course material

1. Improving Access to Palliative Care in A Medical ICU
Improving Access to Palliative Care in A Medical ICUImproving Access to Palliative Care in A
Medical ICUSubstantive: Comments should be at least one full page in length single-spaced
addressing each item in the table. Constructive: Try to offer solutions, not just identify
problems. Specific: Include a specific example of what is being recommended. Sensitive:
Keep comments on a positive note and avoid the use of negative language. Balanced: Point
out strengths as well as weaknesses. • • • • Grading Rubric Percent Available • • • • • • • • • •
• Fishbone diagram is updated – Since the MAP-IT Project Charter builds closely on the
diagram, submission of the worksheet without an updated diagram will not be accepted for
grading, and a late penalty will be enforced until the student submits the entire assignment.
Background and significance of the problem is presented with external and internal
evidence with citations and references – no organizational identifiers are included (2
paragraphs) Each short-term goal is stated in SMART (S = Specific, M = Measurable, A =
Achievable, R = Relevant, T= Time based) terms and includes a direction of change for a
clearly articulated outcome to affect a specific problem Middle range or practice theory is
presented to support an understanding of the practice problem (1 paragraph)
Implementation process framework is identified with a general description of how the
framework applies to your implementation plan and supports your ability to reach your
structure, process, and outcome goals (1 paragraph) The list of team members is complete
and includes everyone who needs to be involved The structures and processes planned to
be improved are clearly prioritized and initial assessments are adequate The structure and
process measures proposed are clearly stated and based on validated or research-based
measures Setting, population inclusion and inclusion criteria are clear and ethical (include
vulnerable populations, not just populations easiest to impact) Strategies and tactics plan is
a) achievable, and tailored to meet the short-, mid- and long-term goals, and b)
comprehensive and evidencebased (includes more than education) Improving Access to
Palliative Care in A Medical ICUORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERSTimeline is specific, measurable, relevant, and achievable within the DNP Project
time constraints, and data collection and implementation are scheduled to occur after UMB
Human Research Protections Office (HRPO) and organizational IRB reviews N/A 5% 10%
5% 5% 5% 5% 10% 10% 15% 5% Percent Earned • • Format • • Data analysis plan is
specific, relevant, and achievable (no undue burden on the Clinical Site Representative and
other members of the team) and meets resource and time constraints QI Project plan for
sustainability is clear and realistic 10% 5% 10% Single spaced (no page limit) Writing is

2. clear, succinct, well organized with absence of errors in spelling, grammar and/or
punctuation Total 100% 1 MAP Portion of MAP-IT Project Charter Worksheet Section 1:
Project Overview 1.1 DNP Quality Improvement Project Name: Improving Access to
Palliative Care in a Medical Intensive Care Unit 1.2 Problem statement: Palliative care
addresses physiological, spiritual, and psychological suffering associated with lifethreating
illnesses. The World Health Organization (WHO) estimates that only 14% of people who
need palliative care actually receive it and the need for palliative care will only increase as
the population ages (2020). Without palliative care, symptoms such as pain and difficulty
breathing often go un-treated or undertreated. Intensive care units (ICUs) have some of the
greatest needs for palliative care services given their high rates of mortality and morbidity.
