Improving access to inpatient palliative care for patients with end-stage liver disease: a quality improvement project.

Abstract

End-stage liver disease (ESLD) is a terminal diagnosis with a poor prognosis and an accelerating mortality rate in the UK. Limited research suggests that patients with ESLD have unmet palliative care (PC) needs, likely due to various factors, including difficulty predicting prognosis and lack of clear specialist palliative care (SPC) referral criteria.This quality improvement (QI) project aimed to assess and improve access to PC for inpatients with ESLD and unmet PC needs over a 6-month period using a novel intervention incorporating the Supportive and Palliative Care Indicators Tool for Liver Disease (SPICT). The project was conducted at a tertiary centre between 2020 and 2022 with three data cycles: one baseline measurement and two Plan-Do-Study-Act (PDSA) cycles. PDSA cycle 1 involved regular screening of inpatients using the SPICT to trigger SPC referral. PDSA cycle 2 also involved screening using the SPICT, but instead to prompt multidisciplinary meeting (MDM) discussion between hepatology and SPC teams. Outcome measures reflecting holistic aspects of PC were assessed across all cycles. PDSA cycle 1 demonstrated a significant reduction in patients receiving no PC measures (67% to 26%, p: <0.001) and increased SPC input (32% to 52%, p: 0.04). Community PC referrals also rose significantly (13% to 39%, p: 0.01).PDSA cycle 2 failed to improve measures compared to baseline. Only 42% of eligible patients were discussed in the MDM. Most agreed plans were implemented, but only a minority included SPC review, community PC referral or advanced care planning. Patients with ESLD continued to have unmet PC needs despite implementing an intervention based on expert guidance. PDSA cycle 1 demonstrated some significant, positive impacts, supporting the clinical utility of the SPICT, but within the context of a small, single-centre QI project with methodological limitations.