G3 Romayne Gallagher - Evaluation of a Palliative Outreach and Consult Team
Transcript of G3 Romayne Gallagher - Evaluation of a Palliative Outreach and Consult Team
Evaluation of a Palliative Outreach and
Consult Team:
Romayne Gallagher MD, CCFP, Palliative Care Program Providence Health Care
Vancouver, BC
Palliative care improves quality
Compared 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 Barriers Consults: • 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 Barriers Outreach: • 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
There has been a 50% increase in the annual number of patients consulted by palliative care at SPH since the implementation of the POCT in 2008.
331
501 497
251
158 157
72
0
100
200
300
400
500
600
2007 2008 2009 2010-YTD 2008 2009 2010-YTD
Num
ber o
f con
sulte
d pa
tient
s
Number of consulted patients - Acute care
Number of consulted patients
SPH MSJ
Decline in average number of days to consult from an average of 14.3 days in 2008 to 12.4 days in 2010-YTD for SPH and from 13.2 in 2008 to 9.5 days in 2010-YTD for MSJ.
14.313.1 12.4 13.2
11.19.5
02468
101214161820
2008 2009 2010 - YTD 2008 2009 2010 - YTD
Avg
time
to co
nsul
t
Average number of days to 1st palliative care consult
Avg time to consult
SPH MSJ
For SPH, the number of palliative care consults per 100 admissions has increased 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.
2.6
3.9 3.94.3 4.3 4.3
4.6
0.00.51.01.52.02.53.03.54.04.55.0
2007 2008 2009 2010-YTD 2008 2009 2010-YTD
Cons
ult r
ate
Number of palliative care consults per 100 admissions
Consult rate
SPH MSJ
For SPH, the average number of critical care days spent by patients consulted by palliative care has decreased slightly each year since the implementation of POCT while the rate of transfers to critical care have remained relatively stable.
1.3
1.0
0.8
0.3
0.6
0.1
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
2008 2009 2010 - YTD 2008 2009 2010 - YTD
Avg.
num
ber o
f crit
ical c
are
days
Average number of critical care days spent by patients with palliative care consult
Avg. number of critical care days
SPH MSJ
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 care Total opioid usage in morphine equivalents
– 2004: 491967 2009: 1624604 Tylenol #3
– 2004: 45080 2009: 864.4 Morphine
– 2004: 45165 2009: 14290 Large increase in methadone, oxycodone, hydromorphone,
sufentanil Fentanyl 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
Palliative Care Companion
Podcasts
POP Tool e
Terminal Care Orders
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 families
Pilot project to screen patients coming into acute care – Identify patients needing palliative approach or
palliative services earlier
Palliative Care Awareness Week