- Email: [email protected]
220 Targeted Palliative Care Initiative in the Emergency Department
Research Forum Abstracts
218 219
Withdrawn The Recognition of Hospice-Eligible Patients in the Emergency Department: A Missed Opportunity
Bacci M, Harland K, Schlichting A, Nugent A/The University of Iowa Carver College of Medicine, Iowa City, IA; University of Iowa, Iowa City, IA
Background: Integrating palliative medicine and hospice services into emergency medicine has become a topic of interest, yet it remains unknown how often emergency department (ED) clinicians recognize that a patient is hospice eligible. This knowledge can substantially impact the quality of care these patients receive by introducing palliative care (PC) earlier. Study Objective: The study objectives were to identify and describe ED patients who are hospice eligible and if they were recognized as such by ED staff. To examine the recognition of these patients, we recorded the frequency of PC discussions [occurring in the ED], PC consults (PCC) initiated from the ED, and hospice referrals within eligible patients. Methods: A retrospective chart review was used to examine all ED visits of adults 65 years or older at a large academic medical center from September 2013 to November 2013 (n¼1886). All physician and social work notes up to and including the visit were evaluated for hospice eligibility from a prognostic standpoint using criteria adapted from the National Hospice and Palliative Care Organization (NHPCO) and Medicare guidelines. We chose to evaluate for hospice eligibility, as no objective method to evaluate for PC eligibility exists. All eligible patients were further reviewed for evidence of a PC discussion, PCC, and hospice referral. Patients already enrolled in hospice were excluded from the study. Results: Of the 1886 ED visits reviewed, 239 visits (12.7%) met hospice eligibility criteria. Of eligible visits, 115 (48%) were patients who had prior ED visits in the past 12 months, and of those with prior visits, 57/115 (49.6%) had multiple visits. PC discussions were documented at 18 of the 239 (7.5%) visits. A formal PCC (initiated in the ED) occurred in 6/18 (33.3%) visits, and a hospice referral was provided to 6/18 (33.3%). Conclusions: The majority of hospice-eligible patients over the age of 65 who visit the ED are not recognized (92.5%) and do not have a documented PC discussion in the ED. Despite the presence of a well-established PC service at the medical center, only a fraction of patients who likely would benefit from this service were given the opportunity to utilize it. This information has the potential both to improve the education of ED staff, and to improve the efficiency of electronic medical records via automated alerts occurring when patients meet predetermined criteria. Ultimately, this knowledge could improve the occurrence of early PC discussions, allowing patients to reap the maximal benefits of these services, as well as decrease the number of preventable ED visits by these patients.
220
Targeted Palliative Care Initiative in the Emergency Department
Shreves A, Sorge R, Chai E, Lee E, Newman D, Horton J, Goldstein N/Icahn School of Medicine at Mount Sinai, New York, NY
Study Objectives: For patients at the end of life, treatment focused on life prolongation can be burdensome, of limited or negative medical utility, and costly. The American College of Emergency Physicians, through the Choosing Wisely campaign, has suggested early referral from the emergency department (ED) for palliative care and hospice services. There is limited data assessing the feasibility of early referral or palliative care interventions in an ED population. Methods: We undertook an interventional study of a novel, emergency department-based, palliative care intervention for patients with advanced dementia and those actively dying with terminal illness. The project was designed as a quality improvement intervention, and deemed exempt for consent by our institutional review board. During the intervention period a palliative care physician stationed in the ED for 12 hours per week approached eligible patients on a convenience sample basis, introduced the concept of palliative care, attempted to address goals of care, and presented options regarding alternative care pathways, during a brief discussion (<1 hour). Care pathways were defined as primarily comfort focused, a combination of comfort focused and life prolongation, primarily life prolongation, or undecided. The primary outcomes of interest, pathway preferences before and after interaction, were recorded before and after the discussion on a structured data form completed by the palliative physician. For additional time-series comparisons, chart review data was collected by the project manager for administrative variables including direct admission
