202 Missed Opportunities: Integrating Palliative Care Into the Emergency Department for Older Adults Presenting as Level 1 Triage Priority from Long-Term Care Facilities

Abstract

Early integration of palliative care from the emergency department (ED) has been identified as an underutilized modality of care with significant potential benefits, but few studies have addressed how to assess which patients are appropriate for such care. Our hypothesis is that patients 65 years of age or greater who present to the emergency department as a level 1 emergency severity index from a long-term care facility have prolonged hospitalizations with high resource utilization and significant mortality and therefore would benefit from early palliative care involvement. For the years of 2014 and 2015, we performed a retrospective chart review of all patients > 65 years of age that arrived in the emergency department of an academic suburban southeastern Level 1 trauma center from a long-term care facility and were triaged as a Level 1 triage priority, using the Emergency Severity Index. The ED course, hospital course, and final outcomes were analyzed and data collected included code status, mortality, length of stay, level of care, and presence of palliative care intervention. Of the 198 patients in the study population 54% were deceased 30 days after hospital discharge with only 25.7% alive at 15 months. Admitted patients had a mean hospital length of stay of 7 days with 73% requiring intensive care. 40.4% of the patients received a formal palliative care intervention during their hospitalization from either the palliative care consult service (12.1%) or by embedded supportive care nurses (28.3%). Formal palliative care interventions occurred a median of 3 days into hospitalization and often changed the direction of care with 85% of patients downgrading their advanced directive wishes and discharge occurring a median of 1 day after intervention. Few formal palliative care interventions began from the emergency department (9.1%). Interestingly, 47.1% of patients who did not receive any documented goals of care discussions or palliative care interventions were deceased at 15 months post-discharge. Elderly patients from long-term care facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment and improve end-of-life care in this vulnerable population and should be considered early in the hospitalization and where available, be initiated in the emergency department.