Triage in

Palliative Care

Setting Dr. Joseph Ninan

Palliative Care Association of Kota Kinabalu

History

• 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

Promises

• 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

Limitations

• 5 ½ day working

week

• No after office hour

service

• Sunday & public

holidays off

Growth

• 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.

Difficulties

• 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

New Tools

• Phase System

• Karnofsky Performance Scale

• Introduced in August 2008

Phase System

• 1. Stable Phase

• 2. Unstable Phase

• 3. Deteriorating Phase

• 4. Terminal Phase

• 5. Bereavement Phase

Karnofsky Performance

Scale (KPS)

• Classification according to performance

• Assess 3 dimension of Health

1. Activity

2. Work

3. Self Care

• Scale form 100 to 0. Divisions of 10

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.

0 Death

Methodology

• 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.

Data

• 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

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5

No. of

Pati

ents

Phase

Phase at 1st Home Visit

2009

2010

2011

10%

33%

48%

9%

0%

Phase at 1st Home Visit 2011

1 2 3 4 5

0

20

40

60

80

100

120

90 to 70 60 to 40 30 to 10 < 10

No. of

Pati

ent

KPS

KPS on Initial Home Visit 2011

2009

2010

2011

0

20

40

60

80

100

120

90 to 70 60 to 40 30 to 10 < 10

No

. o

f P

ati

ent

KPS

KPS on Initial Home Visit 2011

2009

2010

2011

0

10

20

30

40

50

60

70

80

0-7 8 to 30 31 to 90 91 to120 >120

No

. o

f P

ati

ent

No. of Days

Length of Stay in HCP

2007

2008

2009

2010

2011

0

20

40

60

80

100

120

140

2007 2008 2009 2010 2011

No

. o

f P

ati

ent

Year

Place of Death

HOME

PCU

OTHERS

Conclusion

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.

Thank You