Inpatient Palliative Care Team Research Articles

Patient concerns and palliative psychology interventions within an inpatient palliative care service

Multi-professional inpatient palliative care services are increasingly complementing palliative care in hospitals alongside palliative care units. The present study aims to investigate the nature and frequency of patient concerns and palliative psychological interventions in the context of palliative psychological work, as well as the perceived quality of outcomes in an inpatient palliative service. Palliative psychological interventions for terminally ill patients at the inpatient palliative care service at Leipzig University Hospital were investigated in a prospective follow-up evaluation study. Psychological distress (distress thermometer) as well as the perceived quality of the results of the palliative psychological support (from the therapist`s perspective) were recorded. Patient concerns and psychological conversation topics and interventions were recorded. Descriptive and regression analytic procedures were used. Over a year, 355 patients in the inpatient palliative care service received psychological support, 304 participated in the study (mean age 63.8 years, 55% male, 89% oncological disease). An average of 3 palliative psychological interviews were conducted; 64% of patients reported high psychological distress (M=6.5). The most common patient concerns and topics within the interviews were dealing with emotions (87%), resources (83%), conflicting care and autonomy issues (77%) and hope (76%); significantly less common were spiritual concerns (2%) or the patient's legacy (9%). The most frequently used palliative psychological interventions included: support in illness processing and acceptance (74%) or in emotional-relieving interventions (98%) as in normalisation (75%), active listening (97%) or emotional containment (95%). Regression analysis showed that an oncological (vs. non-oncological) disease, a high number of palliative psychological interviews and interventions, comprehensive information regarding the palliative dimension of the diagnosis as well as undisturbed contact in the initial interview had a positive effect on the perceived outcome quality. The study results show that palliative psychologists play an important role in inpatient palliative care teams and should be involved as early as possible in the course of the disease. There is a need for improvement, especially in the palliative psychological care of non-oncological patients.

Continuous Ambulatory Delivery Device Use for Patients Managed by an Inpatient Palliative Care Team

BackgroundThe use of Patient Controlled Analgesia (PCA) via a Continuous Ambulatory Delivery Device (CADD) is a common and effective means of pain and symptom management for hospitalized patients with a malignancy. Studies exploring the indications for starting such a device for hospitalized inpatients referred to inpatient palliative care teams are limited. AimThis retrospective chart review aims to explore indications, timing of initiation, and barriers to the use of a CADD. MethodsOver a six month period, during daily inpatient palliative care consult team rounds, patients who required a CADD were enrolled in this study. Sixty-one adult patients were identified who required a pump for symptom control. The team’s database sheets were used to capture patient demographics. ResultsThe main reasons for initiating a Continuous Ambulatory Delivery Device in the above setting included: lack of efficacy of oral opioids and to increase patient autonomy of their pain management. Approximately 20% of patients required transfer to another unit that could accommodate the CADD. The median length of stay for these patients was 13 days, with a median length of half a day for a pump to be started. ConclusionsThis initial study provides the Palliative Care Consult Team with information on the indications for the use of a CADD. The lack of universal access to a CADD in various areas of our hospital due to differences in departmental protocols may compromise good symptom management and patient safety. These results strengthen the argument that the existing hospital policy requires revamping to improve CADD access.A CADD has been shown to provide hospitalized patients, with a malignancy, with timely access to effective symptom management, and in turn, reducing their length of stay in hospital. These findings will help inform this organization's CADD policy and support the need to broaden access to this device.

