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What’s happening in Yakima:
Jan, 2018 What’s happening in Yakima: The Surprise Question and Five Wishes Laurie Jackson Masters of Divinity Masters Certificate in Clinical Ethics SENIOR DIRECTOR Virginia Mason Memorial’s Care Line for Advancing Illness Home Health & Hospice | Palliative Care | Bereavement | Ethics Advance Care Planning | Spiritual Care
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BEST CARE POSSIBLE The surprise Question What hinders us?
What’s Our Goal? BEST CARE POSSIBLE What hinders us? Uncertain What “Best Care” Looks Like Cure Versus Care, “Treatment” Assumptions Time Uncomfortable conversations Rarely is it bad intent
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The Surprise Question in Yakima
2015: Dr. Mimi Pattison in Yakima at Circle of Life Symposium month adventure to add to hospital electronic admission set Created Inpatient Navigation Team Leader/Administration Buy-In Physician Education In Midst of Virginia Mason/Memorial Affiliation 2017: Haiti Road to New Jersey Road Clinical Trial Began Physician Education/Behavior Modification New Angle to Education: Teamwork 2018: Beginning Work in Clinics
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December 21, 2016: Surprise Question Initiated
The Surprise Question December 21, 2016: Surprise Question Initiated First Hospital to Standardize Every Patient Admission Every Floor Every Physician Electronically Asked and Answered
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The Surprise Question How It Works
Physician Responds to Admission Queries Diagnosis, Code Status, etc. Then, HARD STOP: Would you be surprised if this patient died in the next six months?
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The Surprise Question
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The Surprise Question How It Works
Would you be surprised if this patient died in the next six months? If Physician Replies YES: Physician Able to Continue with Admission If Physician Replies NO: Electronic Order Sent to Navigation Team for Consult Physician asked if Palliative Care or Hospice has been ordered Physician Then Able to Continue with Admission
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First Physician That Answered NO
The Surprise Question First Physician That Answered NO Orthopedic Surgeon Who Replaced a Knee Did we do the education incorrectly? What We Learned From This
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Lessons Learned: (come to presentation) Time to Bust Some Myths
The Surprise Question What We Learned in First Months 2/3 of physicians always answered YES Lessons Learned: (come to presentation) Time to Bust Some Myths
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Over 5,500 Just Under 3,500 The Surprise Question
Total Surprise Questions Answered Jan-Mar, 2017: Over 5,500 Total Number of Admissions Jan-Mar, 2017: Just Under 3,500 Something’s Wrong.
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The Surprise Question Turns Out…Another lesson learned (you’ll have to attend the seminar to learn the lesson)
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Example Admissions – Answers: January, 2016 Patient
The Surprise Question Example Admissions – Answers: January, 2016 Patient First Answer: YES Last Answer: NO Most Common Answer: YES (5/9) Patient Died Within 6 Months Day Doctor Answer Day 1, 12AM Doctor A YES Day 1, 4 AM NO Day 1, 5 AM Doctor B Day 8, 10AM Day 12, 5 PM Doctor C Day 22, 6AM Doctor D Day 22, 8AM Doctor E Day 23, 4PM Day 29, 10AM Doctor F
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Example Admissions – Answers: April, 2016 Patient
The Surprise Question Example Admissions – Answers: April, 2016 Patient First Answer: YES Last Answer: NO Most Common Answer: NO (6/8) Patient Died Within 6 Months (was transferred to hospice and died within one week) Day Doctor Answer Day 1, 3 PM Doctor E YES Day 3, 9 AM NO Day 6, 2 PM Doctor G Day 7, 8 AM Doctor H Day 7, 7 PM Day 14, 11 AM Day 17, 11 AM Doctor I Day 18, 12 PM Doctor J
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Admission as Inpatient
The Surprise Question ALSO TO NOTE: We have to wait six months after a patient’s admission to determine if the physician was correct in assessment of patient’s prognosis Started January, 2017 January Admissions: must wait until August, 2017, to assess Admission as Inpatient When Can We Assess 6-Month January, 2017 August February September March October April November May December June January, 2018
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Admission as Inpatient
The Surprise Question ALSO… Death Records are Published Quarterly (after March 31, June 30, September 30, Dec 31) However…for patients that have been in the hospital and die within 6 months, how many are dying before the 6-month mark? Could we get a taste of accuracy with the data we have? Admission as Inpatient When Can We Assess 6-Month January, 2017 August February September March October April November May December June January, 2018