Fifty percent of patients who have an ICU length of stay (LOS) of at least three days
requiring any form of life-sustaining treatment will die and less than one-third will return to
their baseline in six months (Detsky et al., 2017). This emphasizes the need for supportive,
symptom management in adjunct to or instead of aggressive treatments based on shared
decision making between patient and provider. A systematic review of palliative care
associated outcomes concluded that palliative care increases quality of life and decreases
symptom burden (Kavalieratos et al., 2016). However, it is not the presence of palliative
care alone that makes the greatest impact, it is the early initiation of such services. In a
randomized control trial in a medical intensive care unit (MICU), patients who had
automatic palliative care consultations within 48 hours of admission had more transfers to
hospice care, fewer days spent on a ventilator, less tracheostomies performed, and fewer
readmissions than those who received usual care (Ma et al., 2019). The intervention group
was also found to have had decreased ICU and post-ICU healthcare resource utilization with
a decreased cost in their MICU stay (Ma et al., 2019). Palliative care is underutilized and not
prioritized in a large metropolitan university-system hospital MICU. On average, it takes 6.7
days for a patient to receive a palliative care consultation and as long as 49 days. There is
not a consistent method by which palliative care recommendations are made or how
patients in need of palliative care services are identified in this MICU which contributes to a
delay in care. Improving Access to Palliative Care in A Medical ICUOther barriers include
lack of palliative care education, misconceptions about palliative care, and frequent
physician turnover. Detsky, M. E., Harhay, M. O., Bayard, D. F., Delman, A. M., Buehler, A. E.,
Kent, S. A., Ciuffetelli, I. V., Cooney, E., Gabler, N. B., Ratcliffe, S. J., Mikkelsen, M. E., & Halpern,
S. D. (2017). Six-month morbidity and mortality among intensive care unit patients
receiving lifesustaining therapy: A prospective cohort study. Annals of the American
Thoracic Society, 14(10), 1562–1570. https://doi-org.proxy-
hs.researchport.umd.edu/10.1513/AnnalsATS.201611-875OC Kavalieratos, D., Corbelli, J.,
Zhang, D., Dionne-Odom, J. N., Ernecoff, N. C., Hanmer, J., Hoydich, Z. P., Ikejiani, D. Z., Klein-
Fedyshin, M., Zimmermann, C., Morton, S. C., Arnold, R. M., Heller, L., & Schenker, Y. (2016).
Association between palliative care and patient and caregiver outcomes: a systematic
review and meta-analysis. JAMA, 316(20), 2104–2114.
https://doi.org/10.1001/jama.2016.16840 Ma, J., Chi, S., Buettner, B., Pollard, K., Muir, M.,
Kolekar, C., Al-Hammadi, N., Chen, L., Kollef, M., & Dans, M. (2019). Early palliative care
consultation in the medical ICU: A cluster randomized crossover trial. Critical Care

3. Medicine, 47(12), 1707–1715. https://doi-
org.proxyhs.researchport.umd.edu/10.1097/CCM.0000000000004016 2/25/21 2 The
World Health Organization (2020, August 5). Fact sheets: Palliative care.
https://www.who.int/newsroom/fact-sheets/detail/palliative-care 1.3 Purpose statement:
The purpose of this quality improvement project is to implement and evaluate the
effectiveness of a palliative care screening tool in a medical intensive care unit (MICU). 1.4
Project Goals: 1.4a. Short-term goals: By September 30, 2021, the implementation team will
educate 100% of the unit nurses on how to utilize the Palliative Care Screening Tool. By
December 10, 2021, 100% of patients admitted to the MICU will receive screening for
palliative care needs by a unit nurse. By December 10, 2021, 100% of patients who screen
positive on the Palliative Care Screening Tool will have a palliative care consultation as
documented by a palliative care note. 1.4b. Mid-term goal: By March 1, 2022, 100% of
patients with identified palliative care needs in the MICU will have a palliative care
consultation within 48 hours of admission as evaluated by the Palliative Care in the ICU
Committee. 1.4c. Long-term goal: By January 1, 2023, 100% of patients in the MICU being
treated by the palliative care team will have, on average, a decreased hospital lengths of stay
(LOS) by at least one day as evaluated by the hospital quality improvement staff. 1.5
Population/Setting Affected by Practice Change: This quality improvement project will take
place in a 19-bed medical intensive care unit (MICU) in a large, urban, academic medical
center. Per 12-hour shift, there are about 11 staff nurses who are available to complete a
palliative care screening tool (PCST) as well as one charge nurse and one resource nurse to
