NYMC Faculty Publications

Establishing Goals of Care for Patients with Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

Journal Title

Journal of Pain and Symptom Management

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Publication Date

October 2018




CONTEXT: Few patients with dysphagia due to stroke receive early palliative care to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. OBJECTIVES: To increase documented goals of care (GOC) discussions among acute stroke patients prior to feeding gastrostomy tube placement. METHODS: We undertook a rapid-cycle continuous quality improvement (CQI) process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for palliative care referral prompted by the speech and language pathology evaluation. RESULTS: Over a 6-month period, 21 patients underwent gastrostomy tube placement; 52% had pre-procedure GOC discussions post-intervention, with the rate of compliance increasing steadily from 13% (11/87, pre-intervention) to 100% (2/2) in the final 2 months. CONCLUSION: We effectively increased documented GOC discussions prior to feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early palliative care for stroke patients.