlier paper.¹⁵ The palliative care team would also help with symptom control and support the grieving families during terminal extubation¹⁵ (Supplementary Figure 1).

For patients who had expressed prior wishes of wanting to pass away at home, the palliative care team would assist in “terminal discharge” and liaise with the community home hospice team to help with care transition from ICU to home following withdrawal of life-sustaining support. A workflow on terminal discharge which was reported in our earlier publication was also established to ensure a smooth transition¹⁵ (Supplementary Figure 2).

Post-ICU Care

The palliative care team would continue to collaborate with the primary neurosurgical team to provide continuity of care once the patients leave the ICU following withdrawal of life-sustaining measures. For patients who have a prognosis of short days, they would be transferred to a single room called the End-of-life room (EOL room) in the general ward to provide privacy for the patients and families. Symptomatic patients would be reviewed daily to optimize symptoms control. Families would be updated regularly.

Data Collection

The various QI interventions were progressively initiated since 2013 and was evaluated for a period of 3 years ending in 2015. Data on referred patients was collected prospectively during the QI period. The QI team also retrospectively collected data on “missed” patients who met screening criteria but were not referred as a comparison to those who were referred from January 2013 to December 2015. We also collected data in the post-QI period of referrals to the palliative care team from 2016 to 2018 to review the sustainability of the interventions.

Statistics

Data was analyzed using SPSS version 26 statistical software. All statistical tests were 2 sided and all results were considered statistically significant at p < 0.05. Comparisons between groups and outcomes were completed with either a T-test or Wilcoxon signed rank test as appropriate.

Ethical Consideration

Ethical approval was obtained from the Institutional Review Board (Reference number 2020/00009).

Results

Quality Improvement Period 2013-2015

Baseline characteristics

A total of 107 critically ill patients in the neurosurgical ICU were referred to palliative care team during the QI period from 2013 to 2015. Median age of referred patients was 66. Majority of the patients referred suffered from intracerebral bleed (53.3%) and traumatic brain injury (15.0%) (Table 1).

Table 1.

Demographics of Patients in NS-ICU.

	QI period 2013-2015			Post QI od 2016-2018
	Patients who meet referral criteria but not referred to palliative care	Patients who are referred to palliative care	P values	Patients who are referred to palliative care
Total number of patients	155	107	-	126
Age, median (IQR)	62.00 (50.00-74.00)	66.00 (55.00-73.00)	P = 0.137	68.00 (62.00-76.25)
Gender
Male Female	90 (58.1) 65 (41.9)	59 (55.1) 48 (44.9)	P = 0.732	84 (65.9) 43 (34.1)
Ethnicity
Chinese Malay Indian Others	127 (81.9) 9 (5.8) 12 (7.8) 7 (4.5)	90 (84.1) 11 (10.3) 3 (2.8) 3 (2.8)	P = 0.123	107 (84.9) 7 (5.6) 8 (6.3) 4 (3.2)
APACHE score, median (IQR)	26.00 (24.00-29.00)	26.00 (22.00-29.00)	P = 0.575	27.00 (24.00-30.25)
Charlson Comorbidity Index (CCI), median (IQR)	0.00 (0.00-2.00)	1.00 (0.00-2.00)	P = 0.156	0.00 (0.00-2.00)
GCS on admission, median (IQR)	4.00 (3.00-8.00)	5.00 (3.00-8.00)	P = 0.054	4.00 (3.00-6.00)
Admission diagnosis
– Hypoxic ischemic encephalopathy	27 (17.4)	1 (0.9)	P = 0.001	1 (0.8)
– Poor grade subarachnoid hemorrhage	16 (10.3)	13 (12.1)		17 (13.4)
– Intracerebral hemorrhage	55 (35.5)	57 (53.3)		90 (71.4)
– Traumatic brain injury	25 (16.1)	16 (15.0)		3 (2.4)
– Malignancy	12 (7.8)	7 (6.5)		6 (4.8)
– Ischemic Stroke	6 (3.9)	5 (4.7)		4 (3.2)
– Status epilepticus	3 (1.9)	0 (0.0)		1 (0.8)
– Others*	11 (7.1)	8 (7.5)		4 (3.2)

Abbreviation: IQR = Interquartile range.

