Palliative Care and Emergency Medicine: An Evolving Frontier of Integration

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Palliative Care and Emergency Medicine An
Evolving Frontier of Integration

• Tammie E. Quest, MD
• Director, IPAL-EM
• Sponsored by
• Center to Advance Palliative Care and
• The Olive Branch Foundation

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Learning Objectives

• Define palliative care and the intersection of
  palliative care core principles and practice in
  emergency care
• Identify trends in palliative care in the
  emergency department
• Explore practical best practice models of
  palliative care in the emergency department on
  common illness trajectories
• Introduce the IPAL-EM Portfolio

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Special AcknowledgementThe IPAL-EM Advisory Board

• David Weissman, MD
• (Associate Director)
• Jennifer Raiten
• (Project Coordinator)
• Colleen M. Mulkerin, MSW
• Corita R. Grudzen, MD, MSHS
• Denise G. Waugh, MD
• Eric N. Bryant, MD
• Garrett Chan, PhD, APRN
• Knox H. Todd, MD, MPH
• Patricia J. O'Malley, MD
• Paul L. DeSandre, DO
• Robert J. Zalenski, MD
• Sangeeta Lamba MD

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What Is Palliative Care Integration?

• The term integration is used to indicate the
• incorporation of palliative care principles1 into
  
• daily practice, with or without the involvement
• of a dedicated hospital palliative care team or
• inpatient palliative care unit.
• 1. Palliative Care Principles
• Palliative care is patient-centered care focused
  around patient-determined goals of care.
• The focus is on relief of suffering physical,
  psychological, spiritual.
• Patient and family are the unit of care.
• Palliative care services are appropriate in all
  phases of a life-threatening or limited condition.

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The ED A Critical Site of Care Delivery

• Initial care trajectories are started in the ED
• Communication with patient/caregivers about
  illness/treatment options
• Degree of medical intervention (e.g.,
  ventilation, vasopressors, antibiotics)
• Site of care determined (e.g., ICU, ward, home)
• Yet we know that palliative care services are
  poorly integrated into ED culture/practice.

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The ED A Critical Site for Palliative Care
Delivery

• The Emergency Department is the Safety Net for
  the Acute and Chronically Seriously ill
• 116 M visits per year
• 14 M admitted to the hospital
• 1.1 M from the nursing home
• 1.6M admitted to ICU
• 139,000 died in the ED
• As the population ages, ED visits for crisis
  events in the setting of serious, chronic illness
  are likely to increase

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Key Issues in Emergency Care in the US

• ED Overcrowding
• ED Boarding
• Shortage of On-Call Physicians
• Local crisis and disaster response

Future of Emergency Medicine Institute of
Medicine Report 2007
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Emergency Medicine The Clinical Practice

• Challenges
• Practice is high distraction
• interruptions every 3-6 minutes for 8-12 hrs
• High medico-legal risk
• Clinician and operational efficiency is valued
• Pressure to deliver quality in quantity

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Emergency Medicine The Clinical Practice

• Proud
• Safety net for all
• Problem Solvers
• Will try to handle it
• Receptive to new ideas

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Key to Palliative Care Integration

• Keep the message
• Simple
• Organized
• Systems Sensitive

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Expected Benefits of Integration

• Patient Centered
• Improved control of physical symptoms
• Reduced family anxiety, depression, and
  post-traumatic stress disorder
• Timely implementation of care plans that are
  realistic, appropriate, and consistent with
  patients preferences
• Fewer conflicts about use of life-sustaining
  treatments
• Earlier transition to appropriate community
  resources (e.g. hospice)

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Understanding Patient Flow in theEmergency
DepartmentInput-Throughput-Output
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Models of ED Palliative Care Integration
See Emerging Programs - http//www.capc.org/ipal/i
pal-em/emerging-programs
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Three Basic Models that EDs are Using

• I. ED Primary Palliative Care
• II. ED Specialist in Palliative Care in the ED
• III. Consult Hospital-Based Palliative Care

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I. ED-Palliative Care Consult Only(Most Common)
Emergency Department
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II. ED Primary Palliative Care The ED is the
Nucleus
Emergency Department
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III. ED Palliative Care Specialist Tertiary
Expertise in the ED
Emergency Department
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Observed Models of Integration

• Phone Interviews of ED/Palliative Care programs
  in the US by IPAL-EM Advisory Board Members
• Various Settings
• Academic/University
• Public Hospitals
• Community

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Observed Models of Integration

• Clinical Models Features
• Embed Palliative Care/Hospice Staff in ED
• Help ED staff do more primary PC
• Trigger system for patient identification
• Facilitated referral to PC Unit or PC consult in
  ED
• Focused population targeted
• Bereavement program

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Observed ModelsTypes of Outcomes Measured

• ED throughput
• Hospice referrals
• Cost (Direct/Savings)
• Symptoms/QOL
• PC consults or PCU admits
• ICU utilization
• ED staff stress
• Avoided Hospitalizations Patient
• Family satisfaction

