Medicine (St Vincent's) - Theses
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ItemResponding to Urgency of Need - the Development of a Triage Tool for Palliative Care( 2020)Specialist palliative care services worldwide face the challenge of a workload that is growing in both volume and diversity. Simultaneously it is well recognised that timely access is crucial for the benefits of palliative care to be fully realized. When responding to a workload that at times may exceed resources, services must develop systems to prioritize patient care in a safe and fair manner. Significant efforts have been made to establish criteria defining which patients should receive specialist palliative care and at what point in the disease trajectory they should be referred, yet little is known about how patients should be prioritized once they have been referred. Unlike the field of emergency medicine and disaster response where systematic triage methods have been refined since World War I, limited attention has thus far been paid to how palliative care services should manage demand and consider urgency of response. A small number of studies have established that palliative care triage is a complex process embedded in organizational culture. Triage tools generated from these studies suffered from poor face validity and inter-rater reliability, and so have not been widely implemented into routine practice. This thesis therefore aimed to determine how the urgency of specialist palliative care needs should be assessed and compared between patients, with the practical outcome to ultimately develop an evidence-based, validated tool for palliative care triage – the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool. A series of studies were conducted, employing mixed methodologies to address various aspects of the research question and RUN-PC Triage Tool development. An initial qualitative study was undertaken to explore the attitudes and practices of palliative care providers towards triaging palliative care needs. This exploration led to a greater understanding of clinical decision-making that was used to develop a list of the key triage factors which formed the basis of the triage tool. These triage factors were then examined in the second study, a discrete choice experiment. This online international experiment determined the magnitude of effect that of each of the triage factors had on clinicians’ decision-making. These values became the scoring system for the RUN-PC Triage Tool. The third and final study was a validation study that demonstrated good intra- and inter-rater reliability and moderate to good correlation to expert opinion, which was used as the reference standard. This thesis paints a comprehensive picture of how palliative care clinicians approach the challenging task of triage and provides a practical tool to standardise the process that is evidence-based and validated. This research has significant implications for clinical practice internationally and represents an important step towards improving the transparency, consistency and efficiency of triage in palliative care, working towards equitable access for all.