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Of All Patients That Died in the First Six Months After Admission…
The Surprise Question TURNS OUT WE CAN ASSESS ACCURACY. WHY?? Of All Patients That Died in the First Six Months After Admission… 2016 Mortality Post-Admit 2015 Mortality Post-Admit 1st 30 days: % of deaths 60 days: % of deaths 90 days: % of deaths 120 days: 88.03% of deaths 1st 30 days: % of deaths 60 days: % of deaths 90 days: % of deaths 120 days: 90.40% of deaths Based on death data through 6/30/2017
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The Surprise Question Quarter 1: Jan, 2017 – Mar, 2017 219 51.9% 203
ANSWER ALIVE % DIED GRAND TOTAL NO 219 51.9% 203 48.1% 422 100% YES 2085 96.1% 84 3.9% 2169 2304 88.9% 287 11.1% 2591 CORRECT 2288 88.3% “No” and Died or “Yes” and Alive INCORRECT 303 11.7% “No” and Alive or “Yes” and Died
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The Surprise Question Quarter 2: April, 2017 – June, 2017 225 53.1%
ANSWER ALIVE % DIED GRAND TOTAL NO 225 53.1% 199 46.9% 424 100% YES 2295 96.7% 79 3.3% 2374 2520 90.1% 278 9.9% 2798 CORRECT 2494 89.1% “No” and Died or “Yes” and Alive INCORRECT 304 10.9% “No” and Alive or “Yes” and Died
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Quarter 3: July, 2017 – September, 2017
The Surprise Question Quarter 3: July, 2017 – September, 2017 ANSWER ALIVE % DIED GRAND TOTAL NO 100% YES CORRECT “No” and Died or “Yes” and Alive INCORRECT “No” and Alive or “Yes” and Died Data will be presented at conference
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Quarter 4: October, 2017 – December, 2017
The Surprise Question Quarter 4: October, 2017 – December, 2017 ANSWER ALIVE % DIED GRAND TOTAL NO 100% YES CORRECT “No” and Died or “Yes” and Alive INCORRECT “No” and Alive or “Yes” and Died Data will be presented at conference
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Physician Data Per Specialty
Oncologists: Orthopedists: Hospitalists: Pulmonologists: Data will be presented at conference
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Another Initiative: advance care planning
Five Wishes in Yakima: Changing the Game with Advance Care Planning
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Palliative Care Hospice
How Do Home Health, Hospice, and Palliative Care Actually Relate to Each Other? Palliative Care Home Health Hospice Other Programs
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Another Initiative: advance care planning
Diagnosis Death PHASE 1 Healthy or with reversible illness PHASE 2 Early onset, chronic conditions PHASE 3 Progressive, frequent complications PHASE 4 Hospice eligible (6 months question) PHASE 5 Bereavement Family Support Non-Medical Model Medical Model Palliative Care Chronic and Curative Care Hospice Bereavement 18 years and over Advance Care Planning Memorial Home Care Services/Compass Care
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Five wishes in Yakima: Some statistics
• 70% of individuals would wish to die at home • 82% say it is important to have EOL wishes in writing • 80% say that if seriously ill they would want to talk with their doctor about EOL care • 70% of people die in a SNF, hospital, or LTC facility • 23% have ever written their EOL wishes •7% report having an end of life conversation with their doctor • 8.8x increased likelihood of prolonged grief if loved one dies in ICU vs hospice • 5x increased likelihood of PTSD if loved one dies in ICU vs. hospice • 10 more days spent in the hospital in the last 2 years of life when the patient does not participate in advance care planning Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation
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Five wishes in Yakima: Some statistics
Why are we using FIVE WISHES? Valid in 42 States Customizable Addresses Biggest Fears Cost-Effective User-Friendly Previous Advance Directive Not a DNR in the Home Trained Facilitators To Go To Community Groups, Homes, Churches, Hospital, Clinics for Five Wishes Parties We Have Distributed Over 70,000 Five Wishes In Our Community Memorial Foundation Pays for Five Wishes for Yakima Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation
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Nearly 2 years into Surprise Question, What we are learning:
Physicians often not understanding difference between advance directives and POLST Hospital/Clinic Physicians benefit from team members knowing Decision-making order How to provide difficult conversations Objective methods for providing best care possible for patients with advancing illness and end-of-life concerns We still have work to do Surprise Question is a key element to providing great medical care and getting patients onto extra levels of care Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation
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Questions? Thank you!! Stats thanks to Honoring Choices PNW and Californian Healthcare Foundation
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