Stanford University collaborative quality improvement project leads to improvements in the timeliness of breathlessness assessment in community palliative care
A blog post written by Dr. Angela Rao
Breathlessness is a distressing and debilitating symptom that impairs functional capacity and reduces quality of life. The risk of mortality is increased by 80% in advanced cancer patients who are breathless when compared with those who are not. Timely assessment of breathlessness is essential to optimise pharmacological treatment, and address psychosocial issues and cognitive processes that drive breathlessness. However, chronic breathlessness is systematically under-recognised and undertreated in palliative care, and the impact of breathlessness on individual patients is poorly understood.
This collaborative quality improvement project between Calvary Health Care Kogarah, SPHERE Palliative Care Clinical Academic Group and Stanford University sought to improve the timeliness of breathlessness assessment for patients admitted to a home community palliative care service across the St George and Sutherland Shire, NSW, who were experiencing moderate to severe breathing related distress. The Palliative Care Outcomes Collaboration Symptom Assessment Scale was used to assess breathing-related distress.
The project involved a process of monthly 1-2 hour remote mentorship sessions via Zoom teleconferencing, didactic instruction and project based learning in quality improvement. A root cause analysis identified contributing factors that could be addressed during the 6 month time-frame of the project, which resulted in the identification of four key drivers of breathlessness assessment:
- Creating consistency of practice in scoring breathlessness
Using the symptom assessment scare to score distress rather than the severity of breathlessness.
- Cultivating a preventative mindset that is proactive, rather than reactive
Assessing breathlessness scores early rather than waiting for a crisis to emerge.
- Timely referral to allied health for full breathlessness assessment and management
Eliminating referral lag, where possible.
- Nursing and allied health staff to create a habitual practice of entering Symptom Assessment Scale scores at each assessment
Counter previous practice of entering only severe breathing-related distress scores that require immediate action.
Interventions to address these key drivers included a) educational sessions to facilitate nurses as case managers responsible for the re-assessment of breathing-related distress, b) staff access and training in palliative care data entry software, c) fortnightly monitoring and reporting of the proportion of patients who received a re-assessment; and d) An educational flowchart to support action to moderate to severe breathing-related distress.
The project created new processes and changes in clinical practice including streamlined identification and review of patients who are moderately or severely distressed due to their breathlessness, contemporaneous data entry and ongoing education and support for staff to accurately assess and monitor breathing-related distress.
Future research is required to understand if comprehensive multidisciplinary breathlessness assessment and management can improve the severity of symptoms in people with advanced disease. The ability of this quality improvement project to improve the timeliness of breathing-related distress assessment is an important first step. Community palliative care teams who assess breathing-related distress using a Symptom Assessment Scale may benefit from implementing a similar project without the need for additional local resources.
Dr. Angela Rao
Clinical Trials Co-ordinator
Calvary Health Care Kogarah
Early Career Researcher
Adjunct Industry Fellow, University of Technology Sydney