GAP ANALYSIS: EMERGENCY COMFORT MEDICATION KIT 1

Gap Analysis: Emergency Comfort Medication Kit

Brandi Parker

Jacksonville State University

FNP Project Planning and Development

FNP 796

Dr. Lori S. McGrath

June 15th, 2023

GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 2

INTRODUCTION

The goals of hospice and palliative care are to provide patient symptom palliation; most of the

time, this is done in the comfort of the patient’s home. When symptomatic crises occur, unless these

symptoms are controlled, unwanted hospital admissions and hospice discharges take place (Atokoro,

2019). This Doctorate of Nurse Practitioner (DNP) student recently developed and designed a Re-

hospitalization and Revocation Prevention Program at this student’s local hospice agency. This quality

assurance and performance improvement project has many components; one area this DNP student and

the team would like to explore is the topic of emergency comfort medication kits in the patient's home

and its effect on patient outcomes.

CURRENT STATE

After extensive research on emergency comfort medication utilization and its effects on hospice

patient care, this author recognizes minimal published research data to support a patient-specific protocol

for using emergency comfort medication kits. This author has met with administrators, colleagues,

mentors, and stakeholders to explore how patient care can be improved and personalized. In

implementing the Re-hospitalization and Revocation Prevention Program in the hospice workplace, the

administration has requested that this student identify trends in the patients who have been discharged

alive from hospice services. This student recognizes one specific trend early into the program; data

showed that 78% of the patients who either revoked their hospice benefit or transferred to an inpatient

facility did not have any emergency comfort medication kits in the home. This translates as only four

patients who revoked their hospice benefit had comfort medications in the home; the other fourteen

patients revoked their benefit and were admitted into a hospital or other facility for symptom management

between January 1, 2023, and March 31, 2023.

Consistent guidelines and protocols must be developed to guide the hospice and palliative care

team on patient care and comfort medication kit administration. A study performed by Staats et al., 2018,

concluded that clear structures surrounding the use of the emergency medication kit, along with well-

structured routines in the workplace and increased confidence, facilitated the use of the medication kit.
GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 3

The Centers for Medicare and Medicaid Services (CMS) advocates for the hospice patient to have an

individualized plan of care through the standards and regulations published by the organization (CMS,

2023).

A NEED FOR CHANGE IN CURRENT PRACTICE

While there is limited data to guide medication use in hospice, little is known about the factors

associated with prescribing (Gerlach et al., 2022). Prior negative experiences, fear of medications, and

lack of communication and education contribute to the resistance to emergency medications for comfort.

Lack of adequate home symptom management medications may increase re-hospitalizations and decrease

patient quality care (Phongtankuel et al., 2018). Based on the internal audits performed by the quality

team and this student, there is likely a correlation between unwanted hospice discharges and the

resistance to placing an emergency comfort medication kit in the home.

The Centers for Medicare and Medicaid Services (CMS) define the regulations of hospices in the

United States (CMS, 2023). It is vital to monitor updated national standards and regulations when

considering a topic to research. The National Hospice and Palliative Care Organization (NHPCO) is a

nationally recognized organization that sets standards and guidelines for hospices. Section PFC 4.2 of the

NHPCO Standards of Hospice Care states that the hospice plan of care should address needs identified,

like management of pain and symptoms, and should be provided by the hospice to meet the patient's

individualized needs (NHPCO, 2018). Implementing an individualized emergency comfort medication kit

in the hospice patient’s home would certainly be pertinent to these mentioned standards from CMS and

NHPCO.

ORGANIZATIONAL GOALS

Practice changes develop from evidence-based literature and research, including patient and

caregiver experiences and preferences. This student’s current organization aims to provide patient and

caregiver satisfaction and patient cost management; this translates into the quality of life for the hospice

patient with an individualized experience for the patient and caregivers while providing cost-effective

care. One component of quality care goals includes continuity of care and patient symptom management.
GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 4

This organization plans to improve the patient and caregiver hospice experience by providing proactive

care management versus reactive care management.

