Support Team Assessment Schedule Research Articles

Screening for Discomfort as the Fifth Vital Sign Using an Electronic Medical Recording System: A Feasibility Study

Late referral to a specialized palliative care service hinders quality symptomatic management. The aim of this article is to describe the feasibility and clinical usefulness of screening for patient discomfort as the fifth vital sign using an electronic medical recording system to identify patients with undertreated physical symptoms. For the electronic medical recording system, all admitted patients received routine nurse assessment of discomfort (defined as any physical symptom) at every vital signs check using Item 2 of the Support Team Assessment Schedule Japanese version (STAS). All medically treated cancer patients admitted to seven oncology units were automatically screened at one-week intervals. Positive screening was defined as a STAS score of 2 or more at least two times during the previous week. For each patient identified by screening, a palliative care team reviewed the medical record and provided written recommendations when other treatments might improve the patient's physical symptoms. Of 629 patients screened, 87 (14%) initially met the positive screening criteria. Fifteen (17%) were false positive due to psychiatric symptoms without physical symptoms or due to misrecording. Of 72 cases with actual discomfort, 33 had already been referred to the palliative care team, 14 had received adequate palliative care as determined by the palliative care team, 14 had self-limiting transient discomfort, and one patient died before the screening day. In the remaining 10 cases (11% of symptomatic patients, 1.7% of all screened patients), the palliative care team recommended potentially useful interventions for symptom control; seven patients were referred to the palliative care team within one week. The time required for all screening processes was about 30 minutes per week. This experience demonstrates that screening for patient discomfort as the fifth vital sign using an electronic medical recording system can be successfully implemented and may be useful in facilitating early referral of distressing patients to the specialized palliative care service.

Is a STAS-based tool valid to triage patients at a specialist palliative care inpatient unit?

Many tools exist to assess the symptoms and needs of palliative care patients, but no tool has been validated to prioritise patients referred for specialist inpatient palliative care. The aim of this study was to produce and validate such a tool. A prospective pilot study produced a Support Team Assessment Schedule- (STAS-) based tool--the Admission Assessment Tool (AAT)--and compared this with the existing system of triage at the Marie Curie Hospice, Edinburgh. Validity of the tool was not confirmed and the tool was modified and re-evaluated. One hundred and twenty-seven consecutive patients referred to the hospice received three AAT scores: from the bed manager; the admitting doctor; and the admitting nurse. The hospice's multidisciplinary team assessed the urgency of each patient's admission. The overall correct classification rate was approximately two thirds, but false positive rates were high and there was poor inter-rate correlation. It is concluded the AAT has not been validated.

Preliminary Statistical Assessment of Intervention by a Palliative Care Team Working in a Japanese General Inpatient Unit

The effectiveness of intervention by the palliative care team at the University of Tokyo Hospital was assessed using the Support Team Assessment Schedule. During the study, 316 consecutive patients with malignant tumor disease were referred to the palliative care team, which assessed 11 physical symptoms. Results were tested by paired t test to calculate 95% confidence intervals comparing the mean Support Team Assessment Schedule scores for each symptom from the first time to the last time after palliative care intervention. The study concluded that (1) intervention by a palliative care team in general inpatient units can effectively control pain, nausea, and vomiting in patients up until the terminal stage; (2) it is likely that cough is controllable in the terminal stage with intervention by a palliative care team; (3) mouth dryness, anorexia, constipation, diarrhea, fatigue, and ascites are difficult to alleviate in the long term even with palliative intervention.

