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Moving Palliative Care into the Emergency Department: Ensuring the Right Care for Seriously Ill Patients

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Moving Palliative Care into the Emergency Department: Ensuring the Right Care for Seriously Ill Patients Right from the Beginning CAPC audio conference – PowerPoint PPT presentation

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Title: Moving Palliative Care into the Emergency Department: Ensuring the Right Care for Seriously Ill Patients


1
Moving Palliative Care into the Emergency
Department Ensuring the Right Care for
Seriously Ill Patients Right from the Beginning
  • CAPC audio conference
  • January 11, 2007

2
Philip Santa-Emma, MD, FAAHPMSharol L. Herr,
RN, MSEdMount Carmel HealthColumbus, OhioJ.
Brian Cassel, PhDMassey Cancer CenterVirginia
Commonwealth UniversityRichmond, Virginia
3
Importance 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

4
Current 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.

5
Where 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

6
How 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

7
SWOT 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

8
Perspective 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.

9
Examples 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
10
Mount 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

11
Mount 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

12
Mount Carmel
  • Focus Group Interviews with ED Physicians,
    Nurses, Social Workers, Chaplains
  • Training of resource team comprised of
  • MSWs
  • Case Managers
  • Chaplains

13
Mount 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

14
Mount Carmel
  • Establishing tools and resources
  • Algorithm for patient identification
  • PC standardized order set
  • Prompt on ED computerized documentation system

15
Mount 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

16
Indicators 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

17
Indicators 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

18
Mount Carmel Data
19
Mount Carmel Data
20
Mount Carmel Data
21
VCU volume
22
VCU data
Medical DRGs admitted through ED, ending in death.
VCU Medical Center
23
VCU 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
24
Financial 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.

25
Financial 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.

26
Strategies 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

27
Strategies 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.

28
Strategies 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

29
Conclusions 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
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