Title: Moving Palliative Care into the Emergency Department: Ensuring the Right Care for Seriously Ill Patients
1Moving Palliative Care into the Emergency
Department Ensuring the Right Care for
Seriously Ill Patients Right from the Beginning
- CAPC audio conference
- January 11, 2007
2Philip Santa-Emma, MD, FAAHPMSharol L. Herr,
RN, MSEdMount Carmel HealthColumbus, OhioJ.
Brian Cassel, PhDMassey Cancer CenterVirginia
Commonwealth UniversityRichmond, Virginia
3Importance of the ED
- Most severely-chronically ill patients enter
hospitals through the ED - The ED is where goals of care for that episode
are determined - Treatments are initiated
- Intensity / trajectory is set
- Triage (often to ICU) occurs
- Physicians and staff have (initial) discussions
with patients, families
4Current Status
- The Emergency Departments focus is throughput
and disposition, not development of care goals - Resource utilization is supply-sensitive and
increased intensity specialist use not
correlated positively with quality, outcomes,
satisfaction - The Care of Patients with Severe Chronic Illness
A Report on the Medicare Program.
http//www.dartmouthatlas.org/atlases/2006_Chronic
_Care_Atlas.pdf - Fewer patients dying in hospitals but intensity
of care at EOL is increasing for those
hospitalized. - Barnato et al (2004) "Trends in inpatient
treatment intensity among Medicare beneficiaries
a the end of life". Health Services Research
39 363-375. - Quality of care for severely, chronically ill is
often poor - SUPPORT study Shugarman, LR, Lorenz, K, Lynn, J
(2005). End-of-life care An agenda for policy
improvement. Clinics in Geriatric Medicine 21,
255-272.
5Where does Palliative Care fit ?
- Palliative Care Consultative Services care
coordination function can - resolve symptoms
- clarify or change goals of care
- conduct constructive family meetings
- resolve patient/family/physician conflict
- determine discharge plan of care
- But, most Palliative Care programs are designed
to receive consults and referrals after
admission, and are not designed to help in the ED
or receive patients directly from the ED
6How could the scenario change?
- If PC and ED were better connected we might
expect - Improved symptom management
- More PC consults initiated in the ED
- More patients admitted directly into PC service
or unit from the ED - Fewer patients triaged to ICU
- Better clinical and financial outcomes
7SWOT Analysis
- Strengths
- ED physicians and triage nurses are the
gatekeepers which narrows focus of education - Weaknesses
- Few prototypes of PC-ED connection to date
- PC services downstream, arriving later in
admission - Opportunities
- ED overcrowded, overburdened, under-resourced
ICUs bottlenecked - Threats
- Lack of education about PC and misperceptions may
undermine efforts to improve relationship
8Perspective of ED physicians
- Dr. Knox Todd, Beth Israel Medical Center, NYC
- The emergency department is a bottleneck and a
staging areaa place of transition for many
patients, whether from one health plan to another
or one stage of life to another. Its a place of
crisis and opportunitywhere changes in treatment
philosophy are easier to implement. - Dr Robert Zalenski, Wayne State University
- The contemporary physician should be able to
assess patients needs and support their wishes
regarding either time extension and/or a comfort-
based approach, whether such decisions need to be
made in the emergency department, ICU, medical
ward or outpatient setting. - Dr. Tammie Quest, Emory Hospital and Grady
Hospice - The focus and goal of emergency medicine is
disposition. We need prompt and eager response.
If we can even just get someone on the telephone
to discuss the case with us, it helps with
disposition. - The hospice and palliative medicine community
hasnt really tapped into us the way they might,
but emergency physicians think palliative
medicine is a no-brainer. My goal is to bring
emergency physicians along to the point where we
have established a floor of palliative medicine
skills and competencies. But then to have
hospital-based palliative care available to
respond to the difficult cases would be ideal.
The iron is hot for doing this right now.