Volume 66, no. 4s : October 2015
to our institution’s palliative care unit and ED-to-hospice referrals during the 6month period prior to the intervention, and during the 10 months following the initiation of the intervention. All statistics were performed using STATA v.11 (College Station, TX). Results: During the 10-month intervention period 107 patients were targeted, 2 were lost to follow-up. In both the advanced dementia (n¼48) and actively dying (n¼57) groups patients were more likely to choose a treatment plan that included comfort measures after palliative intervention than before [dementia: 23% before, 45% after (P ¼ .012); actively dying: 21% before, 48% after (P ¼ .001)]. Overall, patients were significantly more likely following intervention to choose a pathway including comfort-focused care (OR 3.1; 95%CI: 1.7-5.7), and less likely to choose a pathway including life-prolonging therapy (OR 0.7; 95%CI: 0.4-0.8). Among admissions to our inpatient palliative care unit in the pre- and post-intervention periods there was a trend towards an increase in referrals directly from the ED (9% vs 14%, P ¼ .06). Other variables showed no significant changes. Conclusion: In our institution early palliative care involvement was feasible, and ED patients with advanced illness and their surrogates were often amenable to goals of care transitions. These findings support broader attempts to integrate and research palliative care interventions and alternative care pathways in ED care.
221
Utility of the Modified “Surprise Question” for Predicting Inpatient Mortality in Emergency Department Patients
Strout TD, Haydar SA, Han PJK, Bond AG/Maine Medical Center, Portland, ME; University of Virginia, Richmond, VA
Study Objective: Prognostication is an essential task in many domains of health care, but is of particular importance in end-of-life (EOL) care. Prognostic estimates delineate the EOL period, shape decisions about the goals of care, and trigger advance care planning efforts. As EOL and palliative care are increasingly incorporated into the emergency setting, useful prognostic tools that are valid and reliable for use with emergency patients are needed. The purpose of this study was to evaluate the predictive ability of the modified “surprise question” when used by emergency clinicians in the emergency department (ED) setting. Methods: Emergency physicians responded to the question, “Would you be surprised if this patient died in the next 30 days?” upon adult and pediatric admissions to a tertiary care center over a six-month period. Excluded were patients taken immediately to the operating room or cardiac catheterization laboratory and direct hospital admissions. Inpatient teams were blinded to the responses. Electronic health records were reviewed retrospectively for clinician’s responses to the surprise question, patient demographics, and hospital discharge disposition. The ability of emergency physician response to the surprise question to predict inpatient mortality was evaluated using chi-square analysis to compare the proportion of patients surviving to hospital discharge as well as with the area under the receiver operating characteristic (ROC) curve. Results: Data for 4,478 patients were evaluated; 48% were female and the median age was 63 years (IQR 43-77). Physicians responded that they would not be surprised if the patient died (negative response) in 12% (n¼536) of cases. Overall, 190 patients (2.4%) died prior to hospital discharge. Emergency clinicians provided negative responses indicting that they would not be surprised if the patient died in a significantly greater proportion of mortality cases (37%, 70/190) than survival cases (14%, 1076/7528), P < .001. The area under the receiver operating characteristic curve for the ability of the modified surprise question to correctly predict inpatient mortality was 0.613 (95% CI: 0.568 - 0.657), P < .001. The overall accuracy of the modified surprise question for correctly classifying those who did and did not die during hospitalization was 85% (95% CI: 84.2% 85.8%). Conclusions: In this setting and sample, emergency physician responses to the modified surprise question were a significant predictor of in-hospital mortality. Due to the exclusion of many high acuity patients who bypassed the usual admission process, the predictive ability of the surprise question may be greater than we observed in this study. Additional research is warranted to determine whether the surprise question is a stronger predictor of inpatient mortality in particular subgroups of the ED population and whether it can accurately predict mortality over the longer-term. Given the simplicity of the modified surprise question, it holds promise as an important prognostic tool to improve the delivery of end-of-life and palliative care in the emergency setting.
