Our primary goal was to pilot the use of the ESAS-r + 1 QoL form in three palliative care outpatient clinics. Our expected outcome is continuous improvement in meeting PC needs, which was accomplished via a process in which patients completed the ESAS-r + 1 QoL form at each OOPC visit by end of the 12-week pilot project in all three clinics.
Setting. This quality improvement project was conducted at a large
Southeastern National Cancer Institute-designated comprehensive cancer center with a specialty outpatient oncology palliative care (OOPC) service within its three geographically discrete clinics. OOPC does not have discrete clinic space and is instead embedded within the Surgical Oncology, Multi-disciplinary Oncology and Hematology-Oncology clinics. The PC team included two attending physicians, three palliative medicine fellows, one nurse practitioner, one clinical pharmacist, and a nurse clinical coordinator. The PC team shared nursing and support staff with these oncology clinics. The three outpatient PC clinics did not have a standardized process in place for symptom assessment prior to this project.
Sample. The project population consisted of all patients seen by OOPC in these three clinics during the 12-week pilot period. There were three check-in desks staffed with a Health Unit Coordinator (HUCs) to check in patients. HUCs handed patients a piece of paper with questions to complete while they waited to be seen. However, each HUC had a different workflow at each clinic. The project was submitted to and approved by the University of North Carolina at Chapel Hill Institutional Review Board (IRB).
Measures
Edmonton Symptom Assessment Scale (ESAS). The ESAS is a well-established measure of physical and psychological domains that asks patients to rate nine common symptoms (pain, tiredness, drowsiness, nausea, appetite, shortness of breath, depression, anxiety, wellbeing) and one fill in the blank symptom they would like to address with their provider. The measure uses a 0 to 10 numeric rating scale to rate severity of the symptom, with 0 being absent of symptom and 10 being worst possible severity. ESAS was validated in PC, hospice patients, and to measure symptom severity in adults with cancer seen by a PC service [13]. ESAS has been revised to make it easier to complete, with added description for symptoms [14]. The scale does not require recall, as it assesses the timeframe of “now.” The ESAS-r is the revised ESAS measure and includes a body diagram to identify the pain site [14]. The ESAS-r has been used extensively in cancer PC, inpatient, and outpatient studies [15].
European Organization for the Research and Treatment of Cancer (EORTC) – Quality of Life in Palliative Care Patients (EORTC-QLQ-C15-PAL). The single QoL question has been validated and was found to be comparable to multi-item questionnaires [16]. It has been used extensively in the PC population with cancer [14, 17-23]. Based on extant literature and our communication with the PC team, there was mutual agreement that the ESAS-r with the global QoL question (ESAS-r + 1QoL) would be used for the assessment.
Plan-Do-Study-Act (PDSA)
Plan. Approval from clinic nurse managers was obtained prior to proceeding with the project planning. The project introduction, project timeline, and instructions were shared via information flyer with the HUCs, Certified Medical Assistants (CMAs), nurses, and clinicians that were involved in caring for the patients seen by OOPC. Flyers were posted at the HUCs’ desk and nurses’ station to serve both as a resource and as a reminder to have the patient complete the ESAS-r + 1 QoL form for each PC patient appointments. The HUCs were able to see on their worklist if the patient was scheduled to see a PC provider at the time of check-in.
Do. The piloting of the ESAS-r + 1 QoL form took place in each clinic at the same time. The existing HUC workflow was used to pilot the assessment form. There were already several different general forms distributed at the time of the clinical appointment. For example, a yellow symptom inventory form was given to patients with breast cancer in the clinic. The same workflow was used to distribute the ESAS-r + 1 QoL form. The HUCs handed out the ESAS-r + 1 QoL form to the patient when they checked in. Clipboards with attached pens were already available at the HUC desk and the exam rooms. The completed ESAS-r + 1 QoL forms were collected by the support staff at the time of rooming and placed in a bin outside the room. Additional time was allowed to a patient who had not completed the questionnaire at the time of rooming. Those forms remained in the exam room and were collected by PC clinicians at the time of the visit. All ESAS-r + 1 QoL items were collected from the patient the end of the visit, regardless of completion status.
Study. Data were collected at weekly intervals. The number of OOPC scheduled and ESAS forms completed were tracked using an excel spreadsheet. At the end of each three-week cycle, the data were analyzed for each clinic separately. The DNP student met in person or via phone call with HUCs to assess barriers and facilitators at the end of each PDSA cycle. Prior to rolling out the project, we worked with the OOPC clinics to secure a designated area to store completed assessment forms. We totaled the number of completed ESAS-r + 1QoL forms and compared it with the total number of completed visits under PC service in a given time period. The denominator was set as the total number of patient visits. If a patient visited the clinic twice in a given time period, then each visit was counted independently in the denominator. The nurse coordinator for the PC team agreed to keep a printed list of appointments for the day and to cross out “no show” patients or patients seen outside the three-clinic area listed above. This information was collected weekly during the pilot period. An Excel data sheet was used to track this data for each clinic. No personal identifier of patients was logged into the data sheet.
Act. The assessment of barriers was performed for the clinic that did not maintain or surpass the set compliance benchmark of 50%. Changes to the pilot project process were made to address barriers observed during each PDSA cycle. Staff input was incorporated when making these changes.
Implementation
It was important to engage stakeholders early in the process. Gaining not only cooperation but also the support from all of the clinic staff was critical for the success of this project. The stakeholders of the intervention included the organization’s executive directors, unit managers, administration personnel, and PC clinicians that provide direct care to the patient (including the physician, advanced practice providers, clinician pharmacist in the PC team, nursing staff, and patients/caregivers). The ongoing update on the progress and data collected up to that point was shared with stakeholders at the end of each PDSA cycle via e-mail.
Reach. The number of patients seen by the OOPC clinic during the DNP project from October 7, 2019 to December 29, 2019 was the total sample. The baseline benchmark at the end of initial PDSA cycle was set at 50% for each of the three clinics. The goal for each cycle thereafter was to continue to look for ways to maintain or surpass the previously reached compliance rate, or 50%, whichever was highest.
Effectiveness. The Plan-Do-Study-Act (PDSA) cycles did facilitate piloting of the ESAS-r + 1 QoL item. The PDSA cycles provided opportunities to make necessary changes to address noted barriers at each PDSA cycle.
Adoption. The clinicians (PC advanced practice providers, PC physicians, clinical pharmacists, and PC nurse clinical coordinators) and support staff (HUCs, CMAs, and nurses) received project information via staff meetings and group email. The contact information was included in the email for further questions. At the end of each PDSA cycle, we performed a site visit to interact with support staff to assess barriers, if any. Adjustments were made to the implementation plan based on feedback from clinicians and support staff.
Implementation. A total of four PDSA three-week cycles were completed during the project time period. We re-educated clinicians and support staff, provided resources, and made adjustments as needed for each clinic that did not meet the set benchmark as described above at the end of each PDSA cycles. Education and changes to the pilot project took place in the first week of new PDSA cycles.
Maintenance. We did not include the maintenance portion of the framework within the project timeline but instead plan to present maintenance as a recommendation for the future.