9Examples of Connecting PC and ED
- Mount Carmel
- 3-Hospital system
- Faith-based, community hospitals
- Integrated with hospice and home care programs
- Virginia Commonwealth University
- Urban, academic medical center, safety net
hospital - PC consult team, 11-bed dedicated PC unit, and
pain / palliative care outpatient clinic in
cancer center
VCU Medical Center
10Mount Carmel
- Six sigma project to increase direct admits (DA)
to PC from the ED - PC LOS essentially same for patients either
directly admitted from ED or coming to PC later
11Mount Carmel
- Survival for discharge higher for patients DA
than transferred - Opportunity to improve throughput
- Directs patients to most appropriate level of
care rather than ICU or telemetry - Extensive education and training initiatives to
develop resource team
12Mount Carmel
- Focus Group Interviews with ED Physicians,
Nurses, Social Workers, Chaplains - Training of resource team comprised of
- MSWs
- Case Managers
- Chaplains
13Mount Carmel
- Focus of training
- Advance Care Planning
- Communication and difficult discussions
- Working with families and patients to establish
goals of care - Use of algorithm and medical record to identify
PC appropriate patients - Review of disease specific guidelines
14Mount Carmel
- Establishing tools and resources
- Algorithm for patient identification
- PC standardized order set
- Prompt on ED computerized documentation system
15Mount Carmel
- Establishing tools and resources (cont)
- Contact information for PC consult service
- Nursing leadership to facilitate direct admission
- Patient and family education resources
- Responsive, collaborative APCU staff, team
16Indicators for admission to the palliative care
unit or palliative consultation
- Patient transferring from SNF DNR ( CC or CC
Arrest) status established or requested - Patient actively dying in pain and discomfort
- Patient currently enrolled in a community hospice
- Previously discharged from MC Acute Palliative
Care Unit - Multiple admissions to the hospital (2 or more
within 6 months) with same symptoms
17Indicators for admission to the palliative care
unit or palliative consultation
- Patient with advanced disease with frequent
infections - Nutritional complications with an albumin of less
than 2.5mg/dl - Primarily bed bound
- Advanced disease with enteral feeding in place
- Sudden acute event such as CVA
- Patient with advanced disease being admitted for
Peg/trach placement - Disease Triggers Malignant Neoplasm esp Lung
Cancer Aspiration Pneumonia, COPD, HF,
Septicemia, Bone Mets, Renal Failure, Hemorrhagic
Stroke
18Mount Carmel Data
19Mount Carmel Data
20Mount Carmel Data
21VCU volume
22VCU data
Medical DRGs admitted through ED, ending in death.
VCU Medical Center
23VCU ED admits ending in death
Adults admitted through ED, medical DRGs,
admissions ending in death, 2001-2005, LOS 3
days, (n728)
Cassel JB Lyckholm LJ 2006 Identifying
Palliative Care Needs in the Emergency
Department Better Care, Lower Cost. Poster
presented at the Southeast regional conference
(March 25 2006, Greensboro NC) and the national
conference (May 19 2006, San Francisco, CA) of
the Society for Academic Emergency Medicine.
VCU Medical Center
24Financial Issues
- While the financial impact is not the driving
reason for connecting the PC and the ED,
questions arise that deserve discussion. - Palliative care consults conducted for patients
10-20 days after admission may control costs
e.g., reduce losses during the last few days
prior to discharge or death, and perhaps affect
the LOS. They do not affect the DRG in most
cases, as they do not change the primary
diagnosis or procedure.
25Financial Issues
- In contrast, initiating palliative care in the ED
may change the goals of care for that admission,
affect the procedures and use of the ICU, and
DRG. Therefore both costs and reimbursement may
be affected. - That being said, at many hospitals typical cases
for which PC is brought in late in the case are
already financial losses, while relatively short
admissions direct to PC may be profitable on
average.
26Strategies to make it happen
- Training, education in the ED
- improving primary palliative care in the ED
- identifying PC-appropriate patients
- seeking PC help for most complex patients
- Marketing
- increase PC consults in ED
- Protocols and triggers
- for consults and direct admissions
27Strategies to make it happen
- ED Observation Units
- a setting to resolve symptoms and discharge home,
or for family meeting and possible PC admission - Other ways to make direct admission easier
- an issue especially on nights and weekends if PC
service not 24/7 - work with residents and attendings in charge of
admissions hospitalists etc.
28Strategies to make it happen
- Dedicated PC specialists in ED?
- few MDs have necessary breadth and depth of
training but NPs, RNs and social workers may be
able to help identify and increase referrals
29Conclusions and Questions
- While both Mount Carmel and VCU have dedicated
units, we do not believe units are necessary for
better linking and coordinating PC and the ED - The goal is to provide best possible care for
patients, right from the start