VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.
The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.
As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.
Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.
They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.
A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.
After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.
Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.
The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.
The nine triggers are:
• Code status changed to "do not resuscitate."
• Conflict about starting or stopping life-prolonging treatment.
• Discussion about goals of care or code status, and/or surrogate distress about decision making.
• A marked decrease in functional status within 2 months.
• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.
• Consideration of percutaneous endoscopic gastronomy tube placement.
• Admission from an extended-care facility with dependence for activities of daily living.
• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.
• A patient or family request for palliative care.
The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.
Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.
Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.
Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.
But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.
For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.
With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.
Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.
One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.
When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.
The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.