* Others included diagnosis such as sepsis, cerebral abscess, lung carcinoma, pneumonia, meningioma, subdural empyema, high spinal cord injury, bleeding gastrointestinal hemorrhage.

Referral rates

Prior to the collaboration, there were only 9 referrals in 2012. During the QI period, the number of referrals increased to 44 in 2014 and 47 in 2015.

Figure 2 reflected the time-line of the interventions implemented and its impact on the referral rates. Engaging stake-holders, establishing a referral criteria and joining the ICU rounds to screen for referrals appeared effective in increasing the referral rate at the initial stage. However, the implementation of a standardized workflow for referral and involving the ICU nurse-in-charge in the screening process was pivotal in increasing the number of referrals from 2014 onward.

Healthcare utilization

ICU and hospital length of stay (LOS)

The median ICU LOS for patients referred to palliative care was 7.30 (IQR = 4.30-12.50) which was significantly higher compared to 3.90 (IQR = 2.20-7.00) days for unreferred patients (p < 0.001). Patients referred to palliative care had a median of 7.00 (IQR = 4.00-11.00) days on mechanical ventilator compared to 4.00 (IQR = 3.00-7.00) days for those not referred, (p < 0.001). Patients were referred to palliative care after a median ICU stay of 3.96 (IQR = 1.36-7.52) days.

The remaining LOS after a palliative care consult was 1.30 (IQR = 0.40-4.31) days for ICU survivors and 1.52 (IQR = 0.71-3.90) days for non-survivors. The total hospital LOS for the group referred to palliative care was 11.70 (IQR = 6.30-35.50) days compared to the unreferred group who had a LOS of 7.10 (IQR = 3.40-22.10) days, (p < 0.05). The post-ICU LOS to discharge was lower for referred patients at 6.30 (IQR = 1.90-26.00) days compared to unreferred group at 12.80 (IQR = 2.90-46.60) days though it was not significant (p = 0.068). No patients were re-admitted to ICU after a palliative care consultation (Table 2).

Table 2.

Healthcare Utilization.

	QI period 2013-2015			Post QI period 2016-2018
	Patients who meet referral criteria but not referred to palliative care (n = 155)	Patients who are referred to palliative care (n = 107)	P value	Patients who are referred to palliative care (n = 126)
ICU and Hospital Length of Stay (LOS)
ICU LOS (days), median (IQR)	3.90 (2.20-7.00)	7.30 (4.30-12.50)	P = 0.001	5.95 (3.18-9.90)
No of days on mechanical ventilator, median (IQR)	4.00 (3.00-7.00)	7.00 (4.00-11.00)	P = 0.001	6.00 (3.00-10.00)
LOS in ICU prior to Palliative Care Referral (days), median (IQR)	NA	3.96 (1.36-7.52)	NA	3.78 (1.84-6.86)
LOS in ICU after referral to Palliative care for patients who survived ICU admission (days), median (IQR)	NA	1.30 (0.40-4.31) N = 71	NA	1.15 (0.31-3.06) N = 93
LOS in ICU after referral to Palliative care for patients who passed away in ICU (days), median (IQR)	NA	1.52 (0.71-3.90) N = 36	NA	1.18 (0.22-2.75) N = 33
Total hospital LOS (from admission to discharge, inclusive of ICU and GW stay) (days), median (IQR)	7.10 (3.40-22.10)	11.70 (6.30-35.50)	P < 0.05	10.05 (5.68-20.13)
Post-ICU LOS (from ICU discharge to hospital discharge) (days), median (IQR)	12.80 (2.90-46.60)	6.30 (1.90-26.00)	P = 0.068	3.95 (1.523-10.05)
Readmission to ICU after palliative care referral (%)	NA	0 (0.0)	NA	0 (0.0)
Readmission to ICU during same hospital episode (%)	68 (43.9)	18 (16.8)	P = 0.001	53 (42.1)
Cost
Gross hospital bills during the stay, median (IQR)	23628.65 (9094.45-41170.33)	27568.95 (15311.35-60661.98)	P = 0.157	29481.10 (14980.20-51463.35)
Cost of ICU stay per day (IQR)	2710.79 (2315.02-3250.07)	2476.93 (2177.43-2900.70)	P < 0.05	2646.55 (2336.12-3110.58)
ICU and Hospital Mortality
ICU mortality (%)	99 (63.9)	36 (33.6)	P = 0.001	33 (26.2)
In-hospital mortality (%)	136 (87.7)	86 (80.4)	P = 0.146	104 (82.5)
Site of Death and ICU/Hospital Discharge Location
ICU discharge location (%)
Died in ICU	99 (63.9)	36 (33.6)	P = 0.001	33 (26.2)
Died Outside ICU	56 (36.1)	71 (66.4)		93 (73.8)
General ward	52 (33.5)	49 (45.8)		54 (42.9)
EOL Room	2 (1.3)	15 (14.0)		32 (25.3)
Home	2 (1.3)	1 (0.9)		3 (2.4)
Terminal Discharge Home	0 (0.0)	3 (2.8)		4 (3.2)
HDU	0 (0.0)	3 (2.8)		0 (0.0)
Hospital discharge location (%)
Died in Hospital	136 (87.7)	86 (80.4)	P = 0.299	104 (82.5)
Home	9 (5.8)	12 (11.1)		11 (8.7)
Nursing Home	7 (4.5)	5 (4.7)		6 (4.8)
Community Hospital	2 (1.3)	1 (0.9)		3 (2.4)
Inpatient hospice	1 (0.6)	3 (2.8)		2 (1.6)
Surgery during ICU admission and Investigations in the last 48 hours of Life
Surgery during ICU admission (%)	85 (54.8)	68 (63.6)	P = 0.201	78 (61.9)
Blood tests last 48 hours (%)	88 (56.8)	36 (33.6)	P = 0.001	46 (36.5)
Imaging last 48 hours (%)	47 (30.3)	11 (10.3)	P = 0.001	22 (17.5)

