Improving access to inpatient palliative care in end stage liver disease through spict screening and multi-disciplinary review: a quality improvement project

Introduction

The prevalence and mortality of end-stage liver disease (ESLD) are increasing in the UK. Disease trajectory is unpredictable, making accurate prediction of prognosis challenging and there has been historic reluctance to refer patients for palliative care input while under medical management. However, early palliative care input alongside active management (parallel planning) is known to increase patients’ quality of life. The Supportive and Palliative Care Indicator Tool (SPICT) has proven utility in the identification of patients with ESLD who would benefit from palliative care input.

Aim

To compare access to and quality of palliative care in inpatients with ESLD before and after the implementation of systematic SPICT screening and MDT approach.

Methods

Palliative care quality indicators were identified from published literature. An initial audit in patients with ESLD was conducted between 01/08/2019 – 30/12/2020 with retrospective data collection from electronic notes. From 19/4/21 systematic screening of all hepatology inpatients using the SPICT was introduced. Patients screening SPICT positive were referred for discussion to a new Enhanced Supportive Care (ESC) cirrhosis multi-disciplinary meeting composed of members of the hepatology and palliative care teams. Audit against quality indicators was repeated following this intervention and data collected between 19/04/2021 – 19/07/2021

Results

67 patients were included in the initial audit and 34 in the post intervention audit. Systematic SPICT screening and ESC cirrhosis MDT review increased palliative care input among patients with ESLD. The intervention resulted in 65% of at-risk patients receiving palliative care input during admission compared to 34% in the 1st cycle. Frequency of community palliative care referrals on discharge also increased from 13% to 32%. Mean time to palliative care input fell from 14 days to 6 days. Of patients who died during admission 75% had formal advanced care planning compared to 48% prior to the intervention. Ward based ceiling of care decisions fell from 39% in the original audit period to 21% in the follow up.

Discussion

This quality improvement project supports the use of the SPICT for screening of hepatology inpatients to identify and improve access to palliative care among patients with ESLD who would benefit from this intervention.