“TIMEOUT” Before PEG Placement: A Policy Approach to Align Shared Decision-Making and Goals of Care Through Palliative Intervention (F425C)

Abstract

1.Describe the performance improvement approach used to design and implement a hospital policy requiring Palliative Care consultation prior to offering percutaneous feeding tube (PEG) placement at our institution.2.Discuss measured outcomes of this quality improvement initiative and how they link high value care to palliative care. Multiple professional societies promote shared decision-making (SDM) and recommend not offering percutaneous feeding tubes (PEGs) in advanced dementia. Many patients, families, caregivers, nursing homes and clinicians may not be aware of these recommendations. To ensure that risks, benefits, and alternatives to PEGs like careful hand feeding and hospice are discussed with surrogates, NewYork-Presbyterian Queens implemented a hospital policy requiring a Palliative Care consultation (PCC) prior to offering PEG placement. This “timeout” intends to improve SDM and PCC access to patients considered for PEGs. Using a Plan-Do-Study-Act approach, we retrospectively identified 2018 PEG insertions (endoscopic/radiologic): 4% had Goals of Care (GOC) documented by the primary team, 10% a PCC, and 42% had a dementia ICD code. With stakeholder buy-in we created and implemented a hospital policy requiring a PCC prior to offering PEGs. The Hospital Medical Board approved the policy June 2019. We measured policy compliance, primary PEG insertion trends pre-policy (July 2018-March 2019) versus post-policy (July 2019-March 2020), associated PCCs and dementia ICD codes, length of stay (LOS) of patients with PEG versus no PEG, and hospice utilization for no PEG. Post-policy implementation,186 patients were considered for primary PEG insertions. Of these, no PEG (103) and PEG (83). Policy adherence was 98% (183/186 had PCC). Primary PEG insertions reduced by 55% (pre-policy=132 vs post-policy=83). Primary PEGs for dementia patients was reduced by 48% (pre-policy=60 vs post-policy=31). Average LOS reduction in PEG (25 d) versus no PEG (16 d) was 9d. Hospice was utilized by 63% (65/103) for no PEG. A PCC "timeout” can help promote SDM by aligning GOC with medical decision-making. When an alternative clinical pathway to PEGs was offered, there was an associated reduction in both primary PEG insertions and average LOS. This policy demonstrated how institutional support promotes palliative care access and links it to high value care.