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CONSULTATION ETIQUETTE FOR PALLIATIVE CARE IN THE EMERGENCY

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CONSULTATION ETIQUETTE FOR PALLIATIVE CARE IN THE EMERGENCY DEPARTMENT A Presentation of the IPAL-EM Project Sponsored by the Center to Advance Palliative Care and – PowerPoint PPT presentation

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Title: CONSULTATION ETIQUETTE FOR PALLIATIVE CARE IN THE EMERGENCY


1
Consultation Etiquette ForPalliative Care In The
Emergency Department
A Presentation of the IPAL-EM Project
  • Sponsored by the
  • Center to Advance Palliative Care and
  • The Olive Branch Fund

? 2011 Center to Advance Palliative Care 1
2
Learning Objectives
  • Describe key elements of ED practice/culture that
    palliative care consultants need to be aware of.
  • Review 10 steps of effective palliative care
    consultations in the ED.
  • List three methods for improving palliative
    careED relationships.

3
EDPalliative Care Collaboration
  • ED staff members recognize that asking a
    palliative care clinician to come to the ED can
    help in . . .
  • Attempting to rapidly achieve consensus about
    goals of care
  • Assisting with challenging symptom management
    problems
  • Developing creative disposition plans
  • Freeing up the ED staff to attend to other
    patients

4
ED Physician Comment
  • I am now a HUGE fan of having palliative
    care in the ED, and recommend getting consults or
    referrals much more often. It really has made the
    difference between just moving a body through the
    system and making a patient feel we care! And
    that means everything at times.


5
EDPalliative Care Collaboration
  • Focus on throughput-output phase
  • Palliative care clinicians recognize that ED
    clinicians have operational needs to keep the
    flow of patients moving as expeditiously as
    possible.

6
Consultations in theEmergency Department
  • Core concept of input-throughput-output
  • Consultants effect throughput and output phases.
  • 2040 of ED patients required a consultation to
    manage disposition.
  • Up to 68 of patients consulted may be admitted.
  • ED consultation time targets 3045 minutes based
    on the nature of the problem
  • Vosk A. Ann Emerg Med. 1998 Nov32(5)57477
  • Hexter DA. ACEP Foresight. 2002 Feb53.

7
Understanding Patient Flow in theEmergency
DepartmentInput-Throughput-Output
8
Categories of ED Consults
  • Consultation for admission (most common)
  • Consultation for opinion only, where the patient
    can be discharged but an opinion is needed for
    specific investigations or outpatient
    arrangements
  • Consultation for treatment or special procedure,
    where a consultant assists with management of a
    specific problem
  • Consultation for transfer of care, where a
    consultant takes over care of the patient
  • Consultation for outpatient referral of patient
    sent for outpatient follow-up

  • Lee
    RS et al. Emerg Med J. 2008 Jan25(1)49

9
Common Reasons for Delaysin ED Consults
  • Delays in consultation response times
  • inconvenience
  • competing priorities
  • lack of financial incentives
  • shortage of physicians
  • failure to enforce rules regarding policies on
    consultants
  • Weston K. Clinical Initiatives Center/The
    Advisory Board Company ED Watch. 20004

10
What Is a Successful Consultation ?
  • You have met one or more of the following needs
    of your referring clinician
  • Answered a question
  • Provided leadership in decision making
  • Improved symptom control
  • Provided knowledge about prognosis
  • Assisted in disposition planning
  • Provided emotional support
  • Improved clinician efficiency

11
Principles of Consultation EtiquetteAdapted
from Goldman L, Lee T, Rudd P. Arch Intern Med.
1983 Sep143(9)175355
  • 1. Determine the question
  • 2. Establish urgency
  • 3. Gather additional data
  • 4. Brevity
  • 5. Specificity
  • 6. Plan ahead
  • 7. Honor turf
  • 8. Teach with tact
  • 9. Personal contact
  • 10. Provide follow-up

12
1. Determine the Question
  • Ask the ED clinician how you can best help
    him/her what question(s) you can answer?
  • Symptom control issue?
  • How to proceed clinically based on goals?
  • Acceptability/indication for an urgent/emergent
    intervention (e.g., should we intubate, place
    central line, initiate emergent dialysis, etc.)
  • Disposition issue?

13
1. Determine the Question (cont.d)
  • Define the action steps needed by the consultant
  • Leadership for disposition planning?
  • Order writing for symptom control?
  • Leadership for sensitive communication with
    patient/family?

14
2. Establish Urgency
  • Requests for consultation can be divided into two
    levels of urgency based on the request from the
    ED clinician
  • Emergent
  • Respiratory failure, decision needed whether to
  • intubate or not
  • Pain out of control
  • 2. Urgent
  • Patient is medically stable question of hospice
  • appropriateness and direct hospice referral
    from ED

15
2. Establish Urgency (cont.d)
  • Who will arrive and when
  • Determine which palliative care team member can
    best meet the request.
  • Be honest about your availability and who will
    come.
  • I feel like our social worker could get started
    she can be there in 20 minutes. Is that soon
    enough?
  • If unable to meet the requested need, offer
    alternative options to assist the ED staff.

16
3. Gather Additional Data
  • Consultants are most effective when they are
    willing to create their own impressions from all
    available data.
  • This likely will require more input than the ED
    already has from . . .
  • Family and primary physician
  • Medical record review
  • Pharmacy records

17
4. Brevity
  • Much of the consultants helpfulness is in the 2-
    to 4-minute verbal review of recommendations
    immediately after the consult.
  • It is very helpful to let the ED provider know
    you will supply documentation to assist in
    his/her dictation/electronic report.
  • The disposition plan and follow-up plan should be
    explicit.