Reliability and validity of the Japanese version of the Support Team Assessment Schedule (STAS-J)

The aim of this project was to develop an appropriate and valid instrument for assessment by medical professionals in Japanese palliative care settings. We developed a Japanese version of the Support Team Assessment Schedule (STAS-J), using a back translation method, and tested its reliability and validity. In the reliability study, 16 nurses and a physician who work in a palliative care unit evaluated 10 hypothetical cases twice at 3-month intervals. For the validity study, external researchers interviewed 50 patients with matignancy and their families and compared the results with ratings by the nurses in the palliative care unit. Our results with hypothetical cases were: interrater reliability weighted kappa = 0.53-0.77 and intrarater reliability weighted kappa = 0.64-0.85. In the validity study comparing nurse evaluations and the results of interviews with patients and families, complete agreement was 36-70%, and close agreement (+/-1) was 74-100%. As a whole, weighted kappa were low: between -0.07 and 0.51. Our results were similar to those in the United Kingdom and Canada. Although this research was conducted under methodologically limited conditions, we concluded that the STAS-J is a reliable tool and its validity is acceptable. The STAS-J should become a valuable tool, not only for daily clinical use, but also for research.

Evaluative research on palliative support teams: a literature review

Sixteen studies on the effectiveness of palliative support teams were analyzed. It was established that in most cases uncontrolled designs with repeated measurements were used. The assessment methods varied strongly. However, the Support Team Assessment Schedule was the most frequently used instrument. Effects reported on patients’ physical symptoms, such as pain, were for the most part positive. Fewer effects were reported regarding psychosocial and spiritual problems of patients and relatives. For instance, various studies indicated that feelings of anxiety did not diminish after referral to a palliative support team. Results about the effects on use and costs of health care services did not point in a clear direction. Accordingly it is unclear whether palliative support teams reduce or increase care consumption and costs. Given the sometimes contradictory findings and the small number of studies conducted, future high-quality research into the effectiveness of palliative support teams is needed.

Institutional Accountability in End-of-Life Care: Organizational Leadership, Measurement, and Consumer Demand

225 IN THE UNITED STATES , recent efforts in the national movement to improve end-of-life care have primarily been driven by individual palliative care experts and their professional specialty societies. These efforts include, for example, a recent statement of principles adopted by a large number of specialty societies,1 identification of clinical competencies that all physicians2,3 and nurses4 should be able to demonstrate, calls for reform in medical education5 and in medical textbooks,6 and revision of licensing and professional certification. These first steps have been essential, foundational ones. However, efforts targeted exclusively to the skills of individual clinicians cannot do the job alone.7 The next wave of reform efforts must focus on institutional accountability and will need to rely upon organizational leadership and, hopefully, consumer pressure. In the process, measurement will play a key role. In its landmark report, Approaching Death, the Institute of Medicine acknowledged the need for institutional accountability when it recommended that healthcare institutions apply methods of continuous quality improvement to the care of the dying.2 Various other groups have also called on health-care institutions to hold themselves accountable for the quality of end-of-life care they provide patients and families.8–12 In all these instances, measuring outcomes of care is seen as central to institutional accountability. Outcome measurement is also centrally related to consumers and in at least two distinct ways. First, quality data is most effective when it is shared publicly, so that consumers and purchasers of health care can choose rationally on the basis of quality. Second, outcome measures ought to be designed on the basis of patient and family needs, as they understand them. In this issue of the Innovations section of this journal, we spotlight two outcome measurement tools developed by Irene Higginson at St. Christopher’s Hospice in London.13 Both the Support Team Assessment Schedule (STAS) and her more recent Palliative Care Outcome Scale (POS) are “audit” tools—data collection instruments that allow palliative care services to audit how well they are performing on a range of issues considered crucial to optimal end-of-life care. Both tools have been designed principally for use with endstage cancer patients and their families.14,15 The STAS has been used by 120 palliative care researchers in a variety of different health care settings, ranging from hospitals to home-based hospices, residential hospices, day care settings, and nursing homes. Seventy-five percent of these applications have occurred in the United Kingdom, but 25% are ongoing in a wide range of countries, including Canada, Australia, Poland, Spain, Singapore, Belgium, France, Ireland, Sweden, Holland, and the United States. Following the interview with Dr. Higginson, we present comments from Dr. Franco Toscani, who describes his experience using the STAS on his palliative care service in Cremona, Italy.16 Dr. Toscani’s remarks are particularly pertinent in that the Italian government has just earmarked 450 billion lira, or roughly $238 million dollars, to the establishment of hospices. More funds are expected next year for the establish-

