An Audit Cycle to Evaluate the Improvement in Documentation of Breathlessness and Non-Pharmacological Interventions in Palliative Care Services

INTRODUCTION

Breathlessness, or dyspnoea, is a prevalent and distressing symptom in palliative care, significantly impacting patients’ quality of life.^[1] Despite its importance, documentation and management of breathlessness are often inconsistent. In advanced cancer patients, about 30% reported dyspnoea, with 70% experiencing episodic breathlessness due to exertion. This is influenced by multiple factors, including physiological, psychological, social and environmental elements.^[2]

In a longitudinal, observational and multicentre study from India, the prevalence of breathlessness in patients with advanced cancer presenting to outpatient clinics was found to be 36.4%, with 28.5% having moderate to severe breathlessness (>4/10).^[3,4] Across centres, the investigators suggested the assessment and proper documentation of breathlessness as an important part of the patient-centred approach for management of breathlessness. Breathlessness is assessed primarily through patient self-report using tools like the numerical rating scale (NRS), as it is a subjective experience.^[5] A 2019 systematic review encompassed the physical, emotional, spiritual, social, control and contextual aspects of ‘total breathlessness’ [Figure 1].^[6]

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Figure 1:

Concept of total breathlessness.

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According to American Society of Clinical Oncology guidelines, chronic breathlessness requires both pharmacological and non-pharmacological interventions to address multidimensional suffering.^[7,8] The breathing, thinking and functioning model [Figure 2] identifies three main cognitive and behavioural reactions to breathlessness that can worsen and perpetuate the symptom through vicious cycles.^[9] Multidisciplinary team (MDT) interventions are crucial for lifestyle adjustments to preserve functionality, alleviate anxiety and train in breathing techniques.^[8,10]

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Figure 2:

The breathing, thinking and functioning clinical model: A proposal to facilitate evidence-based breathlessness management in chronic respiratory disease.

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In December 2021, MDT comprising doctors, nurses, clinical psychologists, medical social workers, physiotherapists and administrative staff was inducted at Homi Bhabha Cancer Hospital and Research Centre (HBCH&RC) in the Department of Palliative Medicine. The standard operating protocol (SOP) for non-pharmacological interventions (NPIs) was developed by the department in 2022. It was presented in the ‘Non-Pharmacological Management for Breathlessness’ video, created and presented by the Department of Palliative Medicine, HBCH&RC, Visakhapatnam, at the IAPCON Conference 2022 under the theme ‘Nurses in Action – Best Practices in Empathy and Empowerment’ [Figure 3].

As routine practice, breathlessness was assessed and documented using the NRS in the Edmonton Symptom Assessment System.^[11] This audit was conducted to determine compliance with the documentation of breathlessness and NPIs.

The research protocol was approved by the Institutional Ethics Committee (Project 12000038).

MATERIALS AND METHODS

The audit cycle involved the analysis of case records in patients with cancer to evaluate the documentation of breathlessness and NPIs.

RESULTS

Part 2

The first intervention was to create codes based on the severity of breathlessness for ease of documentation, as shown in Table 1.

Table 1: Non-pharmacological intervention codes for breathlessness.

Level	Label	Interventions
Mild (1-3)	NPIB1	✓ Pacing activity ✓ Soft food ✓ Avoid constipation ✓ Pursed Lip Breathing
Moderate (4-6)	NPIB2	✓ Continue of B1 ✓ Use of hand held fan ✓ Comfortable clothing ✓ Cross ventilation ✓ Openly discuss the cause of breathlessness with patient and caregiver ✓ Keeping the door unlocked ✓ Keeping the bell next to the bed ✓ Use of supportive aids
Severe (7 and above)	NPIB3	✓ Continue of B1 & B2 ✓ Positioning: a. Fowlers or semi fowlers position b. Bending forward ✓ Avoid crowd around the patient ✓ Wipe the face with wet cloth
EOL (with oxygen/medication)	NPIBE	✓ Eliminate non-essential activity ✓ Use of fan ✓ Positioning ✓ Cross ventilation ✓ Soft food ✓ Personalised according to the patient requirement

NPIB: Non Pharmacological Intervention of Breathlessness, EOL: End of life.

