G3 Romayne Gallagher - Evaluation of a Palliative Outreach and Consult Team
Evaluation of aPalliative Outreach and Consult Team: Romayne Gallagher MD, CCFP, Palliative Care Program Providence Health Care Vancouver, BC
Palliative care improves qualityCompared to conventional care, palliative care is associated with:• Reduction in pain and non-pain symptoms• Improved patient/family satisfaction• Reduced hospital length of stay and cost Jordhay et al Lancet 2000; Higginson et al, JPSM, 2003; Finlay et al, Ann Oncol 2002; Higginson et al, JPSM 2002.
Late Referral Decreases Quality• 237 bereaved family members of hospice patients asked about timing of the referral• 13.7% reported referral “too late”• Compared to family members referred early or at the right time, these respondents reported Lower satisfaction More unmet needs Lower confidence More concerns about coordination Schockett, Teno, Miller, Stuart. JPSM 2005
Prior to POCT launch• MD to MD consultation• MD only team• Availability of 24/7 coverage only at SPH• Not involved in outpatient clinics• Palliative Care Unit seen as a place to send people to for end of life care
Removing BarriersConsults:• Nurses and physicians on team• Access to social worker• Anyone (including patient and family), any discipline can refer• Early referrals and hallway consultations encouraged• 24/7 coverage of whole organization
Removing BarriersOutreach:• Attending rounds• Working with out patient clinics• Increasing visibility• Education
Building capacity• Palliative Immersion Project• Education for medical students and residents• Orientation for nurses• RN training on using SBAR• Terminal care orders on SCM• Palliative Care tools and info on Intranet
Number of consulted patients - Acute care 600 501 497 500 Number of consulted patients 400 331 300 251 200 158 157 100 72 0 2007 2008 2009 2010-YTD 2008 2009 2010-YTD SPH MSJ Number of consulted patientsThere has been a 50% increase in the annual number of patientsconsulted by palliative care at SPH since the implementation of the POCTin 2008.
Average number of days to 1st palliative care consult 20 18 16 14.3 13.2 Avg time to consult 14 13.1 12.4 12 11.1 9.5 10 8 6 4 2 0 2008 2009 2010 - YTD 2008 2009 2010 - YTD SPH MSJ Avg time to consultDecline in average number of days to consult from an average of 14.3days in 2008 to 12.4 days in 2010-YTD for SPH and from 13.2 in 2008 to9.5 days in 2010-YTD for MSJ.
Number of palliative care consults per 100 admissions 5.0 4.6 4.5 4.3 4.3 4.3 3.9 3.9 4.0 3.5 Consult rate 3.0 2.6 2.5 2.0 1.5 1.0 0.5 0.0 2007 2008 2009 2010-YTD 2008 2009 2010-YTD SPH MSJ Consult rateFor SPH, the number of palliative care consults per 100 admissions hasincreased from 2.6 in 2007 to an average of 4.0 post-POCT implementation.The consult rate at MSJ is 4.3 consults per 100 admissions.
Average number of critical care days spent by patients with palliative care consult Avg. number of critical care days 1.6 1.4 1.3 1.2 1.0 1.0 0.8 0.8 0.6 0.6 0.4 0.3 0.2 0.1 0.0 2008 2009 2010 - YTD 2008 2009 2010 - YTD SPH MSJ Avg. number of critical care daysFor SPH, the average number of critical care days spent by patientsconsulted by palliative care has decreased slightly each year since theimplementation of POCT while the rate of transfers to critical care haveremained relatively stable.
Residential Care Medication Review• Compared with 2005 there is a tripling of the morphine equivalent amount of opioid used• Decrease in hazardous NSAID use for pain management• Increase in appropriate end of life medication orders
Pharmacy data in residential careTotal opioid usage in morphine equivalents – 2004: 491967 2009: 1624604Tylenol #3 – 2004: 45080 2009: 864.4Morphine – 2004: 45165 2009: 14290Large increase in methadone, oxycodone, hydromorphone, sufentanilFentanyl patch mostly unchanged
Pharmacy data in residential care• Acetaminophen – 2004: 357673 2009: 597202• Celecoxib: – 2004: 2593 2009: 48• Increase in short term use of naproxen and ibuprofen• Reduction in docusate, increase in lactulose• Increase in lower doses of neuroleptics• Increase in scopolamine
Where do we go from here?Bereaved Relative Study – After-death bereaved relative telephone interview – Taking these results and acting on gaps in education and support of familiesPilot project to screen patients coming into acute care – Identify patients needing palliative approach or palliative services earlierPalliative Care Awareness Week