Measuring Quality of Care in Palliative Care Services

Professor Irene J. Higginson, B.Med.Sci., B.M.B.S., F.F.P.H.M., Ph.D., is a palliative medicine physician who has been researching audit and outcome measures in palliative care for more than 15 years. For the past 3 years she has been based at King’s College School of Medicine and Dentistry and St. Christopher’s Hospice in London, England. In this interview with Innovations associate editor Anna L. Romer, she discusses the purpose of audit and the evolution of two quality of care measures she has designed: the Support Team Assessment Schedule (STAS) and more recently the Palliative Care Outcome Scale (POS). The STAS includes nine core items: Pain Control, Other Symptom Control, Patient Anxiety, Family Anxiety, Patient Insight, Family Insight, Communication between Patient and Family, Communication between Professionals, and Communication Professional to Patient and Family. Staff members grade each of these domains using a forced-choice severity scale of zero to four. The instrument lists the item, for example, “Pain Control” and a few words to cue the person using the form (i.e., “Effect of his/her pain on the patient”). The POS is a new tool that represents an evolution in practice. A key difference between the two tools is that the POS has two parallel instruments—one for a staff member to complete and the other for the patient to complete. In terms of content, the POS includes many of the same domains, but frames the questions with more specificity. The POS staff questionnaire has 10 items and each includes a specific question with a clear time period (the past 3 days). This tool unpacks broad terms such as “communication” into particular questions, for example, about how much information is given, or whether patients have been able to share feelings. The final two items in the POS inquire about how much time has been wasted on appointments and on whether practical matters resulting from the illness have been addressed. In addition to the forced-choice items, there is an open-ended question asking staff or the patient to list the main problems over the past 3 days. Staff also complete a performance status question. In the following interview, Dr. Higginson describes the evolution of the two measures and reflects on the interface between quality of care (i.e., a measure of the care palliative care teams provide based on their own assessments of patient needs and experience) and quality of life (a term grounded in patients’ subjective experience). Dr. Higginson details her hopes for the POS, a tool that attempts to address this gap between health care professionals’ perspectives and patients’ perspectives. This interview is excerpted from a thematic issue, “Measuring Quality in Palliative Care,” Volume 2, Number 1, 2000 of the online journal Innovations in End-of-Life Care at http://www.edc.org/lastacts/.

Using the STAS in a Palliative Care Unit in Cremona, Italy

Recently, the Italian government earmarked 450 billion lira, approximately 238 million dollars, to the development of hospices, and more funding next year is expected for the establishment of palliative care services in hospitals throughout the country. Here Dr. Franco Toscani speaks about the importance of audit for the future of palliative care in Italy and describes his use of Irene Higginson’s Support Team Assessment Schedule, commonly known as the STAS, in both research and as an audit tool at the Palliative Care Unit he directs in Cremona, Italy. This interview is excerpted from a thematic issue, “Measuring Quality in Palliative Care,” Volume 2, Number 1, 2000 of the online journal Innovations in End-ofLife Care at http://www.edc.org/lastacts/.

Measuring patient outcomes in palliative care: a reliability and validity study of the Support Team Assessment Schedule.

This study reports the process and results of a psychometric evaluation of a clinical audit tool, the Support Team Assessment Schedule (STAS), used to measure outcomes of palliative care. The STAS was developed in London, UK to audit community palliative care services provided by a support team. The purpose of this study was to evaluate the reliability and validity of the STAS when introduced in a different setting and with different populations from those for which it had been designed. Evaluation of the STAS was completed using multidisciplinary team members, patients and families from a palliative care unit and an oncology unit of a large urban Canadian teaching hospital. The results from the reliability tests revealed a lack of consistency in the use of the tool by team members with simulated patients in clinical scenarios. The validity analysis highlighted the differences between patients, families and health care professionals' perceptions of the same clinical situation. This study provided a valuable perspective on using a previously developed clinical audit tool in different patient populations and clinical settings. Recommendations for future use of the tool are offered.