18
5. Specificity
  • Make very specific recommendations
  • Pain Given prior history of MS Contin 180mg po
    bid/morphine 30mg 4 times daily and pain is still
    moderate to severe, recommend 6mg/hr IV/sq
    morphine with 2mg IV/sq q 10 minutes prn
    breakthrough pain.
  • Nausea Haldol 1mg IV/sq now and q 2 hours up to
    4 doses based on lack of response to phenergan.
  • Anxiety lorazepam 1mg IV/sq q 6 hours.
  • Spiritual Chaplain called to provide Sacrament
    of the Sick.
  • Psychosocial Will need discharge planning as
    soon as possible social worker Mary Smith has
    been contacted to see patient.

19
5. Specificity (cont.d)
  • Make feasible recommendations.
  • The ED may have policies/protocols for
    drugs/treatments that differ from those in the
    inpatient setting.
  • Before making definitive recommendations, check
    with ED staff to ensure that your recommendations
    are feasible without disrupting normal ED
    operating procedures.

20
6. Plan Ahead
  • Be prepared to arrange the follow-up.
  • As the palliative care expert, you are in the
    best position to help both the patient/family and
    the referring clinician look ahead to plan for
    expected problems and who may help.
  • This is especially important for patients who are
    not admitted to the hospital but return home or
    to another care site.
  • Detail the future problems you anticipate and how
    to manage these.
  • Physical and emotional symptoms
  • Drug/treatment side effects
  • Family concerns

21
7. Honor Turf
  • Appreciate the complexity.
  • I know that things are very busy here so I want
    to establish how I can best help.
  • Ask what is needed explicitly.
  • Leadership for disposition planning?
  • Order writing for symptom control?
  • Leadership for sensitive communication with
    patient/family?
  • Anticipate shift changes.
  • Recognize that the ED is an environment of shift
    changes.
  • New staff members come every 812 hours and may
    need help understanding the case, context and
    complexity.

22
8. Teach with Tact
  • Every consult is a teaching opportunity avoid
    judgment.
  • Make 12 teaching points in a case.
  • Sometimes what we find works best is changing
    the opioid to get pain control. These cases are
    difficult.
  • Place a Fast Fact (www.eperc.mcw.edu) on the
    chart.
  • I have left some quick guides that I use in my
    practice for symptoms that you might find
    helpful.
  • If requested, send a key reference article to the
    ED staff following the consultation.
  • I can email you something about management of
    malignant bowel obstruction if you would find
    that helpful. The topic can be complex.

23
9. Personal Contact
  • Find the ED clinician who called you, but
    understand that he/she may have signed out to
    shift work.
  • Referring clinicians want to be kept in the
    loop in a timely manner.
  • Any discussion regarding disposition should be
    discussed with the clinician before the family.
  • When in doubt as to the referring clinicians
    actions/plans, ASK.

24
10. Provide Follow-up
  • Offer to contact the admitting team/outpatient
    providers and review your consultation
    recommendations.
  • Renegotiate palliative care involvement with the
    admitting team.
  • Provide the palliative care physician with a copy
    of your EMR/dictation and call the palliative
    care physician from the ED with any major changes
    in care.
  • ED clinicians will appreciate follow-up on shared
    cases. It is comforting to hear there has been
    continuity of care.

25
Enhancing theEDPalliative Care Relationship
  • To many palliative care clinicians, the ED can
    seem intimidating due to the rapid pace and
    seriousness of clinical problems.
  • To better learn about ED culture and practice,
    palliative care clinicians can
  • spend a half-day in the ED shadowing ED staff.
  • review ED symptom management policies/protocols.
  • gather with key ED staff for a one-hour meeting
    to learn their common needs around care of
    palliative care patients.
  • assist ED staff to develop or facilitate ED
    debriefings following death or troubling
    encounter.

26
Enhancing theEDPalliative Care Relationship
(cont.d)
  • Invite ED staff to make rounds with the
    palliative care team.
  • Develop collaborative protocols for
    identification of potential unmet needs of
    patients typically referred for palliative care
    services.
  • Provide an in-service on community hospice
    resources.
  • Provide a pocket card with palliative care team
    members contact information.

27
Summary
  • Understanding the role of the consultant in the
    input-throughput-output model is key to success.
  • Understanding the principles of consultation
    etiquette will enhance the ability of palliative
    care teams to improve patient care in the
    emergency department and better meet the needs of
    ED staff.

28
References
  • Cohn SL. The role of the medical consultant. Med
    Clin North Am. 2003 Jan87(1)16.
  • Cortazzo JM, Guertler AT, Rice MM. Consultation
    and referral patterns from a teaching hospital
    emergency
  • department. Am J Emerg Med. 1993
    Sep11(5)45659.
  • Goldman L, Lee T, Rudd P. Ten commandments for
    effective consultations. Arch Intern Med. 1983
  • Sep143(9)175355.
  • Hexter DA. Working with consultants. ACEP
    Foresight. 2002 Feb53.
  • Lee RS, Woods R, Bullard M, Holroyd BR, Rowe BH.
    Consultations in the emergency department a
  • systematic review of the literature. Emerg Med J.
    2008 Jan25(1)49.
  • Salerno SM, Hurst FP, Halvorson S, Mercado DL.
    Principles of effective consultation an update
    for the 21st-
  • century consultant. Arch Int Med. 2007 Feb
    12167(3)27175.
  • Vosk A. Response of consultants to the emergency
    department a preliminary report. Ann Emerg Med.
    1998
  • Nov32(5)57477.
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