Implementing best practice in palliative care

描述(由申请人提供)：姑息治疗和临终关怀专注于减轻痛苦和实现最佳生活质量，包括改善症状、缓解心理痛苦和促进患者及其照顾者的精神福祉。 在美国，姑息治疗计划和服务的增长与人们越来越多地认识到，需要一种理性的、专门的方法来护理患有严重限制生命的慢性病的人相平行。姑息治疗是一个相对较新的分支学科，正在建立支持临床实践的证据基础。一个由国家护理研究所资助的新的国家研究网络--姑息治疗研究合作小组(PCRC)，是包括比较有效性研究在内的证据开发的有效机制。根本的下一步是将新的证据和新兴的临床护理指南有效地实施到实践中。质量监测和业绩改进举措是加强证据执行的重要途径。在过去的5年里，在北卡罗来纳州开发并试行了名为QDACT-PC的地区性护理点质量监控计划；它已被证明很受临床医生的欢迎，可用、可行，并能够生成可靠的信息，用于对姑息治疗质量指标的符合性进行基准测试，推动持续质量改进(CQI)活动，并加强最佳实践。QDACT-PC中发现的与质量指标符合率较低的一个例子与便秘管理有关；数据显示，只有不到50%的患者正在接受目前管理便秘的最佳实践干预，并且症状持续在中到重度水平，直到死亡。我们建议将QDACT-PC引入PCRC的参与研究和临床护理足迹，以创建一个全国性的临床点姑息护理质量监测网络，并展示其实施CQI项目和加强当代临床最佳实践标准的能力。该项目的具体目标包括：(1)开发并在全国实施PCRC专用版本的QDACT-PC(命名为QDACT-PCRC)。QDACT-PCRC计划的升级包括增加关于照顾者、临床地点特征、基于医院的姑息治疗以及与目标2和3相关的问题的新的数据元素和问题模块。(2)通过在便秘管理中进行全网CQI项目，展示QDACT-PCRC在CQI中的使用。QDACT-PCRC将用于对所有站点的当前合规性进行基准测试。PCRC临床提供者将制定一项绩效改进计划，以解决症状及其管理。我们将使用QDACT-PCRC来监控该计划的影响，对绩效改进计划实施迭代增强，以实现90%符合率的目标。(3)测试使用QDACT-PCRC作为一种机制来提供临床决策支持，以加强商定的最佳临床实践。姑息医学最近提出了五项临床活动，不应作为ABIM选择明智活动的一部分进行(例如，生命末期的聚乙二醇管)。我们将使用QDACT-PCRC来衡量在PCRC站点进行的这些活动的当前比率，提供护理点实时教育和临床决策支持模块，以加强最佳实践并监测影响，并根据影响根据需要进行系统更新的迭代周期。该项目的预期成果是建立一个全国姑息治疗的实时护理点质量监测系统，并展示了支持CQI和实施最佳证据的能力。一个必然的结果是质量监测和临床实施信息的汇总数据集，形成了PCRC注册表--旨在成为支持质量监测、研究和学习卫生保健的国家资源。

DESCRIPTION (provided by applicant): Palliative care and hospice focus on the relief of suffering and achieving the best possible quality of life, including ameliorating symptoms, relieving psychological distress, and promoting spiritual well-being for patients their caregivers. The growth of palliative care programs and services in the United States has paralleled the increased realization of the need for a rational, specialized approach to the care for people with advanced life-limiting chronic illness. A relatively new subspecialty, palliative care is building ts evidence base supporting clinical practice. A new National Institute of Nursing Research funded national research network, the Palliative Care Research Cooperative Group (PCRC), is an efficient mechanism for evidence development including comparative effectiveness research. The fundamental next step is efficient implementation of new evidence and emerging clinical care guidelines into practice. Quality monitoring and performance improvement initiatives are an important approach to reinforce evidence implementation. Over the past 5 years, a regional point-of-care quality monitoring program called QDACT-PC has been developed and piloted in North Carolina; it has been demonstrated to be well-liked by clinicians, usable, feasible, and able to generate reliable information that can be used to benchmark conformance with palliative care quality metrics, drive continuous quality improvement (CQI) activities, and reinforce best practice. One example of low conformance with quality metrics identified in QDACT-PC was related to constipation management; data demonstrate that less than 50% of patients are receiving current best practice interventions to manage constipation and that the symptom is persisting at moderate to severe levels until death. We propose to introduce QDACT-PC within engaged research and clinical care footprint of the PCRC to create a national network for point-of-care palliative care quality monitoring, and demonstrate its capabilities for conducting CQI projects and reinforcing contemporary standards for clinical best practice. Specific aims of the project include: (1) To develop and nationally implement a PCRC specific version of QDACT-PC (named QDACT-PCRC). Upgrades planned for QDACT-PCRC include the addition of new data elements and question modules about caregivers, clinical sites characteristics, hospital-based palliative care, and questions relevant to Aims 2 and 3. (2) To demonstrate the use of QDACT-PCRC for CQI by conducting a network-wide CQI project in constipation management. QDACT-PCRC will be used to benchmark current conformance across all sites. PCRC clinical providers will develop a performance improvement program to address the symptom and its management. We will use QDACT-PCRC to monitor impact of the initiative, implementing iterative enhancements to the performance improvement program in order to achieve a goal of >90% conformance. (3) To test the use QDACT-PCRC as a mechanism for delivering clinical decision support that reinforces agreed best clinical practice. Palliative Medicine has recently proposed five clinical activities that should not be conducted as a part of ABIM's Choosing Wisely campaign (e.g. PEG tubes at end of life). We will use QDACT-PCRC to measure current rates of these activities being conducted at PCRC sites, to deliver a point- of-care real time education and clinical decision support module to reinforce best practice and to monitor impact, with iterative cycles of system updates as needed based upon impact. The expected outcome of this project is a national system of real-time point-of-care quality monitoring for palliative care, wit demonstrated capabilities to support CQI and implementation of best evidence. A corollary outcome is an aggregating dataset of quality monitoring and clinical implementation information, forming the PCRC Registry - intended to be a national resource to support quality monitoring, research and learning health care.