APPROACHES TO THE DEVELOPMENT OF PEDIATRIC PALLIATIVE CARE

Considering today’s challenges to medicine and provision of social protection to vulnerable population groups, the issue of developing pediatric palliative care is relevant and crucial. The aim of the study is to analyze the development level of pediatric palliative care in Ukraine and European countries. Material and methods: analysis and generalization of data from scientific-methodological and specific literature, documentary materials, information resources on the Internet, and regulatory and legal frameworks of Ukraine, the Republic of Poland and the Republic of Italy. Research results. The goal of pediatric palliative care is to support the child and their family as soon as a life-threatening disease is diagnosed. Such care is provided throughout the entire trajectory of the child’s disease. Pediatric palliative care is aimed at improving the level of physical, mental, and spiritual well-being of the child and their family within the limits of the diagnosed incurable, often progressive, disease. The solution of multidisciplinary tasks requires the work of an interdisciplinary team in a palliative inpatient department, a mobile crew, and assistance at home. The family-centered model of pediatric palliative care is one of the unique models of supporting the family to adhere to a series of socio-medical interventions and maintenance of intra-family communication, avoid social deprivation of the family, and promote and coordinate the care of a child with an incurable disease. Conclusions. Palliative pediatric care contributes to the improvement of the quality of life of the child and their family. Pediatric palliative care in Ukraine and the world needs solving a range of problems related to financing and specialized education of specialists and parents of the child. The functioning of the inpatient and mobile pediatric palliative care team should be coordinated and continuous. The family-centered model is an effective approach to pediatric palliative care for the child and family.

A grounded theory of interdependence between specialist and generalist palliative care teams across healthcare settings

Background: Individuals with palliative care needs face increased risk of discontinuity of care as they navigate between healthcare settings, locations and practitioners which can result in poor outcomes. Little is known about interactions that occur between specialist and generalist palliative care teams as patients are transition from hospital to community-based care after hospitalisation. Aim: To understand what happens between inpatient specialist palliative care teams and the generalist teams who provide post-discharge palliative care for shared patients. Design: A constructivist grounded theory approach, using semi-structured interviews and constant comparative analysis, including coding, memo-writing and diagram construction. Settings/participants: Interviews (n = 21) with specialist palliative care clinicians and clinicians in other specialties providing generalist palliative care. Specialists had training in palliative care and worked in specialty palliative care practices; other clinicians worked in primary care or oncology and did not have specialised palliative care training. Results: A grounded theory of interdependence between specialist and generalist palliative care teams across healthcare settings was constructed. Two states of inter-team functioning were found which related to how teams perceived themselves: separate teams or one cross-boundary team. Three conditions influenced these two states of inter-team functioning: knowing the other team; communicating intentionally; and acknowledging and valuing the role of the other team. Conclusions: Teams need to explicitly consider and agree their mode of functioning, and enact changes to enhance knowledge of the team, intentional communication and valuing other teams’ contributions. Future research is needed to test or expand this theory across a range of cultures and contexts.

What Kind of Chaplain Progress Note Do You Prefer? Four Focus Groups with Non-Chaplain Inpatient Palliative Care Team Members (Sci263)

What Kind of Chaplain Progress Note Do You Prefer? Four Focus Groups with Non-Chaplain Inpatient Palliative Care Team Members (Sci263)

Adaptations within Palliative Care Delivery Models Due to the COVID-19 Pandemic at a Tertiary Care Hospital.

Background: Since the onset of the COVID-19 pandemic, all facets of palliative care provision for patients with serious illness have faced unparalleled challenges. Methods: We describe our palliative care program's response to the increased clinical volume associated with the pandemic by adapting workflows for inpatient and outpatient palliative care teams caring for oncology and nononcology populations. Results: During the initial surge, the demand for palliative care consultation for patients affected by SARS-CoV-2 was high, accounting for 75% of all inpatient palliative care referral requests for oncology and nononcology patients. Furthermore, our ambulatory clinic experienced a 40% increase in visits for complex oncology patients between February and December of 2020. Discussion: This article highlights transformations in palliative care delivery implemented in response to the pandemic and reflects on how these transformations have shaped our current care delivery models. We further delineate our intentional reliance on key population health principles to drive ongoing innovation in palliative care provision across our clinical teams.

Evaluation of Bereavement Assessment Within Inpatient Palliative Care Consultation.