Following this, interventions to train and to comply with the coding and documentation are shown in Table 2.

Table 2: Interventions implemented.

Measure	Description
Education and awareness sessions	Regular training sessions were held for all department staff
Daily checklist	Implemented to ensure accurate code documentation in the EMR
Staff reminders	Reminders about codes and NPI documentation were given to both new and existing staff
Code display	Codes were prominently displayed on a department board for quick reference

NPI: Non-pharmacological intervention, EMR: Electronic medical record

The documentation of breathlessness was 98.5% (n = 478), 89.3% (n = 600) and 96.7% (n = 736) in February, March and September 2023. In these 3 months, NPI documentation was 90.5% (n = 369), 92.1% (n = 487) and 93.5% (n = 575) in those who reported breathlessness.

Among those with mild breathlessness, 8.5% of patients had no NPI documentation, while 91.5% had NPIB1. In moderate breathlessness, 8% had no documentation, 85.5% had NPIB2, and 6.5% had documented NPIB3. For severe breathlessness, 2.8% had no documentation, 4.3% had NPIB2, 85.1% had NPIB3 and 7.8% had documented NPIBE. In those at end-of-life cases, all had NPIBE documented.

In 2021, symptom clusters with breathlessness included anxiety, fatigue and loss of well-being (all P < 0.01). In 2022, depression, fatigue, loss of appetite, and pain were the associated symptom clusters (P < 0.01). Similarly, common symptom clusters were fatigue (P < 0.0005) and anxiety (P < 0.00001) [Tables 1 and 2, Figures 3 and 4].

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Figure 3:

Non-pharmacological intervention for breathlessness was based on Evidence-Based Management Guidelines in 2020. Homi Bhabha Cancer Hospital & Research Centre (HBCH & RC)

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Figure 4:

Run chart of the audit cycle with data of breathlessness and non-pharmacological intervention. MDT: Multi disciplinary team, SOP: Standard operating procedure, EBM: Evidenced based medicine guideline. NPI: Non-pharmacological intervention.

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DISCUSSION

The results from the audit of breathlessness and NPI documentation show significant improvements over time. In 2021, documentation of breathlessness was recorded at 68%, with no documentation of NPIs. By 2022, breathlessness documentation improved to 80%, and NPI documentation, which was initially absent, increased to 16%. With the introduction of targeted interventions, including implementation of SOP, staff training, a documentation checklist and code reinforcement, the documentation saw further enhancement. Specifically, breathlessness documentation reached 98.5% in February 2023, 89.3% in March 2023, and 96.7% in September 2023, while NPI documentation improved to 90.5%, 92.1% and 93.5%, respectively. These improvements and adherence to documentation can be attributed to the new SOP with codes and MDT involvement. Structured protocols and MDT approaches have been shown to improve breathlessness management in palliative care settings.^[12]

The Palliative Performance Score (PPS) data for patients observed in both phases show individuals falling within the 50–70% PPS range. The results showed that most patients’ NPI codes aligned with their breathlessness severity. Variations in the trajectory of the disease patient performance status might require personalised NPI and modifications from standard NPI codes.^[13] This data underscores the need for longitudinal assessment and tailored NPI interventions.

Despite improvements, challenges such as documentation variability, training gaps and communication issues persisted. Bausewein et al. emphasised the need for consistent training to improve documentation and management^[2] while Booth et al. highlighted the role of structured communication strategies.^[14] Addressing these challenges through targeted interventions can further enhance documentation and management practices. The audit highlights progress made in documentation practices due to the implemented strategies. While achieving a 100% documentation rate remains a goal, the improvements observed indicate a positive impact on both breathlessness and NPI documentation. Along with ongoing training, regular audits, and further research are needed to study patient related outcomes following the interventions.

CONCLUSION

This audit cycle demonstrates the significant impact of an MDT and standardised protocols on improving the documentation of breathlessness and NPI in palliative care. The findings emphasise the importance of ongoing training, structured communication and targeted interventions to address challenges in documentation practices. This could help in future research on patient related outcomes.