Increasing advance care planning referrals for chronic obstructive pulmonary disease patients in the emergency department

Abstract

In Singapore General Hospital (SGH), patients with chronic obstructive pulmonary disease (COPD) are referred for advance care planning (ACP) at the specialist outpatient clinics with about 50 cases referred a year and a completion rate of 10%. One of the commonly cited reasons by patients is that they are feeling well currently and do not need to talk about ACP at that moment. The Emergency Department (ED) saw about 240 COPD patients of P2 or P3 acuity yearly and might be a strategic place for ACP advocacy to take place for COPD patients who are triaged as P2 or P3 acuity. While the memory of the recent exacerbation remains fresh, it could be an opportune moment to start an ACP conversation with such patients in the ED. A quality improvement project (QIP) led by both ED nurses and doctors was executed to increase the number of ACP referrals for COPD patients from the ED. A total of 16 COPD ACP referrals were made, up from the previous baseline of zero. Of note, two of the 16 referrals (12.5%) completed the ACP process. Four more (25%) are still in midst of ACP completion at time of project conclusion.

Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive disease that has a high physical, mental and fiscal burden on patients. ¹ An estimated 300 million people worldwide suffer from the disease, and it is one of the major causes of death globally. ² Patients experience a gradual health decline as the disease progresses. ¹ Some will experience episodes of life-threatening exacerbations that could incrementally lower their quality of life.^3,4

The clinical progression also necessitates frequent decision-making about care plans by patients, family members and practitioners. ³ Patients’ preferences on treatment may vary, especially during an acute deterioration where respiratory support via mechanical ventilation is needed. ³ Family members and practitioners are then faced with difficult decisions regarding life-sustaining treatments.^5,6

The British Thoracic Society and American College of Chest Physicians recommend that Advance Care Planning (ACP) be made an integral part of COPD treatment, and encourage end-of-life goals to be discussed as part of patient care. ³ Advance Care Planning allows the patient to make informed decisions and articulate their values as they discuss their preferred treatment in the event they are incapacitated and unable to communicate their wishes.^1,7 Another benefit of ACP is that patients’ family members are often more accepting when the patient eventually passes on. ⁸

The Emergency Department (ED) might be a strategic place for ACP advocacy in COPD patients who are triaged as Patient Acuity Category Scale (PACS) 2 or 3 – typically patients with mild to moderate exacerbations. The ED provides an opportune moment to initiate the ACP conversation while the memory of a recent exacerbation is still fresh. Literature has shown that improvement in decision-making surrounding goals of care issues is seen when patients are engaged at the time of admission ⁹ or when they experience clinical deterioration. ¹⁰ To our best knowledge, no previous ACP advocacy for COPD patients has been attempted in Singapore EDs.

In Singapore General Hospital (SGH), patients with COPD are referred for ACP at the specialist outpatient clinic setting. There are about 50 referrals a year with a rejection rate of 25% and a completion rate of 10%. One commonly cited reason for rejection by patients is that they are feeling well at the point of consult and do not feel the need to talk about ACP at that moment. Singapore General Hospital Department of Emergency Medicine (DEM) attended to 240 PACS 2 and 3 COPD patients in 2020. The number of ACP referrals for COPD patients in the ED for the same period was zero. Hence, our project aims to improve the ACP referral rate for patients with COPD in the ED.

Descriptive report

The objective of this Quality Improvement Project (QIP) was to increase the number of ACP referrals for COPD patients in the ED from zero to 10 in 6 months (July to December 2021). Approval from the Division of Medicine Chairman was obtained prior to commencement of this QIP as per institutional guidelines. The project timeline was further extended by another 4 months to April 2022 due to the COVID-19 Delta and Omicron waves.

Figure 1.

Root cause analysis.

A root-cause analysis was carried out to elucidate reasons for the lack of ACP referrals for COPD patients in the ED (Figure 1). 26 root causes were identified. This was followed by a voting-based Pareto process to rank the importance of the various root causes. Applying the 80:20 principle on the Pareto Chart, six critical root causes that could yield the greatest impact were identified. The driver diagram was used to help us derive our key drivers and interventions to address these root causes (Figure 2).

Figure 2.

Key driver diagram.

Building ACP expertise

A multi-disciplinary team of doctors, Patient Navigators (PNs), Advanced Practice Nurses (APNs) and Staff Nurses (SNs) was formed to build expertise in DEM. One member of this DEM-ACP team was a certified ACP facilitator, who helped the team to engage the SGH-ACP team. The remaining team members attended an ACP advocacy workshop to be trained as ACP advocates. The DEM-ACP team also met with the existing COPD-ACP team (under SGH-ACP) to understand their experience with COPD patients in the specialist outpatient clinic of the SingHealth Lung Centre.

Hassle-free ACP referral workflow

A simple DEM ACP referral form containing the patient’s and his/her nominated spokesperson’s details was created. This form was used to refer patients to the SGH-ACP team, as well as track referral numbers.

A set of inclusion criteria was created with the expert help of the COPD-ACP team to identify COPD patients. They are known COPD patients with at least one prior ED visit for exacerbation in the last 12 months or a previous ICU admission, have mental capacity and no previous ACP discussion done. These patients would have been triaged as PACS 2 or 3 and treated for their acute conditions by the attending ED physicians prior to referral.