N = number of patients.

Cost

While there were no significant differences in the gross hospitalization bills between the 2 groups of patients, per-day ICU cost was higher for the unreferred group ($2710.79) versus referred group ($2476.93, p < 0.05) (Table 2).

ICU and hospital mortality

Patients who were not referred to palliative care had higher ICU mortality with majority (63.9%) dying in the ICU compared to 33.6% of referred patients (p < 0.001). The in-hospital mortality was not significantly different between both groups of patients groups (87.7% versus 80.4%, p = 0.146) (Table 2).

Site of death and ICU/hospital discharge location

66.4% of referred patients passed away in a non-ICU setting such as in the general ward, EOL room or at home versus 36.1% of unreferred group (p < 0.001) (Table 2).

Surgery during ICU admission and investigations in the last 48 hours of Life

Patients referred to palliative care received significantly less blood tests (33.6%) compared with unreferred patients (56.8%, p < 0.001) at the end-of-life. Referred patients had less imaging (10.3%) compared to unreferred patients (30.3%, p < 0.001) in their last 48 hours of life. There was no difference between the groups of patients receiving neurosurgical interventions during their ICU stay (Table 2).

Process-of-care measures and outcomes of patients

98.1% of patients referred to palliative care had family conferences conducted. There was significantly more social worker involvement for the referred group (59.8%) of patients compared to unreferred patients (43.2%, p < 0.05).

Significantly more referred patients (89.7%) had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU compared to unreferred patients (74.2%, p < 0.001).

A significantly higher percentage of unreferred patients (40.0%) passed away while still receiving life-sustaining support in ICU compared to referred patients (22.4%, p < 0.001).

Significantly more patients referred to palliative care (96.0%) passed away outside the ICU on comfort- directed care compared to unreferred patients (75.7%, p < 0.05). In our institution, comfort-directed care is defined as withdrawal of life-sustaining treatments such as ventilator, inotropes, antibiotics and artificial nutrition and hydration with care focusing on the physical comfort of patients (Table 3).

Table 3.

Process-of-Care Measures and Outcomes of Patients.

