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

BACKGROUND: Implantable Cardioverter Defibrillators (ICDs) are resuscitative devices that prevent death from certain cardiac arrythmias. More than 150,000 devices are implanted in the United States annually. Because a patients' goals may evolve over time, current guidelines direct providers to discuss goals of care and ICD deactivation with patients. However, many patients do not have these conversations, and many have poor understanding regarding their ICD and their ability to turn the shock settings "off". Because of this, most patients continue to have their ICD shock settings "on" and remain at risk of painful shocks towards the end of life. LOCAL PROBLEM: A subset of patients with ICDs in the Parkland Health system were found to have poor ICD knowledge, had few discussions regarding ICDs with healthcare providers, and held preferences to not deactivate their ICD shocks in end-of-life (EOL) scenarios. Poor knowledge and communication inhibit informed decision-making and can lead to worse patient outcomes, which may be more likely in our diverse safety-net hospital population. METHODS: We undertook a quality improvement (QI) project to increase patient understanding of ICD function to promote informed decision making. We used the DMAIC (Define, Measure, Act, Improve, Control) methodology to guide the QI initiative. Our team, composed of physicians and health team members in various departments, worked to create an educational video tailored to our Parkland population based on knowledge gaps in the formerly surveyed patient cohort. We then validated the video as an educational tool by administering pre- and post-surveys to 50 patients with ICDs who were hospitalized. After this, we sought a place to sustainably show the video to the most patients possible, ultimately leading to a partnership with the informatics team in the health system and the creation of a "Care Companion," a way of distributing the video, other information, and a short survey to patients via their electronic patient portal. We are currently piloting this method of distribution, with plans to perform multiple PDSA cycles to determine the best way to administer the video and further education. RESULTS: Among 50 surveyed hospital patients with ICDs, they answered an average of 47% of the knowledge questions correctly, which improved to an average of 81% after watching the educational video. Changes of preferences in hypothetical EOL scenarios were variable but tended to solidify preferences expressed prior to watching the video. However, a situation with no hope of recovery had the largest change after the video, increasing from 42% to 64% of patients that said they would probably or definitely want their device deactivated. The project also led to the creation of an ICD "Care Companion," an electronic tool used to disseminate and gather information through electronic patient portals. CONCLUSION: Our QI project is to enhance education and informed decision-making for patients with ICDs in the diverse, safety-net Parkland health system. Using patient-centered educational material created for our specific hospital population, we were able to increase patient knowledge scores using a validated survey tool and show that the resultant new knowledge also impacted patient preferences regarding their goals of care. We have started disseminating our educational video through the Parkland electronic patient portal to eligible patients and hope to develop a smooth and possibly automated method to send the video to patients, promoting more effective goals-of-care conversations. Collaboration with various partners has been essential to project success. Through this project, we hope to improve the way we care for patients by better aligning our care with patients' own goals and preferences.

Author dc:creator

• Garrett, Brenden Eugene

Contributors dc:contributor

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

• Parkland Health & Hospital System
• Advance Care Planning
• Defibrillators, Implantable
• Health Knowledge, Attitudes, Practice
• Patient Education as Topic
• Quality Improvement
• Terminal Care

Language dc:language

en

Identifier

1596185266

OAI identifier oai:identifier

oai:utswmed-ir.tdl.org:2152.5/10829