Is the Presence of Dyspnea a Risk Factor for Morbidity in Cancer Patients?

Data collected from six home palliative care teams in Ireland were analyzed to determine the prevalence of dyspnea in the population studied and to identify factors associated with the presence of dyspnea that might impact on future care. The prevalence of mild, moderate, or severe dyspnea, as measured by the Support Team Assessment Schedule (STAS), fell from 39% at referral in 327 evaluable patients to 23%. The presence of dyspnea at referral was positively correlated with severity of patient spiritual distress (Spearman ρ = 0.110, P = 0.042) and weakness (Spearman ρ = 0.105, P = 0.008) at referral. In analysis of contingency tables, dyspnea was also significantly associated with low patient (χ 2 9.5, P = 0.002) and family (χ 2 50.78, P < 0.001) well-being, high staff anxiety (χ 2 4.14, P = 0.04), male sex (χ 2 8.9, P = 0.003), a diagnosis of lung cancer (χ 2 59.88, P < 0.001), and dying in hospital rather than hospice or nursing home (χ 2 18.03, P = 0.001). In adjusting for covariates using a logistic regression analysis, however, only the presence of low family well-being, a diagnosis of lung cancer, and increased likelihood of a hospital death remained significantly associated with the presence of dyspnea at referral. These data suggest that the presence of dyspnea may be associated with increased family distress, which may influence place of death.

Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group.

OBJECTIVES: To develop an outcome measure for patients with advanced cancer and their families which would cover more than either physical symptoms or quality of life related questions. To validate...

Prospective study of symptom control in 133 cases of palliative care inpatients in Shatin Hospital.

We report a prospective study assessing the prevalence and severity of physical and nonphysical symptoms, and the benefits from treatment and intervention, in advanced cancer patients presenting to a local palliative care unit in Hong Kong. Patients were assessed by a modified version of the support team assessment schedule (STAS). The study highlighted some symptoms which needed better control, and also reinforced the team morale by demonstrating aspects where there was definite improvement. In general, the STAS was found to be practicable and acceptable by our patients and staff. The most important benefit gained from the study was the successful dissemination of the concept of audit and quality assurance throughout the unit, which is essential for continuous improvement in the future.

Home palliative care for terminal cancer patients: a survey on the final week of life.

As part of a large multicentre study on palliative care units in Italy, carried out between 1 January and 30 June 1995, we describe the place, circumstances and 'quality of death' of patients admitted to home palliative care. Data presented refer to 401 patients (67% of the 601 patients randomly selected for evaluation). Of these 401 patients 303 (76%) died at home. According to the Support Team Assessment Schedule (STAS) pain was fairly well controlled during the final week of life, while the control of other symptoms appeared to be less satisfactory. Invasive procedures were undertaken on 56% of patients, while in hospital the percentage increased to 75%. Twenty-five per cent of patients were totally pharmacologically sedated during the final 12 h of life. Neither the number of symptoms nor other factors were apparently associated with the decision to sedate the patient. The wide variations in the frequency of sedation among centres suggest that the choice to sedate the patient may reflect the provider's behaviour or services' policy rather than the patients' preference or needs. The definition of common criteria and guidelines for sedation of patients should be one of the topics for discussion among palliative care teams.

Do hospital palliative care teams improve symptom control? Use of a modified STAS as an evaluation tool.

