The iValidate program

Communication

The iValidate "Identifying Values, Listening, and Advising High-risk Patients in Acute Care" program was developed by experts in communication, ethics, end-of-life care, and clinical leaders from Barwon Health and Deakin University, with the goal to improve communication and shared decision-making for end of life care. “Although talk about patient- centred care is ubiquitous in modern health care, one of the greatest challenges of turning the rhetoric into reality continues to be routinely engaging patients in decision making”. Barry MJ, N Engl J Med. 2012
Upcoming Courses

REGISTER FOR THE APRIL COURSE (6th and 13th April) HERE https://www.eventbrite.com.au/e/ivalidate-cicmacem-april-2021-registrati...

The initial 2021 course dates are below, please contact CET@barwonhealth.org.au to register interest or ask for details. 

  • The Core iValidate course runs over 2 days with a blend of eLearning modules to complete in your own time, and 2 x 5 hours webinars. The communication skills for engaging with patients with life limiting illness are taught through real life scenarios, video and participants’ own experiences.  Participants need to complete all components of the blended program to obtain recognition for CPD or college competency.
  • Duration: 13 hours total. 11 hours webinar, 2 hours online content

Background

Life-limiting illness can be defined using objective indicators such as the UK Gold Standard Framework (GSF), and the Supportive and Palliative Care Indicators Tool (SPICT). The goal of these indicators is to aid the identification of patients in or approaching the last year of life, to aid the delivery of patient-centred care.  Overall patients can be classified into a clinical trajectory group of cancer, organ system failure, frailty/comorbidity/dementia, or no LLI. These classifications have been tested and used extensively in community and hospital based settings.

Over the last 5 years we have collected data on over 2000 patients in UHG, looking at trajectory of survival, and evidence of discussions about care, for patients with and without life limiting illness (LLI).  

We have learnt;

  1. At least a third of patients in UHG, or referred to ICU, have a life limiting illness
  2. The clinical trajectories of cancer, frailty, or organ failure, reliably identify patients with a high one-year mortality. Patients without a LLI have excellent outcomes.
  3. Less than half of patients with a LLI return to independent living
  4. Goals of care are identified in only 34% of patient with a LLI while in hospital

 

The ivalidate pilot study

In August 2015 18 ICU registrars, residents, and liaison nurses undertook the first 2-day i-validate training. An audit of patients with a LLI referred to ICU for the 4-month period before and after the training, was conducted. 

In summary we found (Table 1,2);

·       Patients with a life-limiting illness referred to ICU have a very high 90-day mortality (46.4%). This is higher than previous UHG audits, and may reflect the i-validate program has “tightened” the criteria for LLI through training and formal audit.

·       Patients with a life-limiting illness lose independence after their acute illness, with only half of those living independently returning to this.

·       The majority of patients with a LLI are referred to ICU within 48-hours of hospital admission. This supports the need for a EOL strategy that leads to patient-centred discussions occurring within 48 hours of admissions

·       The i-validate intervention was associated with a significant reduction in MET calls.

·       Concerns that EOL training may lead to reduced access to ICU or increased mortality are not supported. There was no significant change in either, with the only trend towards the opposite,

·       The intervention was associated with significant improvements in patient-centred care, with increases in documentation, assessment of competence and surrogates, and discussion of patients goals and values.

·       The intervention appeared to be associated with improved resolution of ACPs and hospital GoC. In addition an increase in “non-defined” outcomes was reported. This may reflect the process of GoC was begun but not completed by 48-hours

·       The General Medical ward LLI patients were included as a separate baseline group.  The documentation of GoC (18.1%), and patients goals and values (4.3%)

These results are encouraging, and the are in keeping with recent literature examining the effect of improved communication for ICU patients with end-of-life needs

Publications
  1. Thurston LM, Milnes SL, Hodgson CL, Berkovic DE, Ayton DR, Iwashyna TJ, Orford. Defining patient-centred recovery after critical illness – A qualitative study. J Crit Care. 2020 Feb 6;57:84-90. doi: 10.1016/j.jcrc.2020.01.028
  2. Ragg J, Ragg M, Milnes S, Bailey M, Orford N. Patients with life-limiting illness presenting to the emergency department. Emerg Med Australia. 2019 Oct 30 [epub ahead of print].
  3. Orford N. What is an intensive care specialist? Med J Aust 2019; 211(7)
  4. Simpson N, Milnes S, Martin P… Orford N.  iValidate - A communication-based clinical intervention in Life Limiting Illness. BMJ Supportive & Palliative Care. 2019 Apr 11. doi: 10.1136/bmjspcare-2018-001669
  5. Orford NR, Milnes S, Simpson N, et al. Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study. BMJ Supportive & Palliative Care. 2019;9(1):e21-e21. 
  6. Orford N. Grief After Suicide. JAMA. 2018;320(18):1861-1862. 
  7. Milnes S, Corke C, Orford NR, Bailey M, Savulescu J, Wilkinson D. Patient values informing medical treatment: a pilot community and advance care planning survey. BMJ Support Palliat Care. 2017 Mar 2.
  8. Orford NR, Milnes S, Lambert N, etal. Crit Care Resusc 2016. Prevalence, goals of care and long-term outcomes of patients with life-limiting illness referred to a tertiary ICU. Crit Care Resusc 2016;18(3):181-8.
  9. Orford NR. Mothers: Respect the strong, selfless women in your life. The Age/SMH https://www.smh.com.au/opinion/hospitals-must-shift-focus-of-endoflife-c...
  10. Orford NR. Give death its due in a system focused on life. The Age / SMH https://www.smh.com.au/opinion/hospitals-must-shift-focus-of-endoflife-c...
  11. Milnes S, Orford NR, Berkeley L, et al.  A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital.  BMJSPC, 2015. 
  12. Corke C, Milnes S, Orford N, et al.  The influence of medical enduring power of attorney and advance directives on decision-making by Australian intensive care doctors.  Crit Care Resusc 2009 Jun;11(2):122-128.

 

The i-validate training program

The “i-validate” program (identifying values, listening, and advising high-risk patients in acute care) was developed through the establishment of a group with expertise in palliative care, intensive care, clinical communication, medical education, and ethics. The goal was to improve delivery of patient-centred care for patients with a LLI by teaching communication skills to health professionals, and providing a process of care to implement theses skills.

 

A 2-day, interactive, small group, actor-based, advanced communication workshop, adapted from the Calgary-Cambridge communication model, process of care, and Goals of Care form were developed.  Through a process of literature review, consensus building, and consultation, a six step process of care was developed that included;

1) identification of patients with a life-limiting illness

2) establishment of competence and surrogate decision-maker

3) establish personal goals and values

4) provide medical advice tailored to goals and values

5) achieve consensus between health teams, patient, and surrogates

6) documentation of the steps and decisions on a process driven Goals of Care form

Qualitative Research

The iValidate team is committed to listening to our patients. Over the last few years we have embarked on a qualitiative reserach program;

  • Recovery trajectory "Thurston LM, Milnes SL, Hodgson CL, Berkovic DE, Ayton DR, Iwashyna TJ, Orford. Defining patient-centred recovery after critical illness – A qualitative study. J Crit Care. 2020 Feb 6;57:84-90"
  • Values, goals and preferences