1. Table 1: Patient Demographics
Early Triggered Palliative Care Consults in the ED: An Analysis of Efficacy and Potential Impact
Emmett A. Kistler1, R. Sean Morrison, MD2, Lynne D. Richardson, MD1, Joanna M. Ortiz3, and Corita R. Grudzen, MD MSHS3,4
1Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
2Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
3Department of Emergency Medicine, New York University Medical Center, New York, NY; 4Department of Population Health, New York University Medical Center, New York, NY
This study was approved by the Icahn School of Medicine at Mount Sinai Institutional Review Board.
BACKROUND
METHODS
RESULTS
Palliative care consultations (PCC) focus on symptom assessment, pain management, and establishing goals of care.
PCC that take place earlier on during a patient’s course of care have been demonstrated to improve family perception of care, communication, and emotional support. Preliminary data suggest that PCC can also decrease costs and hospital length of stay for patients with advanced cancer.
Despite guidelines set by the American Society of Clinical Oncology endorsing timely consults, a delay between diagnosis and consultation is common and detrimental to care for patients with advanced cancer.
The Emergency Department (ED) offers a promising setting to connect patients with early consults.
The delivery of palliative care is not standard of care in most ED’s because of challenges such as medicolegal concerns and logistic barriers, which have limited integration in the past.
While several models of integrating PCC into the ED exist, more standardized, outcomes-based data is needed to assess the feasibility of ED-based referrals and to better describe how PCC can be effectively integrated into the ED.
ANALYSIS AND OUTCOMES: Chart review was conducted using the hospital’s electronic medical record system and palliative care database to compare the proportion of patients receiving a completed, documented consult and the time in days between admission and consult.
LIMITATIONS: This was a single site study at an urban, academic medical center with a robust palliative care service.
Patients in the control group receiving a PCC on index admission were most frequently referred by a general medicine service (60%). When all subsequent admissions were reviewed, control patients were most likely to receive a referral from an oncology service (54%).
Figure 2: Rate of Palliative Care Consultation by Intervention and Control Group, Index Visit
Total Participants (n=125)
Intervention group (n=65)
Palliative care consultation
(n=58, 89%)
No consult
(n=7, 11%)
Control group (n=60)
(n=10, 17%)
Internal Med
(n=6)
Oncology
(n=2)
Emergency Med
(n=1)
Unknown
(n=50, 83%)
RESULTS
125 patients thus far have been enrolled and randomized, with 60 patients (48%) receiving usual care.
89% of intervention patients received a documented palliative care consultation during the index admission (95% Confidence Interval [CI], ) as compared to 17% of control patients (95% CI, ) (p<0.01).
When all subsequent admissions were reviewed, 94% of intervention patients (95% CI, ) and 43% of control patients (95% CI, ) received a documented consultation at any point after enrollment (p<0.01).
Intervention patients received a PCC an average of 1.48 days after index admission (95% CI, ) as compared 3.3 days after admission for patients in the control group (95% CI, ) (p=0.16).
CONCLUSIONS
STUDY OBJECTIVE
Table 1: Patient Demographics
For patients with advanced cancer admitted through ED, preliminary data suggest that an early, triggered palliative care referral significantly increases the rate of documented palliative care consults as compared to usual care.
This data highlights a low rate of physician-driven consultations as part of usual care for this patient population.
Despite barriers and what many consider to be a time-pressured, chaotic environment, consultation from the ED represents one way to improve care and decrease time to consultation for specific patient populations.
Future studies may assess the effect of early PCC on patient survival and health care utilization as well as explore clinical decision support mechanisms to prompt consultation based on disease triggers.
This study assesses the efficacy of early, ED-based PCC referrals for patients with metastatic tumors admitted through the ED as compared to usual care based on PCC documentation in patients’ charts.
Control
(n=60)
Intervention (n=65)
Total
(n=125)
Age, average
60.91
59.35
60.1
Gender, % female
56%
55%
METHODS
Figure 1: Cancer by Type
SETTING AND DESIGN: This is a three-year, single-blind randomized control trial taking place at an urban, academic tertiary care center beginning in June 2011.
PARTICIPANTS: Adult patients with solid metastatic tumors who were able to pass a cognitive screen, had never been seen by the palliative care service, and spoke English or Spanish met eligibility criteria. Eligible patients were approached and enrolled for an 8-hour period (9am to 5pm) on Monday, Wednesday and Friday and for a twelve hour period (9am to 9pm) on Tuesday and Thursday. Participants were randomized via balanced block randomization to the intervention or control group.
INTERVENTION: Within 24 hours of enrollment, patients in the intervention group received a referral placed by a research coordinator for a comprehensive inpatient palliative care consultation, including an assessment of symptoms, spiritual/social needs, and goals of care. Control group patients only received a consultation if requested by the admitting physician.
ACKNOWLEDGEMENTS
This study was funded by an American Cancer Society Mentored Research Scholar Grant (Dr. Corita Grudzen). The research reported on this poster was supported by the Patricia L. Levinson Fellowship for Community-Based Research (Emmett Kistler). The investigators retained full independence in the conduct of this research.