It is crucial for palliative care teams to evaluate practices in assessing the risk of developing complicated grief among family members and caregivers of patients. A retrospective chart review of 99 patients seen by an inpatient palliative care team at an academic medical center was conducted to assess for documentation and prevalence of complicated grief risk factors. Factors included patients whose family are their primary caregiver, involvement of young children, mental health or substance use diagnoses in patients or their family members, a history of multiple losses, traumatic or sudden death. 64% of charts did not formally document bereavement assessment while 45% of families exhibited at least one risk factor for prolonged grief. This work suggests the need for increased education for PC providers on grief risk factors as well as the implementation of a formal screening assessment in order to best utilize limited psychosocial support resources to address needs.

1292P A review of in-hospital end-of-life care (EOLC) for oncology patients during the COVID-19 pandemic

Globally, 40 to 60% of all patient deaths occur in an acute hospital setting. Patients with cancer make up a significant proportion of those who die in hospitals. Clinicians involved in their care should be competent at recognising dying and documenting the quality of EOLC delivered to patients and families. Continued evaluation and audit of the care of the dying patient is essential for quality improvement at an organisational level. The management of patients who died in Cork University Hospital under the Oncology Service’s care between 1 January 2021 and 31 December 2021 was analysed. Paper and electronic records were reviewed, and patient care was assessed using the Oxford Quality Indicators (QIs) for EOLC. Ethical approval was granted by the Cork University Hospital Quality and Patient Safety Department. 66 patients were identified (M:F 29:37). The median age at time of death was 64 years [30-82]. The average length of admission resulting in death was 12.4 days [0-44]. 6% of patients died in the emergency department and 12% of patients died in the intensive care unit. The risk of dying was documented in 95.5% of cases and was communicated to 65.2% of patients and 82.8% of patients’ families. There was a do not attempt cardiopulmonary resuscitation (DNACPR) order in place for 89.4% of patients. Unnecessary investigations and interventions were stopped for 71.2% of patients. Symptom assessment was documented in 81.8% of cases. What was important to the patient was documented as explored in 24.2% of cases. 10.6% of patients were offered a chaplain or faith advisor. The inpatient palliative care team were involved in 77.2% of cases. Using the Oxford QIs for EOLC, the average quality score was 3.5, on a scale of 1-5: 1 (very poor): 0%, 2 (poor): 21.2%, 3 (satisfactory): 33.3%, 4 (good): 19.7%, 5 (excellent): 25.8%. The average EOLC quality score was 3.5. Oncology patients at our centre received, on average, satisfactory-to-good quality EOLC. Shortcomings identified have led to the development of a care of the dying Pro-forma to improve EOLC delivery and a survey of bereaved relatives to identify gaps in care. Holistic care of the dying is a fundamental part of the cancer care spectrum and needs to be prioritised in the acute hospital setting.

Impact of Palliative Care Clinical Pharmacists in an Inpatient Care Setting on Total Health Care Expenditures.

Background: Inpatient palliative care clinical pharmacy specialists (IPCPS) on multidisciplinary palliative care (PC) teams have expanding roles in the treatment of pain, nausea, and other symptoms for patients with serious illnesses. Objectives: The aim of this study was to assess the clinical and financial outcomes associated with an IPCPS on an inpatient PC team. Setting and Design: This was a retrospective cohort study conducted in Colorado. Adult patients with an inpatient stay and a PC consult between October 1, 2016 and February 28, 2019 were included. Patients were assigned to the observation group if they received PC from a clinical pharmacist and control group if they received usual PC. The primary outcome was the 180-day change in daily total cost-of-care expenditures. Secondary outcomes included length of index hospitalization and 180-day change in daily morphine milligram equivalents (MME), health care utilization, and opioid adverse effects (AE). Results: A total of 1543 patients were included with 228 and 1315 in the IPCPS and usual care groups, respectively. After adjustment, the IPCPS group had a greater median decrease in daily expenditures (-$22 vs. $6, p = 0.003), higher median increase in daily MME (16.5 vs. 9.7 mg, p = 0.007), and fewer patients with a subsequent hospitalization (34.2% vs. 39.2%, p = 0.010) or urgent care visit (10.5% vs. 14.6%, p = 0.024) but longer mean index hospitalization (9.3 vs. 7.7 days, p = 0.003) and no differences in AE during follow-up (all p > 0.05). Conclusion: IPCPS participation on the PC team can be a component of health care cost reduction while contributing to patient-centered quality care.

