Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

A Quality Improvement Intervention to Increase Palliative Care in Nursing Homes

Authors: Hanson LC, Reynolds KS, Henderson M, Pickard CG

Journal: Journal of Palliative Medicine (2005); 8(3):576–584

DOI: 10.1089/jpm.2005.8.576

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✅ PICO Analysis

Type of Study:

Pre–post quality improvement (QI) intervention with control group

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P – Population

• Setting:
  • 9 nursing homes in North Carolina (7 intervention, 2 control)
  • Facilities varied in ownership (nonprofit, for-profit, hospital-affiliated) and size (80–200 beds)
• Participants:
  • 1169 residents across all sites
  • Majority aged ≥75 years; 81% female at intervention sites
  • High cognitive impairment (76%) and functional dependence (median Functional Ability Score = 17)

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I – Intervention

Quality Improvement (QI) Strategy, structured around Plan–Do–Study–Act (PDSA) model:

1. Team Formation:
   • Interdisciplinary Palliative Care Leadership Teams created at each site (e.g., nursing, social work, administration)
2. Education:
   • One-day off-site training and six on-site education sessions delivered by hospice providers
   • Topics: pain management, hospice services, advance care planning
3. Technical Assistance and Feedback:
   • Monthly strategy meetings with hospice and QI experts
   • Teams received performance feedback reports at baseline, 3, and 6 months
   • Structured curriculum and documentation tools provided
4. Action Plans:
   • Teams created monthly goals for improvement and documented implementation tasks

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C – Comparison

• Control Group:
  • Two matched nursing homes not receiving the intervention
  • No exposure to education, strategy sessions, or performance feedback
• Comparison Strategy:
  • Chart abstraction and hospice data collected at baseline and 6 months in both groups

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O – Outcomes

Person-Centred Outcomes:

• Hospice enrollment:
  • Intervention: increased from 4.0% to 6.8% (p = .01)
  • No change in control sites
• Advance care planning discussions:
  • Increased from 4% to 17% (p < .001)
  • DNR orders increased slightly (58% → 65%, p = .04)

Process Outcomes:

• Pain assessment:
  • Increased from 18% to 60% (p < .001)
  • No significant change in controls
• Nonpharmacologic pain treatment (e.g., massage, repositioning):
  • Increased from 15% to 34% among residents with pain (p < .001)
• Pain medication use (for residents in pain):
  • 77% → 81% (not statistically significant)
• Staff knowledge and confidence:
  • Pre/post test improvements in recognising pain, legal concepts, and palliative communication
  • Confidence in delivering palliative care increased from 66% to 85%

Control Sites:

• No significant change in any measured indicator (hospice, pain assessment, treatment, or ACP discussions)

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Summary Conclusion

This QI intervention—focused on interdisciplinary leadership, structured hospice collaboration, and education—was associated with significant improvements in hospice use, pain assessment, non-drug pain management, and documented end-of-life discussions. Medication orders did not significantly change, suggesting physician engagement was a limitation. Despite methodological constraints (non-randomised control group, modest generalisability), the study demonstrates that PDSA-based interventions can meaningfully enhance palliative care delivery in nursing homes, especially when local hospice partners are engaged as educators and collaborators .

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