Screening Program Improved Palliative Care Beyond the ED

AUSTIN, TEX. — A program designed to address unmet palliative care needs among frail, elderly patients who repeatedly sought acute care at Beth Israel Medical Center's emergency department led to a steady increase in palliative care consultations.

The BriefPal Program at the New York City-based hospital identified elderly patients who had a Karnofsky Performance Status score below 80 (0–100 scale, with 100 being healthy), at least a moderate decline in functional status, and a specific life-limiting condition: advanced dementia, severe congestive heart failure or chronic obstructive pulmonary disease, advanced malignancy, or AIDS.

Stage 2 of the screening protocol identified subgroups of patients with a recent loss of activities of daily living, high symptom burden, extremely poor functional status, and high levels of caregiver burden.

During the 3-month pilot phase, 864 patients older than 65 years were screened; 131 patients met the initial criteria, and 62 met stage 2 criteria. Although 35% of the 62 patients died within 60 days of their index visit, none was receiving palliative care services, coinvestigator Myra Glajchen, D.S.W., reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The team, also led by Dr. Knox Todd, identified multiple barriers to providing palliative care services in the ED. In almost half of cases (49%), the primary care physicians admitting the patients did not want to make the referral, because they felt they were more familiar with the patients or were unfamiliar with palliative care services, Dr. Glajchen said.

In 25% of cases, the patient or family said no. In another 25% of cases, the ED physician balked at making the referral because of concerns about more paperwork or phone calls, time constraints, or a failure to realize the value of palliative care.

Lessons learned by the team included the need for specifically targeted palliative care education in the ED, the crucial role of champions in project implementation, and the importance of rapid quality indicator initiatives to demonstrate tangible results, Dr. Glajchen said.

Ultimately, the team provided brief training in palliative care and quality indicators to 41 emergency physicians, exceeding its goal of 21, and to four of eight physician assistants, 31 of 45 nurses, and three of five social workers. Classes were offered at all hours to accommodate various shifts, and were repeated to address staff turnover.

The team also implemented standardized screening based on the two-stage protocol, and began offering palliative care interventions and referrals for appropriate patients.

Palliative care consultations originating in the ED increased steadily over the course of the project, and by the first quarter of 2008, accounted for fully one-half of all palliative care consultations in the hospital, Dr. Glajchen reported. The team screened 2,451 patients and provided 94 palliative care consultations and 168 ED palliative care interventions in 245 patients identified as having unmet needs. Interviews with 264 caregivers revealed particularly high rates of caregiver burden.

“Caregiver burden is often a driving force of why people come to the ED in the first place,” she said.

Beth Israel uses the National Consensus Project (NCP) for Quality Palliative Care as a framework for its palliative care and will be exploring a range of quality indicator approaches for implementing best practices, said copresenter Dr. Russell Portenoy, chair of pain medicine and palliative care at Beth Israel. Because the NCP model was designed as an inpatient consultative model of specialist care, it is not an exact fit in the ED, he said. However, it can be adapted to fit the ED.

The NCP calls for comprehensive interdisciplinary assessment of patients with advanced illness, goal setting based on patient/family preferences, and an environment that provides privacy. That may require a shift from current ED care, Dr. Portenoy said, in which triage often is done by a registered nurse, care is problem focused and standardized, and treatment is delivered by a continually rotating group of physicians.

In addition, social workers and psychiatrists may not be a core part of the team—and privacy often means pulling a thin curtain around the patient to have very difficult discussions frequently conducted through the help of an interpreter or family member.

Finally, misaligned financial incentives are one of the biggest challenges. Optimal ED-based palliative care will mean getting patients home rather than admitting them, Dr. Portenoy said—and that may make it less attractive to the hospital.

He suggested that palliative medicine specialists focused on the ED will need to refine systems to increase reimbursement for palliative care services delivered by physicians, physician assistants, or nurse practitioners. They also will need to negotiate with hospitals based on the overall quality and potential for cost savings that palliative care can provide on the inpatient side.