	QI period 2013-2015			Post QI period 2016-2018 Patients who are referred to palliative care (n = 126)
	Patients who meet referral criteria but not referred to palliative care (n = 155)	Patients who are referred to palliative care (n = 107)	P value
Family conference during ICU admission (%)	144 (92.9)	105 (98.1)	P = 0.202	125 (99.2)
Medical social worker involvement (%)	67 (43.2)	64 (59.8)	P < 0.05	73 (57.9)
Code status at point of ICU discharge (%)
Active	40 (25.8)	11 (10.3)	P = 0.001	8 (6.3)
DNR Order	115 (74.2)	96 (89.7)		118 (93.7)
– DNR with Maximum ward management	13 (8.4)	16 (15.0)		12 (9.5)
– DNR with Comfort Care only	40 (25.8)	56 (52.3)		87 (69.0)
– DNR with non-escalation of ICU Care*	62 (40.0)	24 (22.4)		19 (15.1)
Patients died outside ICU on comfort-directed care only (%)	28 (75.7)	48 (96.0)	P < 0.05	71 (100.0)

* Refers to patients who passed away in ICU while still on ventilator with an DNR code and non-escalation of other life-sustaining measures such inotropes support.

Post-Quality Improvement Period 2016-2018

We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. Another 126 patients were referred during the post-QI period from 2016 to 2018 (Table 1). The referral rate was sustained during the post-QI period with 39 in 2016, 46 in 2017 and 41 in 2018 (Figure 2).

Patients had a median ICU LOS of 5.95 (IQR = 3.18-9.90) and median of 6.00 (IQR = 3.00-10.00) days on mechanical ventilator. For ICU-survivors, they were transferred out of ICU after 1.15 (IQR = 0.31-3.06) days following a palliative care consult. Similar to QI period, there was no readmission to ICU following a palliative care consult. Most referred patients (73.8%) died outside ICU with fewer investigations at the end-of-life. 99.2% of the referred patients has family conference during the ICU admission and 93.7% had DNR order. All the referred patients passed outside ICU on comfort-directed care without readmission to ICU. (Tables 2 and 3).

Discussion

Outcome of QI Project in Incorporating Palliative Care Into the NS-ICU

The success of this QI project hinged on a multi-faceted approach which included engaging key-stakeholders, establishing an appropriate referral criteria and screening process as well as regular interprofessional team meetings to build mutual understanding and align goals of care. This resulted in a significant increment in referral rates.

Continuity of care was provided by the same palliative care team who continued to see the patients after they were discharged from the ICU. The palliative care team also provided feedback to the NS-ICU team about the patients’ condition and final outcome during their regular team meetings.

The palliative care team also helped to establish terminal extubation and terminal discharge protocols for the NS-ICU which was subsequently incorporated by all the other ICUs.

The QI Project showed that referral to palliative care was associated with more deaths out of ICU, more patients and families opting for comfort care, less investigations in the last 48 hours of life and less costly per-day ICU stay.

Lessons Learnt and Challenges Faced

These were some of the important lessons learnt and challenges we faced.

The need for palliative care for critically ill neurosurgical patients

In 2015, our NS-ICU mortality was 15.9% and hospital mortality was 25.2%. This was similar to the available statistics from the West where 1 in 5 patients do not survive an ICU admission.^16,17 The hospital mortality of both referred and unreferred patients was high. In the NS-ICU where mortality rates are high, the integration of palliative care was even more crucial to ensure good quality end-of-life care for these patients.

Understanding the unmet needs of patients & families through proper communication

Previously, there was no referral criteria nor standardized workflow in place to trigger a palliative care consultation. The QI team established a referral criteria which allowed the NS-ICU nurse-in-charge to screen patients on a daily basis leading to suitable patients being identified earlier.

While this diagnosis-based trigger allowed an efficient means to identify patients, it did not identify the unmet needs of patients and families. Our QI team overcame this challenge by creating common platforms for communication between the various interprofessional teams in the form of weekly interdisciplinary meetings. This allowed the teams to discuss patients’ and families’ wishes, expectations and assess unmet needs.

Adopting a consultative and integrative model of care

We feel that good quality ICU care requires an interprofessional team who can effectively apply a palliative care approach to address distressing physical symptoms, to explore and address unmet psycho-emotional needs of patients and families and adopt a shared-decision making process based on patients’ preferences and values.^18
-20

In our center, we adopted a mixed consultative and integrative model of care which was especially applicable in the NS-ICU where palliative care interventions and recommendations would be guided by the specialized team of neurosurgeons and intensivists pertaining to prognostication and feasibility of neurosurgical interventions.^3,21
-23 This model of care allowed the palliative care team to work with the rest of the other ICU interprofessional teams to effectively co-manage the complex needs of critically ill neuro-surgical patients with distressing symptoms and address the high psycho-emotional needs of their families where life-saving medical and surgical decisions need to be made in a patient-centered manner.