Annals of Emergency Medicine S81
218 219
Withdrawn The Recognition of Hospice-Eligible Patients in the Emergency Department: A Missed Opportunity
Bacci M, Harland K, Schlichting A, Nugent A/The University of Iowa Carver College of Medicine, Iowa City, IA; University of Iowa, Iowa City, IA
Background: Integrating palliative medicine and hospice services into emergency medicine has become a topic of interest, yet it remains unknown how often emergency department (ED) clinicians recognize that a patient is hospice eligible. This knowledge can substantially impact the quality of care these patients receive by introducing palliative care (PC) earlier. Study Objective: The study objectives were to identify and describe ED patients who are hospice eligible and if they were recognized as such by ED staff. To examine the recognition of these patients, we recorded the frequency of PC discussions [occurring in the ED], PC consults (PCC) initiated from the ED, and hospice referrals within eligible patients. Methods: A retrospective chart review was used to examine all ED visits of adults 65 years or older at a large academic medical center from September 2013 to November 2013 (n¼1886). All physician and social work notes up to and including the visit were evaluated for hospice eligibility from a prognostic standpoint using criteria adapted from the National Hospice and Palliative Care Organization (NHPCO) and Medicare guidelines. We chose to evaluate for hospice eligibility, as no objective method to evaluate for PC eligibility exists. All eligible patients were further reviewed for evidence of a PC discussion, PCC, and hospice referral. Patients already enrolled in hospice were excluded from the study. Results: Of the 1886 ED visits reviewed, 239 visits (12.7%) met hospice eligibility criteria. Of eligible visits, 115 (48%) were patients who had prior ED visits in the past 12 months, and of those with prior visits, 57/115 (49.6%) had multiple visits. PC discussions were documented at 18 of the 239 (7.5%) visits. A formal PCC (initiated in the ED) occurred in 6/18 (33.3%) visits, and a hospice referral was provided to 6/18 (33.3%). Conclusions: The majority of hospice-eligible patients over the age of 65 who visit the ED are not recognized (92.5%) and do not have a documented PC discussion in the ED. Despite the presence of a well-established PC service at the medical center, only a fraction of patients who likely would benefit from this service were given the opportunity to utilize it. This information has the potential both to improve the education of ED staff, and to improve the efficiency of electronic medical records via automated alerts occurring when patients meet predetermined criteria. Ultimately, this knowledge could improve the occurrence of early PC discussions, allowing patients to reap the maximal benefits of these services, as well as decrease the number of preventable ED visits by these patients.
220
Targeted Palliative Care Initiative in the Emergency Department
Shreves A, Sorge R, Chai E, Lee E, Newman D, Horton J, Goldstein N/Icahn School of Medicine at Mount Sinai, New York, NY
Study Objectives: For patients at the end of life, treatment focused on life prolongation can be burdensome, of limited or negative medical utility, and costly. The American College of Emergency Physicians, through the Choosing Wisely campaign, has suggested early referral from the emergency department (ED) for palliative care and hospice services. There is limited data assessing the feasibility of early referral or palliative care interventions in an ED population. Methods: We undertook an interventional study of a novel, emergency department-based, palliative care intervention for patients with advanced dementia and those actively dying with terminal illness. The project was designed as a quality improvement intervention, and deemed exempt for consent by our institutional review board. During the intervention period a palliative care physician stationed in the ED for 12 hours per week approached eligible patients on a convenience sample basis, introduced the concept of palliative care, attempted to address goals of care, and presented options regarding alternative care pathways, during a brief discussion (<1 hour). Care pathways were defined as primarily comfort focused, a combination of comfort focused and life prolongation, primarily life prolongation, or undecided. The primary outcomes of interest, pathway preferences before and after interaction, were recorded before and after the discussion on a structured data form completed by the palliative physician. For additional time-series comparisons, chart review data was collected by the project manager for administrative variables including direct admission
Volume 66, no. 4s : October 2015
