Emergency department hospice care pathway associated with decreased ED and hospital length of stay.

INTRODUCTION: While increasing evidence shows that hospice and palliative care interventions in the ED can benefit patients and systems, little exists on the feasibility and effectiveness of identifying patients in the ED who might benefit from hospice care. Our aim was to evaluate the effect of a clinical care pathway on the identification of patients who would benefit from hospice in an academic medical center ED setting. METHODS: We instituted a clinical pathway for ED patients with potential need for or already enrolled in hospice. This pathway was digitally embedded in the electronic health record and made available to ED physicians, APPs and staff in a non-interruptive fashion. Patient and visit characteristics were evaluated for the six months before (05/04/2021-10/4/2021) and after (10/5/2021-05/04/2022) implementation. RESULTS: After pathway implementation, more patients were identified as appropriate for hospice and ED length of stay (LOS) for qualifying patients decreased by a median of 2.9 h. Social work consultation for hospice evaluation increased, and more patients were discharged from the ED with hospice. As more patients were identified with end-of-life care needs, the number of patients admitted to the hospital increased. However, more patients were admitted under observation status, and admission LOS decreased by a median of 18.4 h. CONCLUSION: This non-interruptive, digitally embedded clinical care pathway provided guidance for ED physicians and APPs to initiate hospice referrals. More patients received social work consultation and were identified as hospice eligible. Those patients admitted to the hospital had a decrease in both ED and hospital admission LOS.

Variation in Pediatric Palliative Care Allocation Among Critically Ill Children in the United States.

OBJECTIVES: The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria. DESIGN: Retrospective cohort. SETTING: Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database. PATIENTS: Hospitalized children with nonneonatal ICU admissions from 2007 to 2018. MEASUREMENTS AND MAIN RESULTS: The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria. The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups. CONCLUSIONS: Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology.

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.

Patient Outcomes of a Virtual Reality-Based Music Therapy Pilot in Palliative Care.

Background: Hospitalized patients with palliative care needs often have high levels of physical and psychological symptom distress. Virtual reality (VR) with a music therapy intervention may improve physical and psychological symptoms. Objectives: To assess symptom distress and quality of life (QOL) among hospitalized palliative care patients who participated in a virtual reality-based music therapy (VR-MT) intervention, and to explore VR-MT from the perspectives of health care professionals involved in their care. Design: Single-arm pilot study of a two-day VR-MT intervention. Setting/Participants: Patients seen by an inpatient palliative care consultation service at a U.S. hospital could participate in the VR-MT intervention. Participants created a customized soundtrack with a music therapist and then listened to it while experiencing a 360-degree VR nature-based environment of their choice. Measurements: Patients completed the Edmonton Symptom Assessment System, revised version (ESAS-r) and McGill Quality of Life, revised version (MQOL-R) before and after VR-MT. Members of the participants' health care teams were interviewed. Results: Seventeen patients completed VR-MT (range 20-79 years of age, 59% women). Moderate clinical improvements were observed for total ESAS-r score (Cohen's d effect size, 0.68), physical distress subscale (0.52), and psychological distress subscale (0.60); small improvements were observed in total MQOL-r score (0.26) and the existential subscale (0.27). Health care team members described the value of VR-MT as facilitating meaningful conversations. Conclusions: This pilot study of VR combined with a music therapy intervention for hospitalized patients with palliative care needs supports opportunities for future study of potential improvements in symptom distress and QOL.

Increasing Medical Power of Attorney Completion for Hospitalized Patients During the COVID Pandemic: A Social Work Led Quality Improvement Intervention.

BACKGROUND: The high risk of mechanical ventilation with COVID hospitalizations requires health-care systems to rapidly innovate advance care planning (ACP) delivery for hospitalized patients to promote goal-concordant care. MEASURES: Assess the impact of a social work and care management intervention on the proportion of admitted patients each week with a Medical Durable Power of Attorney (MDPOA). INTERVENTION: Social workers were consulted to assist with identification of a surrogate decision maker and completion of MDPOA forms for hospitalized patients. This intervention utilized change management strategies and was implemented between April and June 2020. OUTCOMES: From a baseline average of 30.1%, the weekly percentage of admitted patients with MDPOA forms rose to 42.8% with correlating evidence of nonrandom special cause variation. LESSONS LEARNED: Use of change management strategies resulted in rapid implementation of an effective ACP initiative. Ongoing needs include focusing on intervention sustainability and education of interprofessional providers about ACP processes.

Virtual Reality-Based Music Therapy in Palliative Care: A Pilot Implementation Trial.

Background: Music therapy (MT) and virtual reality (VR) have shown favorable patient-reported outcomes during serious illness. Objectives: To evaluate implementation measures of feasibility, usability, and acceptability of a VR-based MT intervention. Design: A pilot implementation study of a two-day VR-MT intervention using mixed methods. Patients created a personalized soundtrack with a music therapist, and then paired the soundtrack with a 360° VR environment. Setting/Subjects: Hospitalized patients with palliative care needs. Results: Of 23 patients (ages 20-74 years, 52% women), 17 completed the intervention, including 39% during an intensive care unit stay. Participants scored usability above average. For satisfaction, 53% chose the highest rating. Most participants spoke favorably of VR-MT, describing pleasant emotional and physical responses. Participants provided feedback on length, frequency of use, VR options, and timing of delivery. Conclusion: This VR-MT intervention was feasible, usable, and acceptable for hospitalized palliative care patients. Further study will test VR-MT outcomes.

