New York University College of Nursing researcher and Assistant Professor Abraham A. Brody, RN, PhD, GNP-BC and colleagues reporting in Journal of Palliative Medicine found that initiating a palliative care consult in the emergency department (ED) reduced hospital length of stay (LOS) when compared to patients who receive the palliative care consult after admission.
Their study, "Effects of Initiating Palliative Care Consultation in the Emergency Department on Inpatient Length of Stay," retrospectively reviewed the information from the 1,435 palliative care consults identified through the administrative records system during a four-year period. Half received a consult while in the emergency department. LOS was 3.6 days shorter in the cohort receiving a palliative care consult in the emergency department.
"The ED is a setting for triage, treatment, and determination of subsequent course of care," said Dr. Brody. "Patients with advanced illness are generally triaged by acuity level and then based on their condition, admitted to the hospital floor, the intensive care unit, or a lower intervention care setting, such as a dedicated palliative care (PC) unit in the hospital. Patient preferences are generally not as highly considered in the ED due to requirements for timely disposition."
To better match patient wishes with the care received, the team hypothesized that creating a PC pathway in the ED may lead to an improvement in patient-centered care and a decrease in the intensity and invasiveness of care when appropriate. Specifically, the researchers hypothesized that hospitalized patients who receive PC consultation in the ED will have a lower LOS than those whose consultation occurs after admission.
"By providing early palliative care, patient needs are met earlier on, either preventing admission or reducing length of stay and treatment intensity for patients, which reduces costs to Medicare and the government," said Dr. Brody. "Patients receiving palliative care are less likely to be readmitted as well. Early palliative care can better help patients to have their wishes met, and allow them to return to and stay at home."
The findings are significant in light of the Affordable Care Act (ACA) which allows Medicare to create a Shared Savings Program, otherwise known as Accountable Care Organizations. These organizations are financially rewarded or at times penalized based on how successful they are in improving the quality of care and reducing costs.
The researchers note that this study is a first step toward fully examining the benefits of PC in the ED on hospital utilization. Further study is needed to examine why changes in LOS occurred, as well as whether there are potential differences in intensive care unit LOS, costs, clinical outcomes, and patient satisfaction outcomes.
Additional study is also needed to examine the best methods for implementation of PC intervention in the ED, especially given the time sensitive nature of ED care and the staffing required to provide PC in such a setting.
Acknowledgments: This study was graciously funded by the Metta Fund. The authors would also like to thank Linda Blum, RN, NP, and Catherine Seeley, MD are part of the PC team at CPMC. Finally, we would like to acknowledge emergency medicine practitioners at CPMC: Robin Serrahn, MD, Holly Bennett, RN, and Claudia Colley, RN.
Wu, F. Newman, J.M.,Sutter Health Research, Development, and Dissemination, Concord, California; Lasher, A, California Pacific Medical Center, San Francisco, California; and , Brody, A.A., New York University College of Nursing, New York, New York. (2013). Effects of Initiating Palliative Care Consultation in the Emergency Department on Inpatient Length of Stay. Journal of Palliative Medicine. 16:1632-1637. DOI: 10.1089/jpm.2012.0352
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