Prior studies on ICU LOS included patients from MICU, SICU and CCU.^24
-26 Our study focused only on neurosurgical patients in NS-ICU. The longer NS-ICU stay could reflect the more unique and complex needs of our neurosurgical patients as they could have continued to deteriorate despite neurosurgical interventions and ICU care. Furthermore, the grieving families may have difficulty in accepting the sudden, irreversible and devastating neurological outcomes. As such, there was a need for the expertise of the palliative care team to assist in goals of care discussions and an interprofessional team to support the families.

Continuity of care beyond the ICU

Another important factor behind the successful collaboration included having the same palliative care team provide continuity of care in the post-ICU period. This was vital in minimizing the sense of abandonment experienced by patients and the families as they left the ICU. The majority of referred patients (66.4% in 2013-2015 and 73.8% in 2016-2018) passed away outside ICU setting compared to 36.1% of unreferred patients. Most referred patient passed away either in general ward or EOL room which provided more privacy for the patients and families. We facilitated terminal discharge for 7 patients to help fulfill their wishes of passing away at home.

Following a palliative care consult, the patients were transferred out of ICU to general ward or end-of-life care room within 1.30 (IQR = 0.40-4.31) days during QI period and 1.15 (IQR = 0.31-3.06) days during post-QI period. This reflected how palliative care involvement allowed smooth transition to a non-ICU setting, allowing the ICU bed to be vacated for other critically ill patients who would benefit from intensive care.

A significantly higher percentage of referred patients passed away with a focus on comfort-directed care in a non-ICU settings. Palliative care involvement also resulted in reduction of investigations at the end-of-life, reflected by the significantly fewer blood tests and imaging for patients in their last 48 hours of life.

Moving Forward in Establishing ICU-Palliative Care Collaboration in Other ICUs

With the success of our in NS-ICU, we used the same multi-pronged approach in integrating ICU-Palliative care with other ICUs in our hospital from 2014 onward. The establishment of this collaboration saw a significant increment in referrals from all ICUs.¹⁵

Limitations

There were limitations to our study. We did not have data of a separate comparison group of critically ill patients who met our referral criteria but were not referred to our ICU-Palliative Care Service during the sustainability phase from 2016 to 2018. Making comparisons between these 2 groups of patients would have allowed us to understand the impact of our ICU-Palliative care collaboration in the sustainability phase better.

Our QI initiative was conducted in a single-center with mature neurosurgical and palliative care services of more than 20 years which may not be generalizable in other centers.

While having a diagnosis-based trigger offered an efficient way for screening, it failed to identify unmet psycho-emotional needs of patients and families. Future QI projects should consider incorporating a needs-based criteria as part of their screening.

Lastly, 80.4% (QI period) and 82.5% (Post-QI period) of referred patients passed away during their admission, reflecting that that a large proportion of critically ill neurosurgical patients received palliative care only at the end-of-life. We would recommend that palliative care referral should be based on needs rather than prognosis and future research should explore how to deliver early palliative care to our critically ill patients.

Conclusion

The integration of palliative care into a Neurosurgical ICU was beneficial in reducing blood tests and imaging at the end-of-life, facilitating goals of care discussions and decreasing per-day ICU costs. From our experience, we would recommend that both palliative care and neurosurgical ICU teams to collaborate together to provide holistic and seamless care to these critically ill patients.

Supplemental Material

Supplemental Material, sj-pdf-1-ajh-10.1177_10499091211045616 - Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project

Supplemental Material, sj-pdf-1-ajh-10.1177_10499091211045616 for Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project by Choo Hwee Poi, Mervyn Yong Hwang Koh, Tessa Li-Yen Koh, Yu-Lin Wong, Wendy Yu Mei Ong, Chunguang Gu, Fionna Chunru Yow and Hui Ling Tan in American Journal of Hospice and Palliative Medicine®

Supplemental Material

Supplemental Material, sj-pdf-2-ajh-10.1177_10499091211045616 - Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project

Supplemental Material, sj-pdf-2-ajh-10.1177_10499091211045616 for Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project by Choo Hwee Poi, Mervyn Yong Hwang Koh, Tessa Li-Yen Koh, Yu-Lin Wong, Wendy Yu Mei Ong, Chunguang Gu, Fionna Chunru Yow and Hui Ling Tan in American Journal of Hospice and Palliative Medicine®

Footnotes

Appendix

Appendix A

Impact of Problems, Interventions and Outcomes.