Suitable COPD patients opportunistically identified by on-duty ED doctors and nurses would be referred to the department’s PNs, both of whom were in the DEM-ACP team. The PNs would then notify the DEM-ACP team via a dedicated group chat. One of the DEM-ACP members would then approach the referred patient when they are available.

This one-step referral process was intentionally designed to avoid additional cognitive load on DEM physicians. Prior to this project, PNs were already contacted by DEM doctors for patients with social or discharge issues. Hence, this referral system would be similar to the “normal process” with few additional steps to remember.

The internal ACP referral workflow was first presented to the department during the monthly staff meeting and nursing roll calls in June 2021. Subsequently, reminders and updates were sent monthly in department chat groups. A visual reminder was also placed in the DEM Critical Care Area (CCA), where PACS 2 and 3 COPD patients were usually physically located.

Patient Education

The DEM-ACP team created a set of communication aids for ACP advocacy to COPD patients. Both printed and digital copies of these aids were made available in the department. Advance care planning brochures and workbooks, written in all four languages (English, Mandarin, Malay and Tamil) were provided for patients to increase their understanding of ACP. ¹¹

Results

Due to manpower interruption from COVID-19 Delta and Omicron waves, the QIP was extended for four more months, spanning 10 months till 30 April 2022. A total of 16 COPD ACP referrals were made from the previous baseline of zero.

Two of the 16 referrals (12.5%) completed the ACP process. Four (25%) were still in midst of ACP completion at the time of project conclusion. It takes one to two sessions to complete an ACP once the patient and nominated spokesperson are ready to engage in the ACP discussion. The overall result is summarized in Table 1.

Table 1.

COPD ACP referrals from DEM.

Period	Month	EM - Outpatient				EM - Inpatient
		Referral	Completed ACP	Declined ACP	Pending ACP	Referral	Completed ACP	Declined ACP	Pending ACP
FY21Q2	Jul-21	1	0	1	0	4	0	4	0
FY21Q2	Aug-21	1	0	0	1	5	1	4	0
FY21Q2	Sep-21	0	0	0	0	0	0	0	0
FY21Q3	Oct-21	0	0	0	0	0	0	0	0
FY21Q3	Nov-21	0	0	0	0	0	0	0	0
FY21Q3	Dec-21	1	0	0	1	0	0	0	0
FY21Q4	Jan-22	0	0	0	0	0	0	0	0
FY21Q4	Feb-22	0	0	0	0	1	0	0	1
FY21Q4	Mar-22	0	0	0	0	1	1	0	0
FY21Q4	Apr-22	0	0	0	0	1	0	1	0
FY22Q1	May-22	1	0	0	1	0	0	0	0
Total		4	0	1	3	12	2	9	1
Grand total		4				12

The remaining 10 patients (62.5%) did not complete or subsequently declined to complete the ACP process for reasons shown in Table 2. The reasons varied from patients who passed away before an appointment could be fixed, to patients who changed their minds about ACP discussion.

Table 2.

Reasons for incomplete ACP.

Reasons for decline	No.
Patient passed away before appointment is fixed	3
Uncontactable	2
Patient sees no urgency to discuss ACP	2
Patient not ready due to current condition/care arrangement	1
Patient knows his own preference and has informed family.	1
Family knows patient’s preferences and does not see need for ACP	1
Total	10

Discussion

Shortage of manpower, lack of time available to recruit patients for ACP and interrupted information flow were some challenges that emerged during this QIP. ¹²

One key challenge in the courses of this QIP was the negative impact of COVID-19 Delta and Omicron waves on DEM manpower and floor space. Similar to overseas experiences, ¹³ COVID-19 overwhelmed hospital resources and consequently healthcare professionals were unable to meaningfully discuss ACP with patients and families. To boost thin staffing, additional nurses had to be deployed from other departments. Within the DEM-ACP team, our PNs also had to take on additional nursing duties on top of their usual PN roles. Physicians in the team were likewise forced to prioritise clinical management of unwell patients over ACP discussions during this time. In short, the pandemic removed any available bandwidth for impactful conversations around ACPs.

Another challenge was the lack of internal referrals from within the department. Most of the COPD patients referred to the DEM-ACP team for ACP advocacy were self-screened by the team members. The remaining internal referrals were made by the same few senior and junior doctors. This could be due to the lack of buy-in from majority of the senior doctors and the frequent changeover of junior doctors. This could also be compounded by workload pressures and lack of recognition that the ED setting was the correct place and time to initiate an ACP discussion. The team attempted to mitigate this by monthly reminders sent to the various stakeholders.

Conclusion

Advance care planning advocacy is both time and labour-intensive, making it a challenge in the busy ED. Synergy could be created by training nurses whose existing primary assignment encompasses patient advocacy e.g., ED asthma nurses (for COPD patients), ED geriatric nurses (for elderly patients) and ED PNs (for patients with chronic diseases).

Another consideration would be ACP advocacy training for junior doctors. During this QIP, it was observed that when the primary ED physician continued the ACP conversation after treatment, the patient was more receptive to an outpatient ACP referral. We theorise that this is likely due to the doctor-patient relationship that had already been established.

The DEM-ACP QIP team also plans to leverage on its experience gained and cast the net wider to include other patient populations such as geriatric patients and patients with congestive cardiac failure.