Emergency Department Admission Triggers Sustainably Generate High-Value Palliative Care Consultations (TH310A)

Abstract

•Describe how admission triggers can be implemented in the ED to effectively facilitate earlier palliative care consultation during the inpatient course.•Demonstrate that specificity in trigger design can capture high value consultations while maintaining sustainable workflows. Capturing admitted patients for palliative care (PC) consultation earlier in their hospital course helps achieve better alignment with the quadruple aim. Emergency department (ED) admission triggers have been proposed to facilitate earlier engagement, however their impact is not adequately studied. Demonstrate that specific admission triggers can generate early palliative care consultations directly from the ED while maintaining sustainable workflows. ED admission triggers were derived from literature review and prior quality improvement initiatives. Only three criteria were implemented to ensure actionability and sustainability: presence of serious illness, chair/bedbound >50% of time, and unsurprised if the patient dies this hospitalization. Eligible patients met all three criteria. Any ED interdisciplinary staff could identify eligibility. After verifying, the emergency physician coupled the admission with a “heads-up” PC consult. PC evaluated the patient within 24 hours; they were not expected to call back or come to the ED. High specificity enabled the mature PC consult team to prioritize their fully-stretched resources. Institutional alignment acquired from all stakeholders (ED, ICU, hospitalists, administration) designated this workflow as “standard of care.” Data from 03/2018-06/2018 were tracked through the Palliative Care Quality Network registry. ED-initiated consults during this four-month pilot increased 180% year over year (50 vs.18, p=0.000). Compared to usual PC consults, ED-initiated consults were comparable in age, gender, and palliative performance scale; however, they had significantly shorter median length of stay prior to consultation (0 days vs. 4 days, p=0.000). Among live discharges, more ED-initiated consults received hospice services (51% vs. 38%, p=0.148). Eight planned admissions were avoided. Overall PC consult volume remained proportionately steady, although 21% now originated from the ED. ED-initiated consults were evenly distributed across weeks. Stakeholders valued this new workflow and approved continuing as “standard of care.” Emergency department admission triggers can effectively and sustainably drive earlier palliative care consultation to achieve the quadruple aim.