P2D129: Improving the Utilization of Palliative Care Consultation in the Neonatal Intensive Care Unit

Purpose/Objectives: Perinatal palliative care provides comprehensive, interdisciplinary, and planned care for life-limiting or chronic critical conditions throughout pregnancy and the postnatal period. The utilization of palliative care services remains limited within neonatal intensive care units despite endorsement by the American Academy of Pediatrics and the National Association of Neonatal Nurses. The primary causes of delayed entry into perinatal palliative care are late consultation, healthcare provider misconceptions about patient eligibility, and variability in consult ordering practices. This project aimed to increase the use of early palliative care consults for eligible patients in a neonatal intensive care unit from 33% to 100% by December 10, 2022.

Design/Methods: The Promoting Action on Research Implementation in Health Services framework guided this quality improvement project. Eligibility criteria were standardized, and a trigger list of diagnostic, prenatal referral, and chronicity criteria was implemented in a Level IV neonatal intensive care unit. Interventions to improve consult compliance included staff education, redesigned workflow for consult consideration, and the use of bedside rounding to identify eligible patients. Multidisciplinary team collaboration supported stakeholder engagement and facilitated consult order entry. Weekly manual chart audits collected de-identified patient data. Percent consult compliance was analyzed with a run chart to identify special-cause variation. Education data was collected by self-described clinician surveys using Likert-type responses and attendance at training sessions. Significant differences in clinician survey scores after the educational training were determined by nonparametric analysis.

Results: Median palliative care consult compliance for eligible patients in the eleven weeks before project implementation was 33%. A center line shift happened after the interventions were implemented, reaching 100% compliance for those that met the eligibility criteria on October 1, 2022. Palliative care consult ordering compliance was maintained at 100% for 10 weeks until December 10, 2022, upon project cycle conclusion. Seventeen patients met inclusion criteria after go-live, and consults were ordered for 16 patients (94%). Eight of the 17 patients (47%) met diagnostic, six (35%) met chronicity, and three (18%) met prenatal referral criteria. The median time from admission to palliative care consult order entry was reduced from 40 to 15.5 days after implementation for eligible patients. Educational training was received by 98% of the 49 site healthcare providers. Healthcare provider comfort in identifying palliative care-eligible infants significantly improved after the educational straining (Z=3.02, p=0.003).

Conclusion/Discussion: These results indicate that quality improvement methodology successfully improved early palliative care consult ordering within one neonatal intensive care unit. Standardization of perinatal palliative care eligibility, bedside rounding, and personnel education increased the use of these services. Further research is needed to explore expanding the trigger criteria to additional diagnoses and evaluate the impact on family experiences.