CAPC audio conference January 11, 2007

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 Department’s 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; ICU’s 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 area—a place of transition for many patients, whether from one health plan to another or one stage of life to another. It’s a place of crisis and opportunity—where 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 hasn’t 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: • MSW’s • 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, (n=728) 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