IHI Expedition: Palliative Care in the Emergency Department

Session 5

Tammie Quest, MD

Eric Bryant, MD

Kelly McCutcheon Adams, MSW, LICSW

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 #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

Eric Bryant, MD• He earned an MA Public Policy Analysis from

the University of Colorado, Boulder and his

MD at the University of Pittsburgh Medical

School. He completed his residency in

Emergency Medicine at the Denver Health

Medical Center. He is Board Certified in

Emergency Medicine and Board Eligible in

Hospice and Palliative Medicine. He is a

member of the American Academy of

Hospice and Palliative Medicine and is a

Fellow of the American College of Emergency

Physicians (ACEP). He was President of the

Colorado Chapter of ACEP in 2008 and is

currently on the national ACEP Ethics

Committee.

Today’s Focus…

• Review Homework

• Explore New Content

�Achieving Change That Will Endure

• Close our expedition….

A Round of High Fives!

Homework Assignment

• Identify one priority area for improvement

with clinical documentation and monitoring

components to facilitate improvement

Achieving Change That Will

Endure

Case: The ED Champion

• A 20 bed emergency department employs a palliative care initiative with an ED clinician trained in palliative care to see consults in the ED and is the champion. Great impact is seen in care of patients as well as metrics first 2 years months. The ED champion unexpectedly moves for family reasons.

• After 3 months, the record gains that had been seen are no longer there.

Loss of a Champion

Month Number

MD Leaves

Case Study: Deep Dive

• What can we learn from a PC-ED initiative

that did not last?

• When an initiative is the work of a single

highly-motivated individual what happens

when that individual leaves?

Challenge to Sustaining Change

• Best case:

─ new champions step up,

processes continue, a new

chapter opens

• Worst case:

─ things fall apart, the overall

effort is set back due to

frustration, disappointment

and confusion

• Average case:

─ some awareness persists,

some early adaptors

continue to try, established

processes may continue

but without review and

revision

Strategies that Endure

BroadenDeepen

Enlighten

Broaden

• Build physician support beyond the initial

champion

• Build support beyond the physicians

Broaden

• Nurses, when empowered, are key:

─ For their bedside role

─ For their administrative role (departments and hospitals are run

by nurses)

• Social workers/Case managers:

─ disposition planning often highlights unmet PC needs

• Chaplains:

─ in addition to being resources for PC service are often critical

advocates for both the service and for individual referrals

Deepen

• Infiltrate

• Imbed

Deepen

• Don't just teach at staff meetings, participate in

processes such as QA/QI, M&M and Follow-up

processes

─ Review real cases that didn't go well to illustrate the

need for PC integration

─ Review real cases that went well to demonstrate the

potential

• Support compliance with system-wide quality and

compliance processes such as TJC accreditation

Embed

• Develop, add to or modify existing tools to

include PC best practices and trigger

referrals�Preformatted order sets

�Policies/procedures

Enlighten

• Bedside Teaching/Role modeling; Pocket

Cards

─Symptom management:

�Pain ("Pain 101", advanced pain management)

�Delirium Assessment and Management

�PC Emergencies

�Comfort care of the actively dying

�Communication

─Focus energy on early adopters

� Tips

• Grow a service, not just a practice

• PC needs to be seen not as something

"extra" for the ED to do or accommodate

but as integral to excellent emergency

care

• It will endure when it is part of the ED

culture and not just the passion of one

champion

Wrapping It all Up

Key Points: Session 1

“Getting Started”

Key steps to success:

1. Define the Problem (Needs Assessment)

2. Resource Inventory

3. Anticipate Barriers

4. Develop an Action Plan

Key Points: Session 2

Overcoming Barriers

I. Culture

II. Limited Skills and Knowledge

III. Time Constraints

IV. Environment

Key Points Session 3

Measurement

1. Complete a needs assessment

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

Key Points: Session 4Systems Design & Improvement Tools

• Key Questions:

─What changes are needed in clinical practice (including staffing)?

─How will these changes be captured and reflected in documentation?

─How will data be collected on measures of improvement?

Key Points: Session 5

• Deepen

• Broaden

• Enlighten

Follow up

• The listserv will remain active.

─To use the listserv, address an email to PalliativeCareED@ls.ihi.org.

• A manual with instructions to receive

Continuing Education Credits will be sent

with the follow-up email for today's session.

• Please take 5 minutes to complete the

Expedition evaluation survey.

Thank you!