P3B011: A Discrete Trigger to Increase Specialized Palliative Care Consultation in Children with Heart Disease and Prolonged Cardiac Intensive Care Unit Hospitalization: A Quality Improvement Project

Purpose/Objectives: Children with heart disease are a medically complex population, experiencing high rates of morbidity and mortality. Pediatric Palliative Care (PPC) provides longitudinal support for families navigating complex medical scenarios. Nonetheless, PPC consultation in the cardiac intensive care unit (CICU) occurs at low rates. In 2009, the Center to Advance Palliative Care developed referral criteria for PPC consultation in children with heart disease in the ICU, including those with consecutive ICU length of stay (LOS) ≥14 days.

Design/Methods: This pre- and post-intervention quality improvement (QI) study evaluates the use of a discrete LOS trigger (CICU LOS ≥14 days) to increase rates of recommended PPC consultation within the CICU of an academic pediatric hospital. The SMART aim was to increase appropriate PPC consultation rates in children with a CICU LOS ≥14 days from 30% pre-intervention to at least 60% within 12 months post-intervention.
A multidisciplinary team utilized standard QI planning tools to clarify the causes of low consultation rates and identify key drivers to delineate actionable interventions (Figures 1 and 2). Interventions included a baseline presentation to key stakeholders, implementation of weekly automated emails and text message reminders to CICU providers regarding children with a CICU LOS ≥14 days, and institution of a scheduled weekly huddle with CICU and PPC providers to review eligible children.
All children admitted to the CICU between January 2021 and February 2023 were reviewed, and those with a CICU LOS ≥14 days were included in this study. Data collected included demographics, hospital and CICU LOS, and clinical outcomes. The cohort was stratified into pre- (January 2021 to December 2021) and post-intervention (February 2022 to February 2023) groups and compared by the receipt of PPC consultation. We excluded children with pre-existing consultation or consultation initiated in a separate unit. In patients receiving consultation, we surveyed families’ perceptions utilizing an adaptation of a previously validated survey as a measure of effectiveness and balancing metric.

Results: During the pre-intervention period, there were 466 CICU admissions; 50 had a CICU LOS ≥14 days, with 15 (30%) receiving consultation. In the post-intervention period, there were 426 CICU admissions; 54 had a CICU LOS ≥14 days, with 34 (63%) receiving consultation. Pre- and post-intervention groups did not differ significantly regarding demographics, category of heart disease treatment, CICU LOS, or time from CICU admission to consultation.
A majority of surveyed families report high levels of satisfaction with PPC, especially in the areas of longitudinal psychosocial support, assistance in decision-making, and symptom management. A common response was the desire for PPC involvement earlier in their child’s course.

Conclusion/Discussion: A discrete LOS trigger can effectively increase recommended PPC consultation rates in children with prolonged CICU hospitalization. Families perceive that PPC involvement is beneficial through their CICU journey.