The support team assessment schedule (STAS) has previously been validated as an evaluation tool for community palliative care teams and inpatient units. This study reports on use of an expanded STAS (E-STAS) to determine symptom prevalence and outcome for inpatients and outpatients referred to a multiprofessional hospital palliative care team. E-STAS forms were completed on patients at referral and twice weekly thereafter. Between August 1996 and May 1997, 352 patients had one or more E-STAS forms completed; 122 of this group had three or more assessments. One-hundred-and-eighty-two patients were male and 170 were female, the median age was 68.5 years (range 26-101 years) and all but 27 (8%) had malignant disease. Of the symptoms assessed on referral, the most common were psychological distress 93%, anorexia 73%, pain 59%, mouth discomfort 59%, depression 40%, constipation 36%, breathlessness 32%, nausea 24% and vomiting 13%. In the 122 patients where three or more assessment were completed, statistically significant improvements from first to last assessment were seen in all symptoms except depression. This study suggests that E-STAS may be a useful tool to evaluate interventions by a hospital palliative care team in patients with advanced disease.

Family anxiety in advanced cancer: a multicentre prospective study in Ireland.

Six home care services in Southern Ireland collected data on a total of 757 patients over a 6-month period. Patient and family well-being were measured using the staff-rated Support Team Assessment Schedule and Karnofsky Index. Five hundred and eight patients died while in care, 75% of whom died at home. At referral, 32% of families were rated as having severe or overwhelming anxiety. During the last week of care, anxiety remained severe for 26% of family members. Patient and family well-being were inter-related, and there were significant interactions between family anxiety and patient physical and psychological symptoms, and communication. Discriminant analysis produced two predictive models. In model 1, family anxiety at referral strongly predicts family anxiety in the last week of life. In model 2, family anxiety at referral is excluded from the analysis, and the significant predictor factors at referral for family anxiety in the last 4 weeks of life are patient symptom control, sex of patient, diagnosis and patient age.

A comparison of two measures of quality of life: their sensitivity and validity for patients with advanced cancer

We compared two measures that have been used by professionals to assess the quality of life and care of patients with advanced cancer. The Support Team Assessment Schedule (STAS) is an instrument for palliative cancer support teams to record and evaluate their care; the Hebrew Rehabilitation Centre for the Aged Quality of Life (HRCA-QL) index was used in the National Hospice Study (USA) to assess patients with advanced cancer. STAS has 17 items, each scaled 0 (best) to 4 (worst), and HRCA-QL has five items scaled 0 (worst) to 2 (best). The STAS and the HRCA-QL were assessed contemporaneously by the members of one support team on 128 consecutive patients referred over 17 months. Seventy-four patients spent more than four weeks in care. Ratings for four out of five HRCA-QL items deteriorated significantly in the four to six weeks before death. HRCA-QL index items correlated with similar STAS items. Correlations were highest at referral, especially in patients seen more than four weeks before death (e.g. symptom control (STAS) with health (HRCA-QL) Spearman's rho = -0.64) and the HRCA-QL total was correlated with STAS subtotal of six items (rho = -0.45). There were few correlations at death. The findings support the validity of both measures for the aspects compared, but indicated that STAS was more sensitive to changes in patients in the last six weeks of life.

Validity of the support team assessment schedule: do staffs' ratings reflect those made by patients or their families?

This study aimed to assess the validity of the Support Team Assessment Schedule (STAS), a measure of the outcome of palliative care, through comparisons with the views of patients and family members. STAS ratings completed by two support teams were compared with (1) patients' ratings and (2) family member/carer ratings of seven (of the total 17 STAS) items, collected by independent interviewers. Of 183 patients referred to the teams, 84 (46%) were interviewed and 99 (54%) could not be contacted. Sixty-seven patients had family members or carers, all of whom were interviewed. Tests for agreement between team and patient were high for four items, and showed moderate correlations (Spearman's rho ranged 0.45-0.66) for five items, excepting two items including family needs. The summed scores for seven items were correlated, rho = 0.66, p < 0.0001. Where differences were found, team members identified more problems than patients' self-ratings, except for one item, 'pain control', where team members identified fewer problems. Team ratings were usually closer to those of the patients than to those of the family member; a team rating often lay between the patient's and family member's rating. The STAS is a measure of professional assessment which is independent from, although based on, the patient and family. The results support the validity of STAS as a measure of the outcome of palliative care from the perspective of a palliative care team.

