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ED Palliative Care Screening Can Reduce Admissions for Older Patients

NEW YORK – Emergency departments can play a critical role in reducing the number of geriatric patients admitted to intensive care units, which could both extend lives and reduce Medicare costs, according to a three-year analysis.

The report, published recently in the journal Health Affairs, notes that those goals can be achieved by applying palliative care principles to EDs.

"Data show that more than half of Americans ages 65 and older are seen in the emergency department in the last month of their lives, and that the number and rate of admissions to intensive care units among older adults who are seen in the ED have also increased," said lead author Corita Grudzen, MD, a former Mount Sinai Health System physician. "Our findings suggest that early palliative care inpatient consultation can improve care for older patients, decrease hospital lengths-of-stay and costs, and even extend life.”

The new model for ED care was developed as Mount Sinai's Geriatric Emergency Department Innovations in Care Through Workforce, Informatics and Structural Enhancements program (GEDI WISE).

As part of the training at Mount Sinai, ED triage nurses and nurse practitioners learned to screen patients aged 65 and older to identify those at high risk of ED revisit and hospital readmission as well as those suitable for and desiring palliative and hospice care. They also learned how to expedite referrals.

After screening with the Identification of Seniors at Risk tool, instituted in October 2012, 59% of the 8,519 visitors 65 and older to Mount Sinai's ED had a score that indicated an increased risk for revisit and readmission. The study points out that the five most common presenting diagnoses among those patients were chest pain, shortness of breath, malaise and fatigue, abdominal pain, and dizziness.

Between January 2011 and May 2013, the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3% to 0.9%. The 1.4% drop represents 535 averted admissions among 38,240 unique ED encounters, saving Medicare $3.14 million.

"This study shows that identifying emergency patients who would benefit from palliative care interventions may both improve the quality of care and reduce costs," said Lynne D. Richardson, MD, who developed the model. "This could result in a better match of older adults' goals of care with the environments to which they are discharged from the ED, including decreased admissions to the ICU, and increased referrals to hospice and palliative care provided at home."

Study authors caution that the decline in admissions cannot be solely attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period.