Triage in Palliative Care Setting

Dr. Joseph Ninan Palliative Care Association of Kota Kinabalu

PCAKK inception in 1993 Non-profit charitable NGO in 1998 Community based palliative care service Coverage 30km radius from Association building Home care service to advanced incurable terminally ill cancer patients One volunteer nurse Aim: Pain & symptoms control

History

Seen within 48 Hrs of referral of service Weekly visit & more when necessary Pain & symptoms control Loan of medical equipment Dr.s consultation & visit when necessary

Promises

 5 day working week No after office hour service Sunday & public holidays off

Limitations

1993 2008 One nurse to 4 nurses and one volunteer Dr. Since 2011, 6 nurses & 2 Drs. 60 to 80 patients Adults Cancer, Paediatric Cancer, Organ Failure.

Growth

Maintenance of weekly visit Medical Management Increased work stress Burn Out Lack of hands on training Lack of proper medical documentation Inadequate at medical management

Difficulties

 Phase System Karnofsky Performance Scale Introduced in August 2008

New Tools

1. Stable Phase 2. Unstable Phase 3. Deteriorating Phase 4. Terminal Phase 5. Bereavement Phase

Phase System

 Classification according to performance Assess 3 dimension of Health 1. Activity 2. Work 3. Self Care Scale form 100 to 0. Divisions of 10

Karnofsky Performance Scale (KPS)

100 Normal with no complaints or evidence of disease 90 Able to carry on normal activity but with minor signs of illness present 80 Normal activity but requiring effort. Signs and symptoms of disease more prominent. 70 Able to care for self, but unable to work or carry on other normal activities. 60 Able to care for most needs, but requires occasional assistance. 50 Considerable assistance and frequent medical care required. 40 In bed more than 50% of the time. 30 Almost completely bedfast. 20 Totally bedfast and requiring extensive nursing care by professionals and/or family. 10 Comatose or barely rousable.

KPS

0 Death

 Triage using Phase System. KPS use to assesss performance, prognosticate & determine level of care.

Methodology

 Visitation defined by Phase System Stable once a fortnight & alternate week phone consultation Unstable Daily or alternate day visitation. Deteriorating Weekly visits. Terminal Daily or alternate day visits. Bereavement One week after funeral conducted.

Methodology

 Data Collected from 2009 Looked at 1. Phase & KPS at 1st Home visit 2. Length of stay in Home Care Programme. 3. Place of Death

Data

Phase at 1st Home Visit

100 90 80 70 60 50 40 30 20 10 0

No. of Patients

2009 2010 2011

3 Phase

Phase at 1st Home Visit 2011

1 2 3 4 5

0% 9% 10% 33% 48%

KPS on Initial Home Visit 2011

120

100

No. of Patient

80

60

40

2009 2010 2011

20

90 to 70

60 to 40 KPS

30 to 10

< 10

KPS on Initial Home Visit 2011

120

100

No. of Patient

80

60

40

2009 2010 2011

20

90 to 70

60 to 40 KPS

30 to 10

< 10

Length of Stay in HCP

80

70

60

No. of Patient

50

40

30

20

2007 2008 2009 2010 2011

10

0-7

8 to 30

31 to 90 No. of Days

91 to120

>120

Place of Death
140

120

100

No. of Patient

80

60

40

HOME PCU OTHERS

20

2007

2008

2009 Year

2010

2011

Using the Phase system and Karnofsky Performance Scale has enabled us to achieve the followings:
1. Optimal use of limited manpower/resources in the environment of increasing demand and expectation from the community/patient/family and expansion of service.

Conclusion

2. Guideline for the nurses in their visitation. 3. Better job satisfaction for the nurses and reduces the chances of burn out.

4. Statistically tracking our work load and facilitate future service development and planning.

Conclusion

Thank You