to our institution’s palliative care unit and ED-to-hospice referrals during the 6month period prior to the intervention, and during the 10 months following the initiation of the intervention. All statistics were performed using STATA v.11 (College Station, TX). Results: During the 10-month intervention period 107 patients were targeted, 2 were lost to follow-up. In both the advanced dementia (n¼48) and actively dying (n¼57) groups patients were more likely to choose a treatment plan that included comfort measures after palliative intervention than before [dementia: 23% before, 45% after (P ¼ .012); actively dying: 21% before, 48% after (P ¼ .001)]. Overall, patients were significantly more likely following intervention to choose a pathway including comfort-focused care (OR 3.1; 95%CI: 1.7-5.7), and less likely to choose a pathway including life-prolonging therapy (OR 0.7; 95%CI: 0.4-0.8). Among admissions to our inpatient palliative care unit in the pre- and post-intervention periods there was a trend towards an increase in referrals directly from the ED (9% vs 14%, P ¼ .06). Other variables showed no significant changes. Conclusion: In our institution early palliative care involvement was feasible, and ED patients with advanced illness and their surrogates were often amenable to goals of care transitions. These findings support broader attempts to integrate and research palliative care interventions and alternative care pathways in ED care.
221
Utility of the Modified “Surprise Question” for Predicting Inpatient Mortality in Emergency Department Patients
Strout TD, Haydar SA, Han PJK, Bond AG/Maine Medical Center, Portland, ME; University of Virginia, Richmond, VA
Study Objective: Prognostication is an essential task in many domains of health care, but is of particular importance in end-of-life (EOL) care. Prognostic estimates delineate the EOL period, shape decisions about the goals of care, and trigger advance care planning efforts. As EOL and palliative care are increasingly incorporated into the emergency setting, useful prognostic tools that are valid and reliable for use with emergency patients are needed. The purpose of this study was to evaluate the predictive ability of the modified “surprise question” when used by emergency clinicians in the emergency department (ED) setting. Methods: Emergency physicians responded to the question, “Would you be surprised if this patient died in the next 30 days?” upon adult and pediatric admissions to a tertiary care center over a six-month period. Excluded were patients taken immediately to the operating room or cardiac catheterization laboratory and direct hospital admissions. Inpatient teams were blinded to the responses. Electronic health records were reviewed retrospectively for clinician’s responses to the surprise question, patient demographics, and hospital discharge disposition. The ability of emergency physician response to the surprise question to predict inpatient mortality was evaluated using chi-square analysis to compare the proportion of patients surviving to hospital discharge as well as with the area under the receiver operating characteristic (ROC) curve. Results: Data for 4,478 patients were evaluated; 48% were female and the median age was 63 years (IQR 43-77). Physicians responded that they would not be surprised if the patient died (negative response) in 12% (n¼536) of cases. Overall, 190 patients (2.4%) died prior to hospital discharge. Emergency clinicians provided negative responses indicting that they would not be surprised if the patient died in a significantly greater proportion of mortality cases (37%, 70/190) than survival cases (14%, 1076/7528), P < .001. The area under the receiver operating characteristic curve for the ability of the modified surprise question to correctly predict inpatient mortality was 0.613 (95% CI: 0.568 - 0.657), P < .001. The overall accuracy of the modified surprise question for correctly classifying those who did and did not die during hospitalization was 85% (95% CI: 84.2% 85.8%). Conclusions: In this setting and sample, emergency physician responses to the modified surprise question were a significant predictor of in-hospital mortality. Due to the exclusion of many high acuity patients who bypassed the usual admission process, the predictive ability of the surprise question may be greater than we observed in this study. Additional research is warranted to determine whether the surprise question is a stronger predictor of inpatient mortality in particular subgroups of the ED population and whether it can accurately predict mortality over the longer-term. Given the simplicity of the modified surprise question, it holds promise as an important prognostic tool to improve the delivery of end-of-life and palliative care in the emergency setting.
Annals of Emergency Medicine S81