Stakeholders have discussed that it would be ideal to have a standard protocol that aids in

deciding which patients receive an emergency comfort kit and when the patient or caregiver will receive

it. CMS has publicly reported quality measures that monitor the palliation of symptoms based on

objective data entry from the hospice and subjective data from patient caregiver’s surveys (CMS, 2023).

These public reports have been used to identify gaps in care and areas for hospice improvement. The

publicly reported data by CMS will also continue to be used to provide input and identify program

progress.

IDENTIFIED GAPS

One of the first tasks the organization and team must do is identify the gaps in the system as they

are related to the goal of improved patient quality of life. There are multiple inconsistencies on why some

patients have certain medications for comfort and others do not; a protocol system and organized program

will potentially help manage this. Based on chart audits and research, fourteen patients revoked their

hospice benefit and were admitted into another facility for symptom management; these patients did not

have standard comfort medications; the gap in care is identified here.

The current organizational protocols could be more effective in optimal symptom and medication

management. The emergency comfort medication kit implementation and program is a more minor but

foundational support for the organization’s ultimate goals. There is a relationship between patients who

revoked their hospice benefit and were admitted into a hospital or facility for symptom management;

these patients did not have comfort medications in the home.

STRENGTH, WEAKNESS, OPPORTUNITIES, AND THREATS

This proposed emergency comfort medication kit project in the hospice patient’s home will

optimally strengthen the hospice organization program and improve patient outcomes. Strengths of the

proposed program include increased organization and communication between the team. Another

proposed strength, including the most important, is improving patient quality of life through improved
GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 5

symptom management. Reduced healthcare costs and improved referral source relationships are other

strengths of this plan. Holistic care is another strength of the proposed program. A weakness of the

program will include the hesitancy of the patient or family to allow certain comfort medications in the

home. Another weakness is staff, patient, and caregiver compliance with the program. Despite

educational barriers listed as a weakness, they can also be used as learning opportunities. Opportunities to

educate the team, patients, families, caregivers, and the community can usher in a new era for this hospice

company. Educational opportunities can increase the benefits of hospice and awareness as an entity. The

cost will also play a role in the plan; cost-effectiveness may present as a weakness, but when looking at

the overall framework of healthcare cost, it may have benefits as well.

Standard 4A.1 in the NHPCO Standards of Practice state that administrative leadership should

establish and monitor the organization’s risks, threats, and opportunities (NHPCO, 2018). It is essential to

discuss possible threats related to the proposed program for emergency comfort medication kits. In 2022,

Gerlach et al. performed a retrospective cohort study to identify prescribing guidance for comfort

medications at the end of life. The research study concluded that there is no specific guidance program for

hospices; the only trend identified was a correlation between the frequency of benzodiazepine prescribing

and specific practicing hospices (Gerlach et al., 2022). Threats to the proposed emergency comfort

medication kit program include the lack of a national standardized comfort medication kit guide, lack of

research to support the program, and healthcare providers' hesitancy to learn.

A CALL TO ACTION

Evidence-based practice (EBP) and research to support the practice will only strengthen this DNP

student’s organization. The initiation of EBP will promote a positive culture within the hospice

organization if the appropriate measures are in place. The administration, quality assurance team, mentor,

preceptor, and stakeholders will collaborate with this DNP student on ideas, input, data collection and

entry, program implementation, and program follow-up. A problem statement or critical finding should be

identified, an action plan developed and initiated, and measurable goals should be stated. The quality
GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 6

assurance team and administration will also evaluate and review the program to evaluate its effectiveness.

The DNP student will participate in and oversee this process as a whole.

