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Cost savings and palliative care referrals from the emergency department.

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Early palliative care consultation has the potential to provide comfort to patients and families, and decrease costs and length of stay.

THE NUMBER OF PATIENTS WITH END-OF-LIFE care needs who present to emergency departments (EDs) continues to grow.

Increasingly, emergency physicians seek to provide care and comfort to patients with serious illnesses and others with sudden, unanticipated catastrophic events. (1) Many present to EDs due to refractory pain, increasing symptom burden or failing support systems.

Palliative care consultation has been shown to provide benefits to patients and families. These benefits include optimal pain control, enhanced shared decision-making and reductions in unnecessary and futile tests and treatments. Additionally, early palliative care consultation has been shown to decrease hospital length of stay (LOS). (2)

Historically, emergency physicians have considered obtaining palliative care consultation to be a role best suited for the inpatient teams. Time pressures, lack of longitudinal relationships, complex family dynamics, emergency physician discomfort and lack of education have all contributed to avoiding discussions focused on end-of life issues. (3-7)

Additionally, it has been shown that relatively few patients received ED-initiated palliative care consults even though early consultation has been shown to decrease LOS and increase referrals to home hospice. (8,9)

METHODS--A retrospective chart review was conducted on all ED patients who received a palliative care consult in 2014 at Ronald O. Perelman Center for Emergency Services at the New York University School of Medicine that was either initiated by the emergency physician or at a later time during their inpatient admission.

Records were reviewed for length of stay, admission and discharge destination and variable direct costs. The financial metric chosen was variable direct cost; our institution determines cost via a cost-accounting methodology.

Charts also were reviewed to identify patients who had received hospice placement. Data for length of stay and variable direct costs were compared for those who received a palliative care consult in the ED versus those who received a consult at a later point in their hospital stay.

RESULTS--The emergency physicians initiated 226 palliative care consults in 2014. Forty patients were directly admitted to a hospice program from the ED. Twenty-four of these patients were admitted to our inpatient hospice and 16 were placed in either home hospice or another facility's hospice unit.

* Twenty-four patients were directly admitted to our inpatient hospice from the ED. Thirteen had a length of stay of more than two days while 11 had a length of stay of less than two days. The remaining 16 were admitted to hospice at other institutions or home hospice.

* The 618 patients who did not receive an ED-initiated palliative care consult were placed on the inpatient medicine service where they eventually received a palliative care consult. For all disposition locations this group of 618 had an average LOS of 9.5 days and an average variable direct cost per case of $17,444. Thriteen patients received a palliative care consult in the ED and were admitted to our hospice program; their average LOS was 5.5 days and average variable direct cost was $5,856.

* For the group of patients who had an ED-initiated palliative care consult with resultant hospice placement and a LOS > 2 days, the average LOS was 5.5 days and the average variable direct cost per case was $5,856. If the palliative care consult was initiated outside of the ED with eventual hospice placement, the average LOS was 8.6 days and the average variable direct cost per case was $15,431.

* For those patients who had a total length of stay of less than 2 days, the average length of stay was 0.9 days for those who had an ED palliative care consult with resultant hospice placement versus 1 day for those who had a consult later in their visit resulting in hospice placement. The average variable direct cost per case was $1,017 for ED palliative care referrals versus $2,096 for consults initiated later in the hospital stay.

* Patients with a short LOS < 2 days who had a consult initiated in the ED had an average LOS of 0.9 days and a cost of $1,017 per case. For those who did not receive a palliative care consult in the ED, the average LOS was 1 day, and the average cost was $2,184 per case when including all discharge dispositions.

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DISCUSSION--Palliative care consultation is beneficial to patients and families. Early identification of goals of care, the creation of a forum for optimal patient-family-caregiver dialogue and enhancing a process of shared decision-making will optimize alignment in regards to expectations.

Additionally, maximizing pain control, relieving symptom burden and lessening caregiver stress are significant contributions of palliative care.

Besides the patient and family advantages of early palliative care consultation, our results show length-of-stay and cost-savings benefits. Reducing length of stay by approximately 45 percent and reducing variable direct costs from 50 percent to 70 percent (See Tables 3-6) have significant financial benefits and also improves inpatient bed availability. The majority of the cost savings most likely is due to decreased testing and decreased futile interventions. Additionally, though intensive care unit (ICU) days were not directly measured, we assume another benefit would be a reduction of ICU bed days.

