Direct referral from emergency department to palliative care unit

Abstract

Introduction: It has been observed an increase in the amount of patients that die in the Emergency Department (ED), probably due to the increase in the number of patients that arrive in terminal phase of their disease or they are very old. In Catalonia, 54% of citizens die in the hospital, out of which 35% do in the ED, in restricted and crowded areas. In most cases, 25% of the consultations could be avoided. Aims : There are two hospitals in Tarragona next to the other connected by underground walkway: Acute Care Hospital Joan XXIII (HJ23) and Hospice Care Hospital Sociosanitario Francoli (HSSF). The last one has an interdisciplinary Palliative Care Unit (PCU). In 2013, it was implemented the collaborative work between HSSF-PCU and HJ23-ED with the objective of identify subsidiary patients for palliative care, coordinated by the HSSF-PCU team on call, who attend the patients in the emergency room. They do so to value the patient and its surroundings; check the living wills (if there exist); start and/or modify their palliative treatment; resources coordination; emotional support for the patient and family, and home patient referral or hospital admission when necessary. Key findings: To value the efficiency of this protocol data from 2013 and 2014 was collected. This data included: number of patients at the ED; patients hospitalized in PCU derived from ED; average stay in ED and UHC; mortality index in emergency room and PCU, and patients subjected to be moved to PCU but have died in the ED. In 2013, ED received 81,123 patients, out of which 78 died. The average time they spent in ED was of 14:52 h. Besides, 112 consultations were carried out from ED to HSSF, out of which 57 were hospitalization directly in PCU. In 2014, the ED received 84,098 patients out of which 104 passed away with an average stay of 11:07 h and 132 consultations were carried out at the HSS-PCU. From this, 75 were hospitalizations in PCU. From the total number of ED deceased patients, 33 stayed there more than 12 h, and the 91% of these patients (30) met the hospitalization criteria in PCU. In 7 of them were treated by PCU team in the ED. Considering the all referred patients to PCU, an 87, 8% passed away during this hospitalization, with an median stay of 3 days. The pathologies for referring the patients were: 45% oncologic patients, 24% with acute respiratory failure, 20% had advanced neurological disease or ictus, 11% other causes. There have been other actions taken, apart from the procedure of action, which leads to an increase in the number of consultation; professionals from ED (doctors, residents and nurses) have received clinical training sessions in palliative care Highlights: It is still difficult to take the decision of including a patient in PC and futile treatments sometimes are too long in ED. It would be of great help that decisions made by a patient at the end of their life were shared with their doctors and included in the medical records. In this regard, it is important the development of living wills document model, which is in progress in Catalonia, and will be of great help for professionals when they have to assist a patient at the end of the life. Future strategies should be focused in increasing the time dedicated by PCU at ED, number of beds at PC and professionals’ training. Conclusions: Palliative Care (PC) in ED is an area in expansion and development and at the same time an opportunity to offer a quality multidimensional treatment aligned with the patients’ and families’ wills. Integration of PC in ED offers great quantity of benefits for the patient including better quality at the end of the life, improvement in treatment based on symptoms control and a dignified death. For the families is better because it diminishes the development of complicated grieving. It also helps the different professionals involved in the patient’s attention. The benefits for the sanitary system are: improvement in the assistance, costs reduction, shorter stays, and fewer unappropriated hospitalizations. Everything leads to increase user’s satisfaction. It is important to highlight the high level of satisfaction perceived by the patients and families who have benefited from this procedure. It is this satisfaction that leads to continue working in the same way and trying to find improvement areas.