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Hospitalisations for heart failure: increased palliative care referrals − a veterans affairs hospital initiative
  1. Jadry Gruen1,
  2. Parul Gandhi2,3,
  3. Sarah Gillespie-Heyman4,
  4. Tracy Shamas4,
  5. Samuel Adelman4,
  6. Andrea Ruskin4,
  7. Margaret Bauer5 and
  8. Naseema Merchant6,7
  1. 1 Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2 Cardiovascular Disease, VA Connecticut Healthcare System, West Haven, Connecticut, USA
  3. 3 Cardiovascular Disease, Yale School of Medicine, New Haven, Connecticut, USA
  4. 4 Geriatrics and Palliative Care Services, VA Connecticut Healthcare System, West Haven, Connecticut, USA
  5. 5 Mental Health, VA Connecticut Healthcare System, West Haven, Connecticut, USA
  6. 6 Hospital Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, USA
  7. 7 Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Dr Naseema Merchant, Hospital Medicine, VA Connecticut Healthcare System, West Haven, CT 06516, USA; naseema.merchant{at}


Objectives Heart failure (HF) portends significant morbidity and mortality. Integrating palliative care (PC) with HF management improves quality of life and preparedness planning. At a Veterans Affairs hospital, PC was used in 6.5% of patients admitted for HF from October 2019 to September 2020. We sought to increase the percentage of referrals to PC to 20%.

Methods PC referral guidelines were developed and used to screen all HF admissions between October 2020 and May 2021. Point-of-care education on the benefits of PC was delivered to teams caring for patients who met PC referral criteria. Changes were tested using Plan–Do–Study–Act (PDSA) cycles. Results were analysed using run charts.

Results During the study period, there were 109 HF admissions in patients who were not already followed by PC. Thirty-one (28%) received a new PC consult. The mean age was 81±9.5 years, median B-type natriuretic peptide was 1202 pg/mL, and mean length of stay was 8±5 days. After our intervention, there was an upward shift in the percentage of new referrals to PC with 6 values above the baseline median, which represents a significant change.

Conclusions Through multiple PDSA cycles, referrals to PC for patients admitted with HF increased from 6.5% to 28%. Point-of-care education was an effective tool to teach medical teams about the benefits of PC. Inpatient teams more consistently and independently considered PC for patients with HF, representing a cultural shift. This quality improvement model may serve as a paradigm to improve the care of HF patients.

  • Quality of life
  • Chronic conditions
  • Education and training
  • Heart failure
  • Hospital care

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  • Contributors JG conceived the project concept and PG gathered the stakeholders that comprised the QI team. JG, PG, SG-H, TS, NM, AR and MB designed interventions. JG, TS, SG-H, AR, SA and MB gathered data and JG analysed the data under the supervision of NM and PG. JG lead the writing of the manuscript and all authors contributed to the final draft. JG acted as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.