Identified problems	Impact of problems	Quality improvement interventions	Results
1. No referral criteria	Suitable patients were not identified for palliative care referral, resulting in missed opportunity for referral	Establishing Referral criteria: Hypoxic ischemic encephalopathy Traumatic brain injury with poor neurological prognosis Extensive intracranial hemorrhage/subarachnoid hemorrhage with no further surgical interventions Low presenting Glassgow Coma Scale (GCS) of ≤6	Patients were referred once they met one of the referral criteria.
2. No screening process was available and no standardized system of triggering a referral	Suitable patients were not identified for palliative care referral, resulting in missed opportunity for referral Delay in referrals to palliative care	Establishing a Screening and Referral Workflow to Palliative Care: Daily screening by ICU Nurse-in-charge. Standardized workflow was established to trigger a palliative care consult.	There was improved accessibility of palliative care services to the patients. The referral process was seamless using a standardized workflow.
3. Lack of platform for formal case discussions and communications between ICU, neurosurgical and Palliative care team	Variable buy-in from intensivists and neurosurgeons Intensivists and neurosurgeons may not be aware of the role of Palliative care team in caring for the critically ill patients and their families Low referral to Palliative care	Combined Weekly Interprofessional Meetings: Weekly interprofessional meetings through integrated ICU-Palliative care rounds involving the Palliative care team, NS-ICU nurse, medical social worker and intensivists were done. Discussions between Palliative care and ICU team were done regularly to update on patients’ condition and management plans throughout patient’s ICU stay. i) Palliative care team would update intensivists of the progress and outcome of the referred patients in the post-ICU period	There were better communications between the various interprofessional teams which helped to strengthen collaboration. The ICU team had better understanding of the role of Palliative care team in the ICU. Updating the ICU team on the outcome of the referred patients in the post-ICU period was important for the intensivists as they were reassured that their patients were comfortable at the end-of-life.
4. Intensivists were rotated to ICU on weekly basis	Intensivists were not aware of the presence of ICU-Palliative care collaboration in NS-ICU and were not familiar with Palliative care referral workflow	Orientation for Intensivists: Briefing of intensivists during weekly changeover on the referral criteria and referral workflow	The intensivists would be aware of the ICU-Palliative care collaboration, referral criteria and the referral process
5. 1. Low level of nursing confidence in supporting patients & families with palliative care needs	ICU nurses may not feel confident in addressing the needs of patients and families at bedside	Education and Engagement of NS-ICU Nurses: Communication workshops for all ICU nurses working in neurosurgical ICU were conducted from 2014-2015 Palliative care team would guide ICU nurses on assessment and management of symptoms at bedside during Palliative care review	ICU nurses could identify and address palliative care needs of critically patients. ICU nurses were more confident in assessing and managing symptoms and using opioid infusions for symptoms optimization

Authors’ Note

Ethical approval was obtained from the Institutional Review Board: National Healthcare Group (NHG) Domain Specific Review Board (DSRB) has approved the study. The NHG DSRB reference number for this study is 2020/00009. The ICU-Palliative care collaboration was part of a healthcare quality improvement project. This Quality Improvement Project won the “National Healthcare Group Best Quality Improvement Project Award” in 2015.

Acknowledgments

The authors would like to thank Dr Allyn Hum for her support and revising the manuscript for publication, Miss Li Li (Assistant Manager for ICU Operations), Miss Carin Low Zhi Jun (Research Assistant, Tan Tock Seng Hospital), Miss Jermain Chu Choy Ning (Research Assistant), Dr Heng Xiaowei and Miss Zhang Junjun (Coordinator for Palliative Care Department) for their expertise with data management and analysis.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Choo Hwee Poi

Mervyn Yong Hwang Koh

Tessa Li-Yen Koh

Supplemental Material

Supplemental material for this article is available online.

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