Our results suggest that when palliative care consults occur in the ED, LOS is significantly shorter than when initiated later in a patient's course. This improvement in LOS occurs for "short" admissions (< 2 days) and longer admissions (> 2 days).

There are significant cost savings associated with ED-initiated palliative care referrals. ED palliative care referrals had an average variable direct cost of $5,856 compared to $15,431 for those patients admitted to our hospice unit. The savings were even greater when compared to the $17,444 cost for those who had dispositions to multiple destinations. (See Tables 3-4)

These cases exhibited savings of $9,600-$11,600 per case. Additionally, even for short LOS (< 2 days) cases, there was a 50 percent reduction in costs ($1,000-$1,100 cost-savings per case). (See Tables 5-6)

By decreasing hospital costs and freeing up inpatient beds, early palliative care consultation has the potential for significant impact on hospital patient flow, improved inpatient capacity and an opportunity to avoid unnecessary expense.

A limitation we encountered was the inability to capture costs associated with patients who were directly discharged from our ED to other inpatient or home hospice programs. This group represents 16 of the 40 successful ED-initiated hospice placements. (See Table 1) We would anticipate, however, that this subgroup may exhibit the largest cost savings and potentially offer the greatest benefit to patients and families. More study is warranted.

Another limitation of our study is the lack of information related to the acuity of the patient's presentation to the emergency department. ED providers may feel more confident in initiating palliative care services, and in particular, admitting patients to hospice units, if they evaluate a patient they deem to be actively dying. What is unknown is whether care provided during hospitalizations was thought to be curative, palliative, temporizing or otherwise.

Regardless, our dramatic rise in obtaining ED palliative care consults was the result of a workgroup that was formed between emergency medicine, palliative care, social work, nursing and others. Our current process allows not only emergency physicians but also nurses and social workers to initiate requests for palliative care consults on ED patients.

One of our obstacles had been a culture where "approval" of the private medical doctor was needed to obtain a palliative care consultation. Additionally, there was lack of awareness in regard to services offered by the palliative care team and lack of clarity on 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 and real-time reference materials were made available in the ED. Additionally, 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.

Our findings suggest significant benefits from ED-initiated palliative care consultation in decreasing variable direct costs and shortening length of stay. Rigorous studies are needed to help identify additional potential benefits of ED-initiated palliative care referrals.

REFERENCES

(1.) Lamba S, Nagurka R, Walther S, et al. Emergency-department-initiated palliative care consults: a descriptive analysis. J Palliat Med 15(6):633-6, Jun 2012.

(2.) Wu FM, Newman JM, Lasher A, et al. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med 16(11):1362-7, Nov 13, 2013.

(3.) DeVader TE, Jeanmonod R. The effect of education in hospice and palliative care on emergency medicine residents' knowledge and referral patterns. J Palliat Med 15(5):510-5, May 2012.

(4.) Grudzen CR, Richardson LD, Hopper SS, et al. Does palliative care have a future in the emergency department? Discussions with attending emergency physicians. J Pain Symptom Manage 43(1):1-9, Jan 2012.

(5.) Jelinek GA, Marck CH, Weiland TJ, et al. Caught in the middle: tensions around the emergency department care of people with advanced cancer. Emerg Med Australas 25(2):154-60, Apr 2013.

(6.) Litauska AM, Kozikowski A, Nouryan CN, et al. Do residents need end-of-life care training? Palliat Support Care 12(3):195-201, Jun 2014.

(7.) Ouchi K, Wu M, Medairos R, et al. Initiating palliative care consults for advanced dementia patients in the emergency department. J Palliat Med 17(3)346-50, Mar 2014.

(8.) Grudzen CR, Hwang U, Cohen JA, et al. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med 15(4)396-9, Apr 2012.

(9.) Paris J, Morrison RS. Evaluating the effects of inpatient palliative care consultations on subsequent hospice use and place of death in patients with advanced GI cancers. J Oncol Pract 10(3):174-7, May 2014.

