To Trigger or Not: That Is the Question!

Abstract

Many patients with palliative care needs never receive a palliative care consultation, or they receive it too late in the hospitalization for significant benefit to patient and family.¹ Over the past few years, palliative care clinicians have been exploring whether consultation “triggers” are the solution to improved identification of appropriate patients. Program managers have also wondered whether utilizing triggers would expand the reach of palliative care in their institution and help grow their programs. What follows here is a discussion of triggers and why they should be considered, along with some suggestions on how to structure success when setting up a trigger program.

Palliative care checklists and screening procedures were originally proposed to encourage wider, better, and more timely identification of patients in need of palliative care. The recommended criteria focused on general indicators of need and were based on disease, patient, or family variables.² Unlike other areas of medicine that focus on a specific patient population, the field of palliative care spans many specialties. The need to select criteria that would be relevant across a broad spectrum of specialties made the identification of one-size-fits-all screening recommendations a real challenge. It also became obvious that early palliative care checklists and screening procedures were too generalized, and they cast too wide a net. Paradoxically, they also limited access to palliative care by being so generic that the decision about whether to ask for a consult was often left up to the subjective judgment of the referring physician.

The realization that palliative care screening guidelines were too broad led to the development of specific triggers that identify a subgroup of patients with palliative care needs. The focus is either on a population (e.g., patients with metastatic cancer, with end organ failure, in ICUs, and in emergency rooms) or on clinical characteristics (e.g., length of stay and mechanical ventilation, or age with comorbidities). By utilizing these criteria, the process of identifying appropriate palliative care patients is standardized and rendered more objective. An added benefit is that consultation is no longer strictly dependant on the physician's subjective decision for referral. For example, if a trigger uses the criteria of “stage IV heart failure with symptoms, despite optimal medical management,” rather than “a prognosis of six months or less,” the referral to palliative care is made independent of the cardiologist's estimate of survival. Several sets of specific triggers have been identified and successfully implemented in patient populations^3–5 and care settings.^6–10

Launching a palliative care trigger program is a challenging exercise that requires significant planning. To be successful, several critical components must be considered. In 2011, David Weissman offered five essential steps for using palliative care triggers¹¹:

1. Define your programmatic goals.

2. Evaluate staffing needs.

3. Secure buy-in from stakeholders.

4. Select consultation triggers.

5. Determine the process for applying triggers (e.g., trigger leads to further triage; or trigger leads directly to a palliative care consult).

Weissman concluded his advice on triggers with two additional recommendations: be sure to determine who will take responsibility for implementation of the trigger program, and also identify who will manage the feedback and follow-up.

Despite their current popularity, trigger programs can—and unfortunately often do—fail. The literature on trigger programs that did not meet their intended outcomes is sparse. So drawing from my personal experience, here are some key factors that can jeopardize a positive outcome:

✓ Lack of buy-in from clinicians on the ground.

✓ Lack of accountability.

✓ Lack of consistent feedback.

✓ Too many triggers or those that are too general.

✓ Inadequate palliative care staffing during the implementation phase, resulting in failure to meet the potential demand.

If you are considering triggers for your institution, I would add the following considerations to Weissman's guidelines for success:

1. Decide whether your program would be better served with general screening criteria or specific triggers developed in collaboration with a specific unit (ICU, ED) or specialty service (oncology, cardiology). Although general criteria have a greater reach and may be more appropriate for start-up programs, they can also be too general and prone to subjective judgment. For more developed programs, however, specific trigger criteria may be the better option.

2. Establishing relationships is the key to a successful trigger program. Developing rapport and obtaining buy-in is essential, not only at the leadership level but also from the clinicians whose patients will be screened with the criteria that are selected. Collaborative teamwork will improve patient care and also enhances the ability to reinforce behavior with feedback on outcomes. Neglecting this critical relationship-building step can unfortunately lead to a negative experience that may seriously undermine future collaborations.

3. Currently, there is no consensus on the “best” triggers to use. Programs either utilize published criteria or develop their own triggers tailored to local needs, specific setting, and patient population, or adopt a combination of both. Whichever option you choose, be sure to involve the appropriate stakeholders—physicians, nurses, palliative care clinical team members, and hospital administrators—in the process. Before implementing your triggers, confirm that all parties approve of the proposed criteria. And finally, the triggers that you choose should be aligned with the objectives of your evaluation strategy. (See No. 5).

4. Limit the number of criteria; more is not necessarily better. Lists of triggers used in published studies vary in number, with many programs utilizing 5 to 7 triggers.

5. The outcome measures that you establish to monitor and evaluate your trigger intervention will support feedback and facilitate quality improvement, so they should reflect the goals of your program, be relevant to all stakeholders, and be easy to track and collect. When selecting outcomes, a review of existing data will help select appropriate metrics. For example, although ICU triggers have not been shown consistently to reduce hospital length of stay, they have been associated with reduced ICU excess days and cost.¹²

Whichever decision you make—to trigger or not—there are excellent resources available to help you move forward. A report from the Improving Palliative Care in the ICU Advisory Board outlines a step-by-step approach to choosing and using specific screening criteria for palliative care consultations in the ICU.¹³ This same process can also be applied to the development of triggers for other settings. If triggers are not the best option for your institution, the Center to Advance Palliative Care has developed A Guide to Building a Hospital Based Palliative Care Program that offers other strategies to increase access to palliative care.¹⁴

It is possible that specific triggers will help bring about the culture change necessary for primary palliative care to take root in all healthcare settings. Despite the current enthusiasm for triggers, however, palliative care experts unanimously agree that additional research is needed to address a host of unanswered questions. What are the “best” triggers, which populations should be screened, which settings benefit the most from this approach, should “triggers” lead directly to a consult or perhaps to additional screening; how “automatic” should the process be; and do we fully understand the workforce implications of potentially dramatic growth in trigger-based referrals. You can expect to see more published studies aiming to answer these questions in the near future.

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