A key finding has been identified; fourteen of the eighteen revocations from hospice services

from January 1, 2023, through March 31, 2023, went to the emergency room and were admitted for

symptom management. Out of eighteen hospice revocations, only four of these patients had emergency

comfort medications in their homes. This student would like to implement comfort kits in the homes of

patients who are at high risk for emergent symptom management. This high-risk group includes patients

who live in outlying rural areas, have a cancer diagnosis, patients with a prognosis of two weeks or less,

and those who are already scored at risk for revocation.

This author and the team will work together to overcome obstacles and improve patient care in

the hospice setting. The hospice medical director will prescribe the comfort kit once the initial hospice

care plan has been established, medications are reconciled, and allergies are cross-checked. The comfort

medication kit order will be sent to a local pharmacy to fill the medications. The family or patient

caregiver will be responsible for picking the medication up and will sign a form that reviews the

responsibility of the patient-caregiver and expectations of the patient and family with the comfort

medications in the home. This form will be filled out and signed on admission to hospice services. Once

the comfort kit is in the patient’s home, the hospice case manager-skilled nurse will go to the patient’s

home and assist the family in securing a safe storage area for the kit, keeping it put up and locked. The

patient and caregiver will be educated to call hospice before opening the kit. When the kit has been

deemed appropriate to utilize, a skilled nurse will go to the patient’s home to administer the first dose and

ensure patient or caregiver competency in medication administration, as evidenced by a return

demonstration and verbal understanding. The case manager will visualize the kit at a minimum of once

weekly to ensure that medication counts are correct and all parties are held responsible.

A standard comfort kit will include the following: a thirty-milliliter bottle of Morphine

Concentrate 20 mg/ml, fifteen Haloperidol 1 mg tablets, fifteen 0.125 mg Hyoscyamine tablets, and

fifteen 0.5 mg Lorazepam tablets. If a patient has a Morphine allergy, liquid Oxycodone 20 mg/ml may
GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 7

be administered in the kit instead. These medication choices are based on recommended standards in

hospice care for the patient who is at the end of life. The Hospice and Palliative Nurses Association

(HPNA) recommends an opioid for dyspnea and/or pain management, Haloperidol for agitation and/or

nausea, Hysocamine for terminal secretion management and visceral pain, and a benzodiazepine for

anxiety and/or dyspnea management at the end of life (HPNA, 2023). The cost of these medications

includes an estimate of fifty dollars per kit, based solely on a generic medication cost estimate (Good Rx,

2023). However, this student has a prior relationship with a local family-owned pharmacy, and the cost

could easily be negotiable.

Compared to the cost of re-hospitalization for unmanaged symptoms, even fifty dollars is less

than the standard emergency room visit, or hospital stay for each patient; investing in the patient early on

will help prevent wasted healthcare dollars in the big picture. In 2020 alone, Medicare underpayments to

hospitals due to re-hospitalizations were up to $100 billion from over $75 billion in 2019 (CMS, 2023). In

addition to healthcare cost savings, hospital referral source relationships will be more cohesive if the local

hospice can help keep down financial loss for the hospital. Most importantly, patient care and quality of

life can be improved by planning ahead. Auditing revocations for a specific time frame will measure the

plan's success with measurable and reportable data. This student will work with the quality team to

identify the patients who revoked their benefits and were hospitalized for symptom management before

and after the implementation of the comfort kit.

The American Nurses Association (ANA) states that all nurses should have basic skills in

recognizing and managing pain, dyspnea, nausea, constipation, and other unpleasant symptoms the

hospice patient may experience at the end of life (ANA, 2016). Training the hospice team and

implementing a comfort care kit protocol can help the healthcare team achieve the goals of symptom

management. As stated in prior written works, this author’s goals are to continuously search for ways to

recognize the importance of end-of-life care, improve processes for end-of-life care, and disseminate

evidence-based knowledge to all healthcare professionals.

GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 8

References

American Nurses Association Center for Ethics and Human Rights. (2016). Nurses' roles and

responsibilities in providing care and support at the end of life. Silver Spring, MD: American

Nurses Association. https://www.nursingworld.org/~4af078/globalassets/docs/ana/ethics/

endoflife-positionstatement.pdf

Atokoro, M. (2019). [Emergency medication kits in home palliative care]. Cancer and

Chemotherapy, 46(2), 205–208. https://pubmed.ncbi.nlm.nih.gov/30914518/

Centers for Medicare and Medicaid Services. (2023). Find & compare providers near you. Medicare.gov.

Retrieved 6/16/2023, from https://www.medicare.gov/care-compare/details/hospice/011591?

city=Trussville&state=AL&zipcode=35173#ProviderDetailsQualityIndicatorsContainer

Centers for Medicare and Medicaid Services (CMS). (2023). Hospice Quality Reporting Measures:

Current Measures. cms.gov. Retrieved 6/16/2023, from https://www.cms.gov/medicare/quality-

initiatives-patient-assessment-instruments/hospice-quality-reporting

Gerlach, L. B., Zhang, L., Strominger, J., Kim, H. M., Teno, J., Bynum, J. P. W., & Maust, D. T. (2022).

Variation in benzodiazepine and antipsychotic prescribing among hospice agencies. Journal of

General Internal Medicine: JGIM, 37(15), 3814-3822. 10.1007/s11606-022-07604-3

Good Rx. (2023). Search for your prescription and start saving now. https://www.goodrx.com. Retrieved

6/23/2023, from https://www.goodrx.com/go/homepage-lander-sem-7-tl?c=homepage-lander-

sem-

7&utm_campaign=127243741&utm_content=121594328045&utm_source=google&utm_mediu

m=cpc&utm_term=kwd-979791501822&gclid=CjwKCAjwhdWkBhBZEiwA1ibLmA-

EHKXKJ2I1cyEX0Mw8fTrnWY7s7FIdI5gReUlAdBIPZ1FTqef5FBoCEhAQAvD_BwE&gclsrc

=aw.ds&ajs_event=Experiment%20Viewed&ajs_prop_experiment_name=Next%20Best

%20Action%20on%20SEM-7&ajs_prop_variation_name=Variation_1&ajs_prop_path=/go/

homepage-lander-sem-7-tl&ajs_aid=09af1008db04481a95e2e285ccd4956d
GAP ANALYSIS: EMERGENCY COMFORT KIT PROTOCOLS 9

Hospice and Palliative Care Nursing Association, (HPNA). HPNA Nursing Care Resource Guide:

Anxiety. https://www.advancingexpertcare.org. Retrieved 6/23/2023,

from https://www.advancingexpertcare.org/wp-content/uploads/2023/03/NRG_Anxiety-Final-

2023.pdf

Hospice and Palliative Care Nurses Association. (2022). HPNA Nursing Care Resource Guide: Care of

the patient nearing the end of life. https://www.advancingexpertcare.org. Retrieved 6/23/2023,

from https://www.advancingexpertcare.org/wp-content/uploads/2023/03/NRG_End-Of-Life-FINAL-

2023.pdf

National Hospice and Palliative Care Organization. (2018). Standards of practice for hospice programs:

Professional development and resource series. https://www.nhpco.org. Retrieved 6/16/2023,

from https://www.nhpco.org

Phongtankuel, Veerawat, MD, MS, Adelman, Ronald.D., MD, Trevino, Kelly, Ph.D., Abramson, Erika,

MD, MSc, Johns, Phyllis, MBA, Oromendia, Clara, MS, Henderson, Jr., MA, & Reid, M.C., MD,

Ph.D. (2018) Association between nursing visits and hospital-related dis-enrollment in the home

hospice population. American Journal of Hospice and Palliative Medicine 35 (2) 316-323. doi:

10.1177/1049909117697933

Staats, K., Tranvåg, O., & Grov, E. K. (2018). Home-Care nurses’ experience with medication kit in

palliative care. Journal of Hospice and Palliative Nursing, 20(6), E1-E9.

10.1097/NJH.0000000000000518