Palliative program yields triage changes in the ED

Turnaround accomplished in just six months

If your hospital doesn't have a palliative care program yet, it soon will, and that may mean changes in the way you triage your patients.

The 2007 American Hospital Association Annual Survey of Hospitals, which included data analysis from the New York City-based Center to Advance Palliative Care (CAPC), shows that 1,240 hospitals now provide palliative care programs. What's more, 50% of all facilities with more than 75 beds have a program, and 70% of those with more than 250 beds have a program, CAPC says. According to CAPC, the total in 2000 was 632.

While the advent of such a program may mean changes for your ED, it can be a win-win for your department and the new program. The Mount Carmel Health System in Columbus, OH, initiated its program in 1997, and not only has the program proved successful, but it has helped speed throughput in the ED. When there is a palliative care bed available, it usually takes 30 minutes from door to transfer, vs. 90-140 minutes for an admitted telemetry or ICU patient, says Loren Leidheiser, DO, chairman of the Department of Emergency Medicine at Mount Carmel's St. Anne's Hospital in Westerville, OH.

It was not time-consuming to make the adjustment, he adds. "It was almost a relief," he explains, because now there was another alternative for moving patients out of the department.

Filling needs

The St. Anne's ED sees about 73,000 patients a year, while the hospital is relatively small — about 185 beds, notes Leidheiser. "While we see 1,000 pediatric patients a month and we are not a major trauma center, we do see a lot of patients in their 60s, 70s, and 80s," he says. "We also have a cancer center, so this provided a patient population that included people with chronic illnesses that raised more management issues than cure issues."

The ED had to move admitted patients out, the program had to provide needed services, and the administration was seeking new ways to get patients into the hospital, Leidheiser summarizes.

To begin the process, Leidheiser invited the leaders of the new program to come to one of his department's bi-weekly meetings for nurse and physician leaders. They then pushed out the information to the rest of the department.

"The big issue was communication, since we write our own orders in the ED," says Leidheiser. "This allows us to control throughput better, but with the new palliative care program, there were additional things to consider when admitting patients."

The palliative care program provided the ED with indications for direct admits and for palliative care consults. The palliative medicine service developed a list of triggers, says Sharol Herr, RN, MSEd, CHPN, a nurse clinician with Mount Carmel Palliative Medicine Services. [The complete list of triggers is available.]

The triggers were shared with the entire ED staff via e-mail. Leidheiser says, "That was the springboard, but the true piece that led to success was the palliative care people sent progress e-mails that I would forward. They would identify doctors who were using the program really well, and I would send out congratulations, which would serve as an ongoing reminder."

Mount Carmel keeps a supply of palliative service admission orders in the ED so they were handy, Herr says, "and they have the list of triggers posted by every documentation computer in the ED." Now, they are able to look in a template and determine whether a patient is appropriate for palliative care, notes Leidheiser. For example, if a patient comes in with an abdominal or pulmonary mass that is a brand-new diagnosis, "we immediately use palliative care services and do not lose the 36 hours it takes for an internist to admit the patient, and then consider a consult after those 36 hours," he says.

Education critical

Staff education is critical to the success of a transition such as this one, Leidheiser emphasizes. "You can put in all the triggers you want, but education is huge," he says. "Your staff has to understand what kind of care the program will be giving and how the patient will benefit from it."

In fact, adds Herr, the entire ED staff had to be educated because the medical staff informed her they did not have the time, for example, to sit down with the family and discuss the program in depth. A resource team of chaplains, social workers, and case managers can initiate the palliative care process by informing the ED clinical staff when a family has told them they only want palliative care for their loved one, she says.

"We developed a resource team to have those difficult discussions with families in the ED about advanced care planning and establishing goals of care," Herr says. The hospital has several chaplains on staff, including some whose primary unit assignments are the ED, she says. They are on call 24/7. In addition, there is a caseworker or a social worker in the ED at all times.

Sources

For more information on adapting triage processes to accommodate a palliative care program, contact:

  • Sharol Herr, RN, MSEd, CHPN, Nurse Clinician, Mount Carmel Palliative Medicine Services, Columbus, OH. Phone: (614) 898-4308.
  • Loren Leidheiser, DO, Chairman, Department of Emergency Medicine, St. Anne's Hospital, Westerville, OH. Phone: (614) 898-5550.