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 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. 2
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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. 5 The Expedition Session #3: May 17 th, 2012 1:30pm EST Measurement Strategies Session #4: May 31 st, 2012 1:30pm EST System Design and Improvement Tools Session #5: June 14 th, 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
Discussion of Homework What were you able to do? What did you learn? What successes did you have? What barriers did you encounter? 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) Reminder - What do ED staff members care about? 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
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-ofed-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 populations 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 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 Operational Clinical Service Customer Service Example Continuous Data Collection with Monthly Reporting 10-20 Charts Reviewed (Quarterly) 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 42