307 Descriptive and Retrospective Analysis of a Triggering Tool Used to Identify Emergency Department Patients With Unmet Palliative Care Needs

Abstract

Patients with serious or advanced illness are likely to find themselves in an emergency department (ED) at some point along their trajectory of illness. Identification of appropriate patients as they present to the ED can be a challenge and has been extensively studied. It has been shown that > 50% of inpatient palliative care (PC) consults are generated by ED admitted patients however < 7% consultations originated while in ED . Early PC consults are shown to decrease inpatient length of stay and demonstrate a trend in optimized utilization metrics. Our aim using a novel triggering tool was to understand: 1) volume of ED based palliative medicine consultations, 2) why palliative patients are utilizing the ED, and 3) if this tool could predict patients who subsequently obtained supportive services, or had hospital readmissions, multiple ED visits, critical care admissions, or contributed to hospital mortality over a 1yr period. In June 2016, we trialed a simple triggering tool (fig1) completed by ED physicians to help identify patients presenting to the ED with advanced illness and unmet PC needs. A retrospective chart review of the patients identified during the month of June 2016 was then performed to describe health care utilization metrics in a subsequent 1 year period ending June 2017. Specifically, number of ED visits, hospital readmissions, total hospitalized days, critical care admissions, readmission risk score, palliative care consultations, hospice enrollment, and mortality in a subsequent 1-year period ending June 2017 was extracted. Continuous variables were summarized with median and range while categorical variables were summarized with frequency and percent. All tests are two-sided and p-values less than 0.05 are considered statistically significant. In June 2016, 65 encounters were generated with 58 unique patients; 5 patients had 2 or more ED visits during the month. Patient characteristics at their sentinel ED visit are summarized: median age was 73.5y (Range: 45, 101). The most frequent diagnoses were metastatic cancer (43%), advanced CNS disease (21%) and CHF (19%). 66% of patients were admitted and 22% to ICU/PCU. 15.8% had a prior palliative consult and NONE of these were admitted to the ICU. 80% of all had more than one noted unmet PC need (Step 2). ED consultants suggested 5 (9%) could avoid the ICU. Of patients’ eligible, according to Step 1, 28% (16/58) had more than one life-limiting diagnosis (range1-3). Fifty-two (90%) eligible patients had more than one Step 2 palliative modifier (median 3;Range: 0, 6). The most common were predicted death within 12 months (59%), functional decline (52%), and uncontrolled symptoms (45%). Further investigation revealed that patients who had more life limiting diagnoses also had more palliative modifiers (P=0.031). No life-limiting diagnoses (Step 1) or palliative modifiers (Step 2) were indicative that the patient would be readmitted within 30 days, readmitted within 6 months, and/or die within 1 year of their sentinel visit. Finally, a higher proportion of patients who may have benefited from an inpatient consult died within one year of their sentinel ED visit (P=0.007). Patients presenting to the ED with life-limiting diagnoses often have unmet palliative care needs and would likely benefit from PC services provided in the ED. We have begun a prospective study using meaningful Step1/Step 2 triggers and hope to suggest more meaningful indications for the ED-based PC consult.