What Macstrak Can Do For You!

1. What Macstrak Can Do For You! Rhonda Allan RN, MN CCU

2. Objectives • Present clinical issue • Review current literature • Demonstrate how Macstrak data can be used

3. Clinical Issue • Referral and transplant centre that receives large number of patients with end stage HF and multi-system failure • Staff experiencing feelings of frustration and helplessness • Mostly anecdotal evidence • Lack of policies and guidelines to direct care for patients who may be nearing end of life

4. Tackling the Issue • Multi-disciplinary committee • Review of our end of life experiences • Literature review

5. Looking at our Data • Macstrak Activity Reports • Centre, Bed-size, National • Provides data on patients within unit • Diagnosis • LOS • Acuity • Mortality

6. CCU Patients by Diagnosis 30 CCU 25 National - CVS National 20 % 15 10 5 0 AMI UA R/O MI UA CHF

7. CCU Killip Class

8. CCU Patient Acuity

9. CCU LOS

10. CCU Mortality Rates

11. Literature Review • Majority of articles are on end of life care in palliative care settings and on the cancer population • Paucity of literature involving end of life care and the cardiac population • Most cardiac end of life care articles focus on HF population

12. Literature Review • Illness trajectory • Patient preferences • Care providers’ philosophies • System Issues

13. Illness Trajectory • Unpredictable terminal phase related to multiple exacerbations and recoveries Best Lung Cancer Function Heart Failure Death Worst Time Jaarsma et al., 2002; Cooney, G., 2005

14. Illness Trajectory • Prognostic uncertainty • Zone of ambiguity in treatment direction and plan • Prognostic paralysis Murray et al., 2005; Davidson et al., 2003

15. Illness Trajectory • Less access to specialized palliative care • Less access to community support • Less opportunity to die at home Davidson et al.,2003; Murray et al., 2005

16. Patient Preferences • Symptom management vs. survival • 19% had an unstable resuscitation preference • 24% of physicians did not correctly perceive their patients resuscitation preference Krumholtz et al (1998); Fried et al (2002)

17. Care Providers’ Philosophies • Personal perspectives on death • Comfort level with death and dying • Perceptions of palliative care • Medical futility vs. patient autonomy Davidson et al., 2003; Austin et al.,2005

18. System Issues • Multiple specialists lack an integrated whole person approach • Lack of continuity of care • Inadequate palliative care resources Austin et al.,2005; Murray et al., 2002

19. What Next? • Needed further exploration: • higher mortality rate • longer LOS

20. Macstrak Support • Connected with the Macstrak office • Specialized reports generated • End of Life • Long LOS

21. Mortality by Discharge Diagnosis (EOL)

22. Heart Failure Mortality • CIHI - Ontario • 30-day mortality after first admission for HF 11.6% • One year mortality 33.1% • UNOS - Status 1A 5-10% mortality per week • Mechanical circulatory support • Mechanical ventilation • High dose inotrope dependent patients - Status 1B 0.5-2% mortality per week • IV Inotropes not ICU dependent - at home or on ward

23. Acuity (EOL)

24. Length of Stay (EOL)

25. Mortality by Discharge Diagnosis (Long LOS)

26. Acuity (Long LOS)

27. Can we solve our problem? • Don’t have all the data yet • Decision made to do a research project

28. Research Project • How are end of life issues approached in the CCU? • What is the optimum time families should be approached for end of life discussions? • What are the indicators that predict which patients should be approached for end of life discussions?

29. Chart Review • Macstrak database was queried to identify all ventilated patients treated in one year • Retrospective chart review • Demographics, admission profile and acuity • Occurrence and outcomes of family meetings • DNR and withdrawal outcomes

30. Discussion – Approaches to EOL Care • Poor documentation of family meetings • Attendance of multidisciplinary team members lacked consistency • A greater proportion of family meetings were held for those patients that died • Outcomes of these meetings resulted in DNR and withdrawal orders

31. Discussion – Timeliness • Delays in family meetings resulted from poor prognostic abilities • Difficulty of topic resulted in avoidance and deference • Families needed time to make care decisions • Prolongation of pain and suffering

32. Discussion – Indicators • Ventilated • Admission diagnosis of cardiogenic shock and cardiac arrest • Past medical history of AMI, renal insufficiency • Grade IV LV, increased Apache III score or creatinine • Longer use of inotropes or IABP • Longer LOS

33. Discussion – Study Limitations • Actual number of family meetings unknown due to lack of documentation • Retrospective design • Small sample size • Single centre

34. Implications for Practice • Develop best practice guidelines for end of life care: • to improve documentation of family meetings • to increase nursing and attending cardiologist presence during family meetings • to reflect a more timely approach • to improve care for end of life patients • to provide relief of pain and symptoms

35. Current Status • Committee working on guidelines • Received Safer Healthcare Now EOL coaching team • Staff have increased awareness of issues

36. Conclusions • Macstrak data is useful in helping to investigate clinical issues • Macstrak Project Office can provide assistance and special reports

37. QUESTIONS?