Palliative care for people with HIV/AIDS: Views of patients, carers and providers

This study compared the views of palliative care reported by patients, informal carers and the Community Care Team (CCT), a multidisciplinary team caring for people with late stage HIV/AIDS illness. Patients and their carers were interviewed at home, 3-4 weeks after referral to CCT. They rated nine items of the Support Team Assessment Schedule (STAS), a standardized measure of palliative care. Items included current problems such as pain and symptom control, anxiety and service needs. Satisfaction with health services was also recorded. CCT separately recorded the severity of 17 STAS items as part of a continuing audit of care. Relatively few patients (19) and carers (8) were interviewed. Main reasons for non-interview of (105) patients were: 57 too ill and 30 less than 4 weeks in care. CCT's audit showed that non-interviewed patients had significantly more severe problems for five out of 17 STAS items. Patients and CCT identified continuing problems with symptom control, pain control, patient and family anxiety, and communication from professionals. Agreement between patient, carer and CCT ratings was reasonable. Patients and CCT ratings were significantly correlated (Spearman rho = 0.66, p < 0.005). However, patients rated pain as significantly more severe than did CCT (p < 0.05, Wilcoxon Z = -2.45). All patients and seven carers rated the care given by CCT as good or excellent. There were negative comments about communication with other professionals. Studies of palliative care which rely on data gained by patient interview may be biased to include patients with fewer problems. To overcome this providers may wish to audit their care. This study indicates that the views of palliative teams are a reasonable reflection of patients' and carers' experiences, and that the STAS is a valid tool, which we hope will be useful for those wishing to audit their work.

Effectiveness of two palliative support teams

The palliative care of 227 consecutive patients by two support teams was measured according to 17 key indicators in the Support Team Assessment Schedule (STAS), an instrument previously developed and validated for use in these settings. Mean time in care was 71 days (range 1-547); 56 per cent of patients died at home, 26 per cent in hospital, 18 per cent in a hospice. Totalled ratings (sum of 15 items, excluding two items owing to missed ratings) improved in 83 per cent of cases, remained unchanged in 3 per cent and deteriorated in 13 per cent. The main problems which the STAS identified at referral were family anxiety, symptom control, patient anxiety and communication between patient and family. Fifteen of the 17 items showed significant improvements (Wilcoxon Z ranged from -3.18 to -8.20, p less than 0.00005) between referral ratings and ratings for the last week of the patient's life; family anxiety and spiritual needs did not. Patient anxiety and symptom control, although improved, also remained relatively severe at death. These results demonstrate the value of measuring key indicators and indicate areas where improvement in palliative care is needed.

Assessing the symptoms, anxiety and practical needs of HIV/AIDS patients receiving palliative care.

We report the work of two community teams who care for people with AIDS/HIV related illness, the characteristics of patients referred, and the impact of the teams on four aspects of quality of life. Data was collected on 140 patients (85 St. Mary's Home Support Team, 55 Bloomsbury Community Care Team) who were referred to and remained in the care of these teams until death. All patients were male, mean age 37.9 years, 116 were homosexual. Most referrals were from genito-urinary medicine clinics (48%) or AIDS wards (41%). There was a wide range of reasons for referral. At referral 62% were in hospital and 35% at home. Mean time in care was 31 weeks 5 days. Fifty-seven per cent died in hospital, 22% at home and 21% in a hospice. The Support Team Assessment Schedule (STAS), consisting of 17 items of care, was used by the teams to measure aspects of quality of life. Throughout care until death four STAS items: pain control, symptom control, patient anxiety and practical aid are reported in detail. Symptom control was a commonly severe problem at referral and although the teams had some success in improving this item it remained a serious problem throughout care. Patient anxiety, also a commonly severe problem at referral, improved significantly throughout care. Pain control was less commonly severe at referral and improved significantly throughout care. Practical aid, in contrast, was rarely a severe problem at any stage of care.