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Observed Models Try Something that Works in
Your Setting
Techniques Program Program Program Program Program Program Program Program
Techniques A B C D E F G H
Embed Palliative Care/Hospice Staff in ED ?   ?         ?
Help ED staff do more primary PC       ?   ?   ?
Trigger system for patient identification     ? ?   ?    
Facilitated referral to PC Unit or PC consult in ED       ? ?   ?  
Focused population targeted       ?         ?
Bereavement program   ?            
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Observed Models Reported Outcomes
REPORTED OUTCOMES A B C D E F G H
ED throughput   ?    ?  
Increased hospice referrals ?   ?  ?    
Reduced cost       ? ?  
Improved symptoms/QOL          
Increased PC consults or PCU admits ?   ?  ?         
Better ICU utilization ?       ?   ?
ED Staff stress reduced ? ?            
Hospitalizations avoided      ?  ? ?      
Patient/Family satisfaction             ?  
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Getting Started orMaking what we have even
better.
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IPAL-EM Opening Portfolio

• Making the Case
• Evaluation of ED-PC Metrics and Quality
• Four Things to do in one week
• Getting Started
• PC ED Screening Tool
• Clinical Practice Guidelines for Quality
  Palliative Care in the ED
• Clinical Practice Guidelines for Quality
  Palliative Care in the ED Self Assessment
• Billing for Palliative Care in the ED
• Consultation Etiquette

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Making the Case

• Type Slide presentation
• Key talking points, evidence, guidelines
• Target Audience
• Hospital administrators
• ED staff
• Why should we do this?

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Getting Started Organizing an ED Palliative
Care Initiative

• Type Monograph, Technical Assistance
• Practical First Steps to organized an
  ED-Palliative Care Initiative
• convene a workgroup
• assess needs and resources
• develop an action plan
• engage the entire ED team

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ED-PC Clinical Practice Guidelines

• Type Guidelines
• Eight domains of palliative care
• Modified to ED Specific Guidelines
• Guidelines and Indicators
• Best Practices in ED Primary Palliative Care

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ED-PC Clinical Practice Guidelines Self
Assessment

• Type Checklist
• Partner document of the guidelines
• Allows the ED to perform a self assessment and
  then choose key areas to focus on

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Evaluation of ED-PC Metrics Quality

• Three categories of metrics are recommended
• Operational metrics to assess patient flow,
  disposition, readmissions and resource
  utilization
• II. Clinical metrics to assess quality of
  clinical care
• services
• Customer metrics to assess satisfaction data
• from patients/families

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Key Factors When Deciding on Metrics

• ED size
• Admission rate
• Availability of critical care/ICU
• Availability of a palliative care service,
  inpatient palliative care unit
• Local hospice providers
• Special populations (e.g. patient with Sickle
  Cell Disease, Pulmonary Fibrosis, Advanced Heart
  Failure/LVAD)

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Four Things to Do in a Week

• Type Monograph, Technical Assistance
• Quick Method to get efforts started
• Identify your ED champions
• Review the existing literature
• Identify local hospice and palliative care
  resources.
• Develop a plan to complete a needs assessment

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Consultation Etiquette

• Type Slide Presentation
• Focuses on the Palliative Care Consultant in the
  ED

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Consultation EtiquetteEnhancing the
EDPalliative 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.

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Billing for Palliative Care in the ED for ED
Providers

• Type Monograph, Technical Assistance
• Key Points How Emergency Clinicians Bill for
  Primary Palliative Care Efforts in the ED
• Critical care time
• Parenteral administration of controlled
  substances
• Goals of care discussions

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ED Palliative Care Screening Tool

• Type Monograph, technical assistance

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ED Palliative Care Screening Tool Target
Populations Simple, Organized, Systems
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ED Palliative Care Screening Tool Timing/Urgency
Component for Palliative Care Referral
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Expansion of the IPAL-EM Portfolio

• More to come
• Looking for programs to add information to IPAL
  resources tools, cards, protocols.
• Contact jennifer.raiten_at_mssm.edu
• Future opportunity to submit demonstrations of
  the portfolio at CAPC 2012 National Seminar
  stay tuned!

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What Might Better EDPalliative Care Integration
Yield?

• Patient-Centered
• Improved control of physical symptoms
• Reduced family anxiety, depression and
  post-traumatic stress disorder
• Timely implementation of care plans that are
  realistic, appropriate and consistent with
  patients preferences
• Fewer conflicts about use of life-sustaining
  treatments
• Earlier transition to appropriate community
  resources (e.g., hospice)

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What Might Better EDPalliative Care Integration
Yield?

• System-Focused
• Improved ED/Hospital Metrics
• Less ED crowding
• Less use of nonbeneficial treatments
• Reduced hospital length of stay
• Fewer readmissions
• Fewer inpatient and ICU deaths
• Improved Patient Safety
• Smoother transitions across care sites

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What Might Better EDPalliative Care Integration
Yield?

• Better Resource Utilization
• Integration of palliative care into hospitals has
  been shown to improve care and reduce cost.
• Cost avoidance occurs as a direct result of
  better matching of patient/family-centered goals
  of care with use of life-sustaining treatments.
• In practice, this means fewer ICU days and less
  use of high-cost, minimal-impact life-sustaining
  treatments.

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Live Q A Period
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Continue the Discussion . . .

• At the conclusion of this audio conference,
• we welcome you to continue the discussion with
• your peers and faculty on CAPCconnectTM Forum!
• Go to http//www.capc.org/forums
• to post your message and comments within
• Palliative Care and Emergency Medicine
• discussion topic!