Transitions in Palliative Care Provision Across Healthcare Settings in the US: A Grounded Theory of Interdependence Between Specialist and Generalist Palliative Care Teams (SCI932)

Background: Individuals requiring palliative care near the end of life often receive that care in multiple healthcare settings, from both specialist and generalist palliative care teams. There is a need to better understand the processes that take place between the two teams that create or disrupt continuity of palliative care provision. Aim: The aim of this study was to develop a substantive theory of the psychosocial processes that occur between inpatient specialist palliative care teams and generalist teams outside the hospital setting who care for palliative patients after discharge. Methods: Semi-structured interviews were conducted with interdisciplinary clinicians from specialist palliative care teams and generalist healthcare teams in the U.S. Purposeful and theoretical sampling was used to recruit 21 clinicians. Data were analysed using constructivist grounded theory methods including constant comparative analysis of iterative levels of coding, memoing and diagramming, and abductive analysis of the literature. Results: A grounded theory of interdependence identified the psychosocial processes that contribute to team perception and function, and the outcomes of those processes. Specialist and generalist palliative care teams function with different degrees of interdependence in relation to other teams caring for shared patients based on how they perceive themselves as a team. When teams function more interdependently across healthcare setting boundaries, clinicians perceive outcomes to be more positive for patients, families, and themselves. In contrast, when teams function more independently within boundaries, outcomes are perceived to be more negative. Additionally, a team’s self-perception and way of functioning further perpetuate that self-perception and way of functioning over time. Conclusion: This substantive theory contributes new insights into how palliative care specialists and generalists should work and communicate with each other across healthcare settings to provide continuous and collaborative care for patients and families experiencing advanced illness. It provides a theoretical starting point for additional research to explore interventions that impact teams’ relationships and collaboration across healthcare settings.

Added Value of Early Consultation of an Inpatient Palliative Care Team in Hospitalized Older Patients With High Symptom Burden: A Prospective Comparative Study.

Background:It is estimated that in 2050 one quarter of the population in Europe will be aged 65 years and older. Although the added value of a palliative care team is emphasized in the literature, the impact of the palliative care team on the symptom burden in older non-cancer patients is not yet well established.Objectives:To structurally measure symptoms and to investigate whether proactive consultation with a palliative care team results in improvement of symptoms.Design:This study has a prospective comparative design.Setting/Participants:Older patients, admitted to a Dutch University Medical Centre for who a health care professional had a negative response to the Surprise Question, were selected.Measurements, Results:In period one, 59 patients completed the Utrecht Symptom Diary (USD) at day one of admission and after 7 days. In period 2 (n = 60), the same procedure was followed; additionally, the palliative care team was consulted for patients with high USD-scores. Significant improvement on the USD Total Distress Score (TSDS) was observed in both groups without a difference between the 2 periods. This study showed an association between consultation of the palliative care team and improvement on USD TSDS (adjusted odds ratio: 4.9; 95% confidence interval: 1.816-13.198), despite low follow-up rate of advices (approximately 50%).Conclusions:This study emphasizes the importance of creating awareness for consulting the palliative care team. Further research should focus on assessing the reason behind the low follow-up rate of the advice given and understanding the specific advices contributing to symptom improvement.