Robert Fermia, MD, MBA, Christine Wilkins, PhD, LCSW, Danielle Rodriguez, Kevin B. Read, MLIS, MAS, Nicholas Gavin, MD, Christopher Caspers, MD, and Catherine Jamin, MD

Robert Femia, MD, MBA, is chair in the Ronald O. Perelman Department of Emergency Medicine at NYU School of Medicine in New York, New York.

Christine Wilkins, PhD, LCSW, is advance care planning program manager in the Department of Social Work at NYU Langone Medical Center in New York, New York.

Danielle Rodriguez is senior program coordinator in the Ronald O. Perelman Department of Emergency Medicine at NYU School of Medicine in New York, New York.

Kevin B. Read, MUS, MAS, is assistant curator in the NYU Health Sciences Library at NYU School of Medicine in New York, New York.

Nicholas Gavin, MD, is acting chief of service for the Emergency Department at NYU Lutheran Medical Center in the Ronald 0. Perelman Department of Emergency Medicine at NYU School of Medicine in Brooklyn, New York.

Christopher Caspers, MD, is chief of observation medicine and associate chief of service for the Ronald O. Perelman Center for Emergency Services in the Ronald O. Perelman Department of Emergency Medicine at NYU School of Medicine in New York, New York.

Catherine Jamin, MD, is chief of service for the Ronald O. Perelman Center for Emergency Services and director of emergency critical care in the Ronald 0. Perelman Department of Emergency Medicine at NYU School of Medicine in New York, New York.
TABLE 1 ED-INITIATED PALLIATIVE CARE CONSULTS 2014

Number of total ED-initiated consults                 226
ED consults resulting in direct hospice placements    40

TABLE 2 LOS FOR ED-INITIATED ADMISSION TO OUR HOSPICE SERVICE

Number of ED placements to our hospice services with    13
LOS > 2 days

Number of ED placements to our hospice services with    11
LOS < 2 days

Total ED placements to our hospice services             24

TABLE 3 LOS + COST DIFFERENCE FOR ED VS NON-ED-INITIATED PALLIATIVE
CARE CONSULTS (LOS > 2 DAYS); ALL DISPOSITIONS

                                                   Average
                                    Number   LOS   Variable Direct
                                                   Cost per Case

ED palliative care consults with    13       5.5   $5,856
resultant hospice placement

Palliative care consults not        618      9.5   $17,444
initiated in ED--all discharge
dispositions (home, SNF, home
hospice, outside hospice, etc.)

TABLE 4 LOS + COST DIFFERENCE FOR ED VS NON-ED-INITIATED PALLIATIVE
CARE CONSULTS (LOS > 2 DAYS) WITH HOSPICE PLACEMENT

                                                     Average
                                      Number   LOS   Variable Direct
                                                     Cost per Case

ED palliative care consults with      13       5.5   $5,856
resultant hospice placement

Palliative care consults not          235      8.6   $15,431
initiated in ED leading to hospice
placement

TABLE 5 LOS + COST DIFFERENCE FOR ED VS NON-ED-INITIATED PALLIATIVE
CARE CONSULTS (LOS < 2 DAYS) WITH HOSPICE PLACEMENT

                                                     Average
                                      Number   LOS   Variable Direct
                                                     Cost per Case

ED palliative care consults with      11       0.9   $1,017
resultant hospice placement

Palliative care consults not          22       1.0   $2,096
initiated in ED leading to hospice
placement

TABLE 6 LOS + COST DIFFERENCE FOR ED VS NON-ED-INITIATED PALLIATIVE
CARE CONSULTS (LOS < 2 DAYS); ALL DISPOSITIONS

                                                         Average
                                          Number   LOS   Variable Direct
                                                         Cost per Case

ED palliative care consults with          11       0.9   $1,017
resultant hospice placement

Palliative care consults not initiated
in ED--all discharge dispositions         47       1.0   $2,184
(home, SNF, home hospice, outside
hospice, etc.)
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Title Annotation:Finance
Author:Fermia, Robert; Wilkins, Christine; Rodriguez, Danielle; Read, Kevin B.; Gavin, Nicholas; Caspers, C
Publication:Physician Leadership Journal
Date:Sep 1, 2016
Words:2189
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