Clinical informatics accelerates health system adaptation to the COVID-19 pandemic: examples from Colorado.

OBJECTIVE: Large health systems responding to the coronavirus disease 2019 (COVID-19) pandemic face a broad range of challenges; we describe 14 examples of innovative and effective informatics interventions. MATERIALS AND METHODS: A team of 30 physician and 17 nurse informaticists with an electronic health record (EHR) and associated informatics tools. RESULTS: To meet the demands posed by the influx of patients with COVID-19 into the health system, the team built solutions to accomplish the following goals: 1) train physicians and nurses quickly to manage a potential surge of hospital patients; 2) build and adjust interactive visual pathways to guide decisions; 3) scale up video visits and teach best-practice communication; 4) use tablets and remote monitors to improve in-hospital and posthospital patient connections; 5) allow hundreds of physicians to build rapid consensus; 6) improve the use of advance care planning; 7) keep clinicians aware of patients' changing COVID-19 status; 8) connect nurses and families in new ways; 9) semi-automate Crisis Standards of Care; and 10) predict future hospitalizations. DISCUSSION: During the onset of the COVID-19 pandemic, the UCHealth Joint Informatics Group applied a strategy of "practical informatics" to rapidly translate critical leadership decisions into understandable guidance and effective tools for patient care. CONCLUSION: Informatics-trained physicians and nurses drew upon their trusted relationships with multiple teams within the organization to create practical solutions for onboarding, clinical decision-making, telehealth, and predictive analytics.

Palliative Care Scorecard.

BACKGROUND: In response to poor healthcare quality outcomes and rising costs, healthcare reform triple aim has increased requirements for providers to demonstrate value to payers, partners, and the public. OBJECTIVE: Electronically automating measurement of the meaningful impact of palliative care (PC) programs on clinical, operational, and financial systems over time is imperative to the success of the field and the goal of development of this automated PC scorecard. DESIGN: The scorecard was organized into a format of quality measures identified by the Measuring What Matters (MWM) project that are defined as important to the team, automatically extracted from the electronic health record, valid, and can be impacted over time. SETTING: The scorecard was initially created using University of Florida Health (UF) data, a new PC program, and successfully applied and implemented at University of Colorado Anschutz Medical Campus (CU), a second institution with a mature PC program. MEASUREMENTS: Clinical metrics are organized in the scorecard based on MWM and described in terms of the metric definition, rationale for selection, measure type (structure, process, or outcome), and whether this represents a direct or proxy measure. RESULTS/CONCLUSIONS: The process of constructing the scorecard helped identify areas within both systems for potential improvement in team structure, clinical processes, and outcomes. In addition, by automating data extraction, the scorecard decreases costs associated with manual data entry and extraction, freeing clinical staff to care for patients and increasing the value of PC delivered to patients.

Inpatient Palliative Care for Neurological Disorders: Lessons from a Large Retrospective Series.

BACKGROUND: Patients with neurological disorders are the second most common patient population to receive inpatient palliative care services after cancer; however, there have been few reports describing the characteristics and needs of this population. OBJECTIVE: To understand which patients with neurological diagnoses utilized these services, reasons for consultation, and whether patterns of use changed over time. DESIGN: Retrospective case series. SETTING/SUBJECTS: Neurological patients seen by our academic hospital-based palliative care consult service from January 2010 through December 2014. MEASUREMENT: Demographics, diagnoses, reasons for consultation, patient characterization, and outcomes were extracted from medical record. METHODS: Data extracted from the chart was analyzed using primarily descriptive statistics with Chi-square used to compare group proportions and regression to examine temporal trends. RESULTS: A total of 3170 patients received inpatient palliative care consultations, of whom 291 (9.2%) had a neurological diagnosis. Among these patients, 85 were excluded because of insufficient data, leaving 206 patients (mean age 70.0 ± 16.0 years; 111 (54%) female). Of the patients, 49% had a chronic diagnosis and 51% received a new diagnosis during their hospitalization, most commonly ischemic stroke. The proportion of patients with chronic diagnoses increased over time, with dementia representing the most common diagnosis in 2014. The most common reason for consultation was eliciting goals of care (82%). Advance directives were present at admission in 61 (30%), 130 (63%) at the time of consultation, and 190 (92%) patients after consultation. The proportion of people with advance directives after consultation significantly increased over the study period (p = 0.01). DISCUSSION: Hospital-based palliative care is primarily utilized to clarify goals of care in neurological patients and that advance directives were commonly not completed prior to consultation. CONCLUSIONS: Outpatient and hospital neurologists should routinely address advance directives, particularly as the proportion of patients with chronic neurological diagnoses increases.

