ED-initiated palliative care consults have the potential to decrease costs and length of stay, found a recent study.1
“We anticipated that creating a culture and redesigning workflows, which made it easier to obtain palliative care consults in the ED, would lead to better outcomes for patients and families, in that care choices would be aligned with patient wishes,” says lead author Robert Femia, MD, chair of the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Medical Center.
The ED set out to make it “easy, acceptable, and the norm” for ED providers to initiate the palliative care consult in the ED, says Femia. “We went from 66 to 226 palliative care ED consults annually.”
A Culture Change
Researchers conducted a retrospective chart review on all ED patients who received a palliative care consult in 2014. The consults were either initiated by the EP, or at a later time during their inpatient admission. The researchers compared length of stay and costs for 226 patients who received an ED-initiated palliative care consult, with 618 patients who received the consult at a later point in their hospital stay. Their findings include the following:
• For patients who had an ED-initiated palliative care consult, resultant hospice placement, and a length of stay greater than two days, the average length of stay was 5.5 days. The average direct variable cost was $5,856.
• If the palliative care consult was initiated outside of the ED with eventual hospice placement, the average length of stay was 8.6 days. The average direct variable cost was $15,431.
“Our dramatic rise in obtaining ED palliative care consults was the result of a work group that was formed between emergency medicine, palliative care, social work, nursing, and others,” says Femia.
The ED’s new process allows not only physicians, but also nurses and social workers, to initiate requests for palliative care consults. “One of our obstacles had been a culture where approval of the private medical doctor was needed to obtain a palliative care consultation,” Femia explains.
Previously, many ED providers weren’t aware of the services offered by the palliative care team. There was also lack of clarity about the depth of conversation expected of the ED provider when discussing end-of-life issues with the patient and family.
“Multiple education initiatives were undertaken,” says Femia. “Real-time reference materials were made available in the ED.”
ED providers were encouraged to start a gentle conversation with family, inquiring as to whether they had decided on their goals of care. “However, based on comfort level, these conversations could be deferred to the palliative care consultant,” says Femia.
For some patients, a shared decision-making process avoided tests, interventions, hospitalizations, and other care that the patients felt were unnecessary and not aligned with their goals.
“By having discussions about goals of care, it is not surprising that some patients avoided options that they presumably felt were unnecessary, futile, painful, and not aligned with their desires,” says Femia. The study demonstrated that it also resulted in lower costs to the healthcare system.
Femia expects to see more options made available to dying patients earlier in the course of their visit to the healthcare system. “Better care coordination will become the norm, via new interfaces such as telehealth, care navigators, outpatient, and home-based options,” he says.
Robust shared decision-making by informed patients who understand multiple care options available to them, says Femia, “represents a high ethical standard.”
REFERENCE
- Femia R, Wilkins C, Rodriguez D, et al. Cost savings and palliative care referrals from the emergency department. Physician Leadership Journal, Sep/Oct 2016; 8-11.
SOURCE
- Robert J. Femia, MD, MBA, Chair, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York City. Phone: (212) 562-6561. Fax: (212) 562-3001. Email: [email protected].
ED-initiated palliative care consults have the potential to decrease costs and length of stay, found a recent study.
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