Aligning Patients' Defibrillator Status with their Goals of Care: A Multidisciplinary Quality Improvement Project at Parkland Hospital

BACKGROUND: Implantable Cardioverter Defibrillators (ICDs) are life-prolonging devices that prevent death from life-threatening arrythmias. Over 150,000 devices are implanted in the US each year. Given the possibility of patient goals evolving over their life course, current national guidelines direct providers to explore goals-of-care and ICD deactivation with patients. However, many patients never have these conversations with their providers, especially in underserved patient populations where healthcare resources may already be limited. As a result, a significant portion of patients continue to have their ICD shock settings "on" and remain at risk for unwanted painful ICD shocks towards their end of life, which can inflict unnecessary suffering on both patients and their caregivers. OBJECTIVE: Our project aim is to ensure 100% of patients at Parkland Hospital with ICDs have alignment between the shocking function of their device and their goals of care by January 1, 2024. METHODS: A Quality Improvement (QI) effort was undertaken at Parkland Hospital to increase alignment of patients' ICD on/off status with their goals-of-care. The DMAIC methodology (Define, Measure, Act, Improve, Control) was selected to guide the QI effort. First, a cohort of 113 patients with ICDs at Parkland were identified using an existing palliative care registry. From that cohort, a retrospective chart review was conducted to assess medical and demographic data. Additional data was collected about existing patient educational tools. Next, patient knowledge, goals, and experiences were assessed using a survey adapted from validated published tools. Of the 113 patients in the registry, 26 patients completed the phone survey. Based on knowledge gaps identified in the survey, a patient education video was created, alongside updates within the EPIC electronic medical record system, to streamline the process of ICD discussions and deactivation. Multiple iterative PDSA cycles were undertaken to implement the education video and EPIC tools into providers' workflow. RESULTS: From 2019 to 2023, the project progressed through each of the DMAIC stages: Define: In our 113 patients, 75% were male, 48% were Black, 26% were Hispanic, and 19% were uninsured or requiring financial assistance at Parkland. From the 113 patients, 26 patients ultimately completed the phone survey, of whom 27% spoke English as a second language and 80% had a high school degree or less. Of note, nearly 40% of this original 113 patients passed away in the five months between initial identification and phone survey, indicating a very ill and near end of life patient population for whom goals of care discussions are especially crucial. Existing education material were primarily written documents, featured a range of reading levels, featured White-appearing individuals, and very few included Spanish language versions. Measure: Of the 26 patients who completed the phone interview survey, only 31% of patients correctly identified that deactivation of ICDs did not require surgery, only 54% were aware that the heart does not stop beating after deactivation, and only 19% correctly stated ICD deactivation does not require pacemaker function to also be deactivated. These scores were lower than reports in prior published literature. Act: An expert multidisciplinary committee was convened to evaluate the data, synthesize root cause analyses, and determine interventions. Improve: A patient-centered ICD educational video was created, featuring Parkland patients, animations about key concepts, and versions in English and Spanish. In addition to the video, efforts were undertaken to standardize the processes for goals of care discussion/ICD deactivation (including EPIC order sets, consult placements, and process maps). Several iterative PDSA cycles were conducted to assess how best to integrate these tools into provider workflow. Control: Evaluation of the patient education video and EPIC integration is currently ongoing. CONCLUSION: Our QI effort is the first to address the specific goals of care discussion challenges of Parkland patients with ICDs as they near the end of life. This project utilized a patient-centered design approach to develop educational content that was intentionally inclusive and accessible to Parkland patients, as well as addressed their main common knowledge gaps. Through our efforts, we hope to empower patients at Parkland with the knowledge and tools to become active participants in their own care plans. Ultimately, we hope this project reinforces the importance of centering the voice of our patients at the core of our medical decisions, system designs, and improvement processes.

Author dc:creator

• Chen, Christine Lynn

Contributors dc:contributor

• Reed, W. Gary
• Sulistio, Melanie
• Newcomer, Kelley F.

• Decision Making
• Defibrillators, Implantable
• Guidelines as Topic
• Quality Improvement
• Terminal Care
• Attitude to Health
• Parkland Health & Hospital System
• Texas

Language dc:language

en

Identifier

1522122340

OAI identifier oai:identifier

oai:utswmed-ir.tdl.org:2152.5/10616