aid and remind nurses to complete it when admitting a patient. On average, 20 critically ill
patients are admitted to the unit each week. Special consideration will be given to the most
vulnerable patients who are admitted who may require more time to screen. These patients
include non-English speaking patients, patients with an artificial airway, and nonverbal
patients. 1.6 Middle Range/Practice Theory and Implementation Process Framework The
middle range theory used to guide this quality improvement project is Kolcaba’s Comfort
Theory. Katharine Kolcaba developed the Comfort Theory which states that unmet comfort
needs in stressful health care scenarios are met by nurses (2001). A screening tool for
unmet palliative care needs will allow nurses to quickly identify which patients are at the
highest risk for discomfort. Improving Access to Palliative Care in A Medical ICUHaving
early access to palliative care will relieve physical symptoms such as dyspnea and pain but
will also address spiritual and emotional distress. At its core, palliative care is a holistic
practice that aligns with Kolcaba’s four contexts of comfort: physical, psychospiritual,
environmental, and sociocultural. The Framework for Complex Innovations has several key
constructs that will ensure the success of this quality improvement project. The first are the
implementation climate and management support (Helfrich et al., 2007). Many of the unit
nurses have expressed the need for more palliative care resources and management is
encouraging the use of a PCST to achieve this. The next construct is 2/25/21 3 the
innovation champion (Helfrich et al., 2007). Two nurses who are passionate about palliative
care have stepped forward to serve as champions and will help to educate their peers on
how to use the PCST and remind nurses to complete the screening when they receive a new
admission. Additionally, the innovation fits with users’ values which will foster proactive

4. palliative care consultation because the organization and its providers believe that patient
comfort is a priority. Finally, financial resource availability will not inhibit implementation
because there are very little resources, other than staff time, to implement a PCST. In fact,
palliative care consultation within 3 days of a hospital admission has shown to save an
average of $3,237 per patient when compared with patients who did not receive palliative
care (May et al., 2018). Helfrich, C.D., Weiner, B.J., McKinney, M.M. & Minasian. L. (2007).
Determinants of implementation effectiveness adapting a framework for complex
innovations. Medical Care Research and Review, 64(3), 279-303 doi:
10.1177/1077558707299887 Kolcaba, K. (2001). Evolution of the mid range theory of
comfort for outcomes research. Nursing Outlook, 49(2), 86–92. https://doi-org.proxy-
hs.researchport.umd.edu/10.1067/mno.2001.110268 May, P., Normand, C., Cassel, J. B., Del
Fabbro, E., Fine, R. L., Menz, R., Morrison, C. A., Penrod, J. D., Robinson, C., & Morrison, R. S.
(2018).Improving Access to Palliative Care in A Medical ICUEconomics of Palliative Care for
Hospitalized Adults With Serious Illness: A Meta-analysis. JAMA Internal Medicine, 178(6),
820–829. https://doiorg.proxy-
hs.researchport.umd.edu/10.1001/jamainternmed.2018.0750 Section 2: MOBILIZE 2.1
Team Members: Table 1: Implementation Team Members’ Role, Contact Information & Buy-
In Category Project Faculty Advisor Clinical Site Representative Administrative Sponsor
Other Name, Credentials, Job Title/Role Dr. Gina Rowe, PhD, DNP, MPH, FNP-BC, PHCNSBC,
CNE Contact Information (Phone, Email) How You Got Buy-In How You Plan to Maintain
Buy-In growe@umaryland.edu Blackboard meetings throughout the semester and
continuing through all DNP courses. Abigail Butts, MS, RN, CCNS, CCRN Unit Manager
adb9@gunet.georgetown.edu Cindy Minetree DNP, RN, NE-BC Critical Care and
Neuroscience Clinical Nursing Director Cynthia.l.minetree@gunet.ge orgetown.edu
Presented initial Fishbone diagram and evidence table to demonstrate significance of the
problem and EBP to address the problem. Met with CSR to discuss practice problems on the
unit. Identified need for more palliative care resources as a problem. Met with sponsor to
present practice problem and they agreed it would be an important issue to tackle. Beth
Orrell ANPBC, ACHPN beth.a.orrell@gunet.georgeto wn.edu Presented QI idea at Palliative
Care in the ICU Committee meeting. michelle.n.milic@gunet.georg etown.edu Presented QI
idea at Palliative Care in the ICU Committee meeting. 301-738-6375 (703) 568-3463 202-
444-1152 Palliative Care Nurse Practitioner Michelle Milic, MD Critical Care and Palliative
Medicine Physician Improving Access to Palliative Care in A Medical ICU