Lessons Learned: Inpatient Telepalliative Medicine Consultations during COVID-19 Pandemic

As the COVID-19 pandemic proceeds, systems continue to struggle with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high quality patient care. The reduced visitation capacity in hospitals has resulted in high levels of patient and family suffering, and patients both with and without COVID-19 require expert symptom management and goals of care conversations. A manuscript was published describing the rapid implementation of telepalliative medicine consultation by the Inpatient Palliative Care team at UCSF in attempts to meet these critical patient and family needs. This piece details additional lessons learned that were inadequately addressed in the original manuscript and/or that have been revealed in the months since the program’s inception. Key learning points include the need for: committed investment in effective hardware and software; communication skills adapted to effectively utilize technology to benefit patients and families; creative workforce models to render technology effective; interdisciplinary input in care models to reduce provider as well as patient and family suffering; and attention to burdens placed on already overstretched nurses and intensivists during respiratory pandemics.

A Machine Learning Based Risk Stratification Tool to Coordinate Referrals Between Inpatient Specialty and Palliative Care for Patients with Heart Failure (RP320)

•Explain how clinical stakeholders were involved in the multidisciplinary model building process of our model.•Explain what results of our risk score look like and how they can be used by cardiologists and palliative care teams to discuss and coordinate referrals. Most inpatient palliative care teams rely on referrals from treating physicians. Reliable prognostication necessary to support timely referrals has proven challenging for treating physicians. We engaged palliative care and cardiology providers to develop and evaluate a machine learning based risk stratification tool to identify patients with heart failure (HF) who are likely to die within 12 months of their hospitalization. Our tool will be shared with cardiology and palliative care teams and provides along with a risk score provider defined criteria such as frequent emergency department visits or high pain score to contextualize the risk score. We chose one randomly selected hospitalization for each patient (N=76,955) ages 18+ years with a diagnosis of HF who was hospitalized during 06-2007 to 10-2015 across 14 Kaiser Permanente Southern California (KPSC) hospitals. Predictive models were built and tested using extreme gradient boosting and cross-validation on 90% of the sample. Validation was conducted on the remaining 10%. Our predictor set is drawn from the highest performing models in the literature and clinician input. Clinicians choose specific predictors to display along with the risk score. The model area under the curve (AUC) is 0.83, sensitivity is 66%, and the positive predictive value (PPV) is 79% for default probability cut-offs. PPV can be increased to 90% with a sensitivity of 41%, and changes in referral volume for different probability cut-offs will be presented across hospitals and all of KPSC. Models will be run nightly. We will work with clinicians to identify palliative and cardiology team members who should receive the risk score every morning and discuss referrals. We engaged with key clinical stakeholders to design and validate a high-performing risk-stratification model to target and coordinate referrals between specialty and palliative care providers.

Rapid Implementation of Inpatient Telepalliative Medicine Consultations During COVID-19 Pandemic

As coronavirus disease 2019 cases increase throughout the country and health care systems grapple with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high-quality patient care, our specialty is called on to consider new methods of delivering inpatient palliative care (PC). Telepalliative medicine has been used to great effect in outpatient and home-based PC but has had fewer applications in the inpatient setting. As we plan for decreased provider availability because of quarantine and redeployment and seek to reach increasingly isolated hospitalized patients in the face of coronavirus disease 2019, the need for telepalliative medicine in the inpatient setting is now clear. We describe our rapid and ongoing implementation of telepalliative medicine consultation for our inpatient PC teams and discuss lessons learned and recommendations for programs considering similar care models.

A New Perspective on Spiritual Care: Collaborative Chaplaincy and Nursing Practice.

Spirituality is a key focus and ethical obligation of nursing practice, but many nurses express uncertainty or discomfort with this aspect of their role. The purpose of this article is to explore the domains of religion, spirituality, and culture as commonly conceptualized by chaplains, as a framework for nurses to provide spiritual care interventions to patients in acute care hospitals. Using anecdotes and illustrations from palliative care practice, this article discusses the enhanced benefits to patients and families when spiritual needs are addressed, with specialty-level chaplain interventions, primary spiritual interventions provided uniquely by nurses, or interventions that require the cooperation of both professions. Lessons learned from the inpatient palliative care team experience can also apply to chaplaincy and nursing care for patients in settings beyond the acute care hospital and in disciplines beyond palliative care.