Caring about prognosis: a validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year.

BACKGROUND: Identifying patients, at the time of hospital admission, who are at high risk for 1-year mortality is an ideal opportunity to introduce palliative interventions into the hospital care plan. The CARING (C = primary diagnosis of cancer, A = ≥ 2 admissions to the hospital for a chronic illness within the last year; R = resident in a nursing home; I = intensive care unit admission with multiorgan failure, NG = noncancer hospice guidelines [meeting ≥ 2 of the National Hospice and Palliative Care Organization's guidelines] criteria is a practical prognostic index developed and validated in the Veteran's Administration hospital setting that identifies patients at high risk of death within 1 year, although its effectiveness in a broader patient population is unknown. OBJECTIVE: To validate the CARING criteria in a university and safety-net hospital setting. DESIGN: Retrospective observational cohort study. SETTING: Inpatient. PATIENTS: Adults admitted to medical and surgical inpatient services during the study period of July 2005 through August 2005. MEASUREMENTS: Mortality at 1 year following the index hospitalization was the primary end point. The CARING criteria were abstracted from the chart using only medical data available at time of admission. RESULTS: At total of 1064 patients were admitted during the study period. Primary diagnosis of cancer (odds ratio [OR) = 7.23 [4.45-11.75]), intensive care unit admission with multiple organ failure (OR = 6.97 [2.75-17.68]), >2 noncancer hospice guidelines (OR = 15.55 [7.28-33.23]), and age (OR = 1.60 [1.32-1.93]) were predictive of 1-year mortality (C statistic = 0.79). One-year survival was significantly lower for those who met ≥ 1 of the CARING criteria. CONCLUSIONS: The CARING criteria are a practical prognostic tool validated in a broad inpatient population that can be utilized on hospital admission to estimate risk of death in 1 year, with the goal of identifying patients who may benefit most from incorporating palliative interventions into their hospital plan of care. Journal of Hospital Medicine 2013;8:696-701. © 2013 Society of Hospital Medicine.

A palliative care needs assessment of rural hospitals.

BACKGROUND: Palliative care services are lacking in rural hospitals. Implementing palliative care services in rural and remote areas requires knowledge of available resources, specific barriers, and a commitment from the hospital and community. OBJECTIVE: The purpose of the study was to determine awareness, knowledge, barriers, and resources regarding palliative care services in rural hospitals. METHODS: A descriptive survey design used an investigator-developed needs assessment to survey 374 (40% response rate) health care providers (chief executive officers, chiefs of medical staff, chief nursing officers, and social worker directors) at 236 rural hospitals (<100 beds) in seven Rocky Mountain states. RESULTS: Significant barriers to integrating palliative care exist: lack of administrative support, mentorship, and access to palliative care resources; inadequate basic knowledge about palliative care strategies; and limited training/skills in palliative care. Having contractual relationships with local hospices is a key facilitator. Respondents (56%) want to learn more about palliative care, specifically focusing on pain management, communication techniques, and end-of-life care issues. Webinar and online courses were suggested as strategies to promote long distance learning. CONCLUSIONS: It is imperative for quality of care that rural hospitals have practitioners who are up to date on current evidence and practice within a palliative care framework. Unique challenges exist to implementing palliative care services in rural hospitals. Opportunities for informing rural areas focus around utilizing existing hospice resources and relationships, and favoring Web-based classes and online courses. The development of a multifaceted intervention to facilitate education about palliative care and cultivate palliative care services in rural settings is indicated.

Characteristics associated with higher cost per day or longer length of stay in hospitalized patients who died during the hospitalization or were discharged to hospice.

BACKGROUND: Palliative care has been recommended as an approach to improve the quality of care for patients with advanced illness, while achieving hospital cost savings. However, studies are lacking that identify hospitalized patients who are more likely to have higher cost per day or length of stay (LOS) who may benefit from palliative care consultation. OBJECTIVE: Identify characteristics associated with higher cost per day or longer LOS in hospitalized patients at the end of life--those likely to benefit from palliative care consultation. DESIGN: Observational study. SETTING: Academic medical center. PATIENTS: Adult inpatients who died during the hospitalization or were discharged to hospice. INTERVENTION: None. MEASUREMENTS: We hypothesized that several patient characteristics would be associated with higher cost per day and/or longer LOS. Using administrative data, we developed univariate and multivariate models to evaluate association between these patient characteristics and cost per day and LOS. RESULTS: Patients cared for on the cardiothoracic surgery service had significantly higher cost per day ($12,937; P < 0.0001) and LOS (7.0 days; P = 0.001). Neurosurgery patients also had higher cost per day ($2255; P = 0.03), and surgical oncology patients had a longer length of stay (5.3 days; P = 0.003). Patients 65 years and older had a significantly lower cost per day (-$811; P = 0.02) and LOS (-1.8 days; P = 0.003) for each decade increase in age. CONCLUSIONS: Our data suggest that younger patients and those cared for by surgical specialty services may receive the most benefit from palliative care consultation, a finding that needs to be corroborated in other centers.