Impact of a Consult Cap for a Busy Inpatient Palliative Care Program (S773)

Abstract

•Describe implementation of an inpatient consult cap at a large academic hospital.•Examine the impact of implementing a daily consult cap on a palliative care program. The ability of many hospital-based palliative care programs to provide high-quality care in a sustainable fashion is now paradoxically threatened by their own success. Approximately 10% of such programs have responded by instituting caps on consults, but the effects are unknown. We identified all palliative care inpatient consults requested from July 1, 2014 to April 30, 2016 at a large academic hospital. We describe the implementation of a hospital-wide daily cap on new consults on May 1, 2015, and compare the volume, characteristics, and timing of consults in the year before and year after the cap. The hospital-wide cap on new palliative care consults was typically set at 8 per day and varied based on available staffing and census. Consults requested after the cap were prioritized the following day. Mean monthly consult requests increased from 157.7 (range 126-196) in the year before to 173.7 (range 155-209) in the year after the cap (p<0.001), while the proportion actually seen decreased from 96.4% to 88.6% (p<0.001). There was no difference in mean pre-consult length of stay (8.4 days [SD 14.8] vs. 8.6 days [SD 14.3], p=0.75), the proportion of patients transitioned from aggressive to comfort care (38% vs. 35%, p=0.08), or the number of patients discharged to hospice (287 (25.4%) vs. 263 (24.4%), p=0.59). Following the cap, reduced proportions of consults originated from the Oncology and ICU services, and an increased proportion from General Medicine, but not all changes were statistically significant. Implementation of a daily cap on new palliative care consults did not reduce consultative demand, increase the time to consultation, or change the rates of hospice referrals or transitions in goals of care.