Improving Support for Children Facing Serious Illness or Death of a Loved Adult (FR408A)

•Explore barriers that hinder adult-focused palliative care team support for children affected by the serious illness or death of a loved adult.•Identify how developmental changes in child perspectives of illness and death influence family discussions and coping.•Describe the impact of the “Coping for Kids” program on palliative care team member comfort exploring the child experience when a loved adult is serious ill or dying. The illness and death of loved ones are stressful for children, yet mechanisms to support children during a loved adult's illness are often lacking. We conducted a quality improvement initiative focused on inpatient palliative care team members (PCTM) to: (1) improve recognition of children affected by serious illness or death of a loved adult, and (2) increase provider comfort exploring and supporting the child experience and coping. Small group interviews and a focus group with PCTM illuminated knowledge gaps and barriers. A child and family support program, “Coping for Kids,” was implemented. The program included: age-specific handouts, provider “tip sheet”, one-time educational sessions for PCTM and inpatient social workers (SW), and a resource library of age-appropriate books for families and children. Pre- and post-implementation surveys assessed program efficacy. Perceived PCTM barriers included limited knowledge and training regarding child coping, uncertainty providing guidance, lack of resources, and time constraints. Fifty-one pre- and 33 post-implementation surveys were completed. Confidence identifying affected children was “somewhat”-“very” comfortable for > 90% pre/post-implementation. Confidence coaching families was “somewhat”-“very” comfortable for 75% pre- and 72% post-implementation. 30% identified “all team members equally appropriate” to provide coaching. Family comfort talking with children was assessed “frequently”-“always” in 46% pre- and 55% post-implementation. Implementation increased resource access 2-to-4-fold. Over 85% of respondents found the tip sheet helpful. PCTM reported only modest improvements in the top 5 barriers, particularly for "unsure what guidance is helpful". Comparatively more robust improvements were reported in all 5 barriers by SW. “Coping for Kids” shows promise to improve recognition and support of children affected by serious adult illness or death. Despite improved access to resources, ongoing care team discomfort persists. Opportunities exist for continued education, identification of needs, and program refinement.

Team Well-being and Resilience Practices in Hospice and Palliative Care

High functioning, resilient teams do not happen by chance. Teams, similar to individuals, need to be educated, nurtured and formed over time, by a consistent vision and process. With proper team formation, the compassionate care of patients, families and colleagues can be developed, modeled and reinforced. Self-compassion is another focus to help caregivers cope with the stresses of the work and mitigate against burnout. The primary intervention which will be discussed is a regularly scheduled reflection process, e.g. 30 minutes weekly or 90 minutes monthly, with a pediatric hospice team, an inpatient palliative care team and an outpatient palliative care team. The reflection process incorporates mindful meditation, journaling, listening exercises, individual and group reflection to encourage and practice self-awareness, self-reflection, greater emotional intelligence and leadership skills. Specific tools employed include the Search Inside Yourself © Program, books by various authors, selected music, videos and personal journals. Qualitative feedback from team members, patient, family and colleague satisfaction scores has been positive. Buy-in from all team members, initially, was difficult, but over time, all team members have recognized the value of the process and have incorporated the exercises not only in their work, but in their personal lives and other roles/jobs. Other key success factors are organizational support for time for this process and individual champions to develop and lead the reflective process. The workshop will include a demonstration of exercises used in team reflections with learner participation.

Factors Associated with Improvement in Uncontrolled Cancer Pain without Increasing the Opioid Daily Dose among Patients Seen by an Inpatient Palliative Care Team.

Background: Increasing the total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase. Objective: The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