Intervention to improve care at life's end in inpatient settings: the BEACON trial.
BACKGROUND
Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings.


OBJECTIVE
To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings.


METHODS
Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design.


METHODS
Six Veterans Affairs Medical Centers (VAMCs).


METHODS
Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools.


METHODS
Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends.


RESULTS
Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints.


CONCLUSIONS
This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.
Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL, 35233, USA.
F Amos
FA
Bailey
Beverly R
BR
Williams
Lesa L
LL
Woodby
Patricia S
PS
Goode
David T
DT
Redden
Thomas K
TK
Houston
U Shanette
US
Granstaff
Theodore M
TM
Johnson
Leslye C
LC
Pennypacker
K Sue
KS
Haddock
John M
JM
Painter
Jessie M
JM
Spencer
Thomas
T
Hartney
Kathryn L
KL
Burgio
D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D004333:Drug Administration Routes; D005260:Female; D006801:Humans; D007297:Inpatients; D033183:Interdisciplinary Communication; D008297:Male; D017063:Outcome Assessment, Health Care; D059408:Pain Management / Q000379:methods / Q000592:standards; D010166:Palliative Care / Q000379:methods / Q000458:organization & administration / Q000523:psychology; D010347:Patient Care Planning / Q000592:standards*; D010348:Patient Care Team / Q000458:organization & administration*; D017410:Practice Guidelines as Topic / Q000592:standards; D058996:Quality Improvement; D016414:Resuscitation Orders; D013192:Staff Development / Q000379:methods; D013727:Terminal Care / Q000379:methods / Q000458:organization & administration / Q000523:psychology; D014481:United States; D014728:Veterans
D000701:Analgesics, Opioid