IHI Expedition: Palliative Care in the Emergency Department

Session 3

Tammie Quest, MD

Garrett Chan, PhD, APRN, FAEN, FPCN, FAAN

David Weissman, MD, FACP

These presenters have nothing to disclose

Today’s Host

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Kayla DeVincentis, Project Coordinator, has

worked at IHI since 2009, starting as an intern in

the Event Planning department. Since then, Kayla

has contributed to the STAAR Initiative, the IHI

Summer Immersion Program, and the IHI

Expeditions. Kayla obtained her Bachelor’s in

Health Science from Northeastern University and

brings her interest in health and wellness to IHI’s

Health and Fitness team.

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Overall Program Aim

The aim of this Expedition, Emergency Medicine and Palliative Care, is to help empower professionals to care for patients and families with palliative care needs in the emergency department setting.

The Expedition

Session #3: May 17th, 2012 1:30pm EST

� Measurement Strategies

Session #4: May 31st, 2012 1:30pm EST

� System Design and Improvement Tools

Session #5: June 14th, 2012 1:30pm EST

� Achieving Change That Will Endure

Introducing Today’s Faculty

Tammie E. Quest, MD• Associate Professor, Emory University

School of Medicine, Department of

Emergency Medicine and Division of

Geriatric Medicine, Atlanta VAMC

• Director, Emory Palliative Care Center

• Director, Improving Palliative Care –

Emergency Medicine (IPAL-EM)

• Director, Education in Palliative and

End of Life Care – Emergency

Medicine

Introducing Today’s Faculty

Garrett Chan, PhD, APRN, FAEN, FPCN, FAAN• Associate Adjunct Professor at the University

of California, San Francisco

• Lead Advanced Practice Professional and

Associate Clinical Director for the Emergency

Department Clinical Decision Unit

• Clinical Nurse Specialist with the Palliative

Care Service at Stanford Hospital & Clinics

• Author of leading peer reviewed articles in

palliative care in the emergency department

Today’s Focus…

• Review Homework

• Explore New Content

─Measurement Strategies

• Move forward on our trek…

Homework from Session 2

• Form a Project Workgroup to steer the

initiative

• Conduct a ED-wide meeting (invite

hospital leaders) to discuss potential

barriers and strategize on ways to

overcome them

• Identify 3 key barriers and 2 strategies to

address each one

�What were you able to do?

�What did you learn?

�What successes did you have?

�What barriers did you encounter?

Discussion of Homework

Objectives of Session 3

Measurement Strategies

• Identify key areas for measurement of impact of a palliative care initiative in the ED

• Identify the 3 key types of palliative care metrics of a palliative care initiative in the ED

• Describe target patient populations for measurement

Reminder -

What do ED staff members care about?

• Providing excellent patient care

• Triage and disposition

• Optimizing and efficiently using ED

resources

• Reducing ED length of stay

• Increasing ED throughput

• Decreasing ED boarding of admitted

patients

• Increasing patient/family satisfaction

• Effective risk

management/compliance

• Meeting core hospital measures (Joint

Commission)

• System-Focused─ Improved ED/Hospital

Metrics�Less ED crowding

�Less use of non beneficial treatments

�Reduced hospital length of stay

�Fewer readmissions

�Fewer inpatient and ICU deaths

─ Improved Patient Safety�Smoother transitions

across care sites

Reminder -

What do ED staff members care about?

Before Measurement:

Know Your ED Characteristics

• ED size

─Visits/year, beds, observation unit

• Admission rate

─Number, acuity

• Core ED Metrics

─Average/median LOS

• Special populations

─Sickle Cell Disease, Pulmonary Fibrosis, Advanced Heart Failure/LVAD)

ED- Palliative Care

Measurement

(Metrics)

Garrett Chan, PhD, APRN, FAEN,

FPCN, FAAN

4 Steps to Make the Most of

Measurement

1. Complete a needs assessment

(Expedition Sessions 1 & 2)

2. Select Metrics that are easily obtainable

3. Determine how often data should be

collected

4. Develop a system to report and use your

data

Reference Document

http://ipal-live.capc.stackop.com/downloads/ipal-em-evaluation-of-

ed-palliative-care-metrics-quality.pdf

Axiom

• Only measure data elements that will

make an impact or drive change

Axiom

• Decide what to measure by discussing

with key stakeholders

Narrow Down Your Patient

Population for Measurement

Patient Selection

Starters…I.Transfers from a long-term care facility or medical foster

home

II.Metastatic or locally advanced incurable cancer

III.Hospice program enrollee

IV.Out-of-hospital cardiac arrest

V.Advanced dementia (defined as needing assistance with

all ADLs, having limited to no coherent speech or

ambulation, and incontinence)

ED-Palliative Care Metrics

• Three categories of metrics are

recommended:

I. Operational

II. Clinical

III. Customer service

ED-Palliative Care Service

Metrics

I. Operational metrics: to assess patient

flow, disposition, readmissions and

resource utilization

II. Clinical metrics: to assess quality of

clinical care services

III. Customer metrics: to assess

satisfaction data from patients/families

Operational Metrics

Operational Metrics

Informs the ED staff about patient flow and

outcomes of patients with high likelihood of

palliative care needs

Patient Selection

Starters…I.Transfers from a long-term care facility or medical foster

home

II.Metastatic or locally advanced incurable cancer

III.Hospice program enrollee

IV.Out-of-hospital cardiac arrest

V.Advanced dementia (defined as needing assistance with

all ADLs, having limited to no coherent speech or

ambulation, and incontinence)

Data Elements for Collection

• 1. ED LOS-hours

• 2. ED discharge status

─ death in ED

─ admit-ward

─ admit ICU

─ admit Palliative Care Unit

─ hospice referral (home or

other site)

─ Long term care

─ Home

• 3. Death within 72 hours of

hospital admission (ICU vs.

ward)

• 4. Hospital total and average

daily direct cost

• 5. ED referrals for palliative

care consultation in ED

• 6. ED referrals for hospice

Report by Diagnostic Category

• Report by Diagnostic Category

─Mean/median ED LOS (hours)

─Discharge status

�% Returning to ED within 30 days

�% readmitted to hospital within 30 days

─Number of hospice referrals

─Number of palliative care referrals (if available)

─Hospital direct cost (admissions only)

Clinical Metrics

Clinical Metrics

• Identify gaps in patient care

• Denominator:

─Tailor Key populations you decide for your program

─ May use the IPAL-EM 5 key populationsI. Transfers from a long-term care facility or medical

foster home

II. Metastatic or locally advanced incurable cancer

III. Hospice program enrollee

IV. Out-of-hospital cardiac arrest

V. Advanced dementia

Clinical Metrics: Examples

• % of patients where the health care

decision-maker is documented in the

medical record

• % of patients prescribed opioids with

bowel regimen on discharge

• % patients with documented pain

assessment on presentation

Clinical Metrics: Examples

• % families with documented offer of

spiritual support after ED death

• % patients in target populations who have

a documented palliative care assessment

• % caregivers in target patient populations

screened for caregiver strain

Customer Service

Patient-Surrogate Satisfaction

• Important perspective of emergency

department palliative care

• Accessible domains:

─communication

─end-of-life care experience

─other?

Customer Satisfaction Metrics:

Examples

• % of live ED discharges who reported they

were fully informed about their

condition/treatment options

• % of surrogates/families who report

excellent end-of-life care after ED death

• % of patients reporting excellent

pain/symptom management

Determine How Often Data

Should be Collected

Domain Example

Operational Continuous Data Collection

with Monthly Reporting

Clinical Service 10-20 Charts Reviewed

(Quarterly)

Customer Service Interval of Usual ED

Survey (Quarterly)

Develop a System

to Report Your Data

• Regularly present the

data (e.g. monthly,

quarterly) to:

─ED leadership

─Palliative care leadership

─Hospital leadership

Use the Data to Improve

• Identify and design

focused quality

improvement

projects to enhance

both clinical

processes and

outcomes

Homework

Before Session 4

• Review charting/EMR systems

• Identify other potential sources of data (eg,

hospital databases)

• Select a preliminary panel of key metrics

with specified data sources

Next Session

Thursday, May 31, 1:30 PM – 2:30 PM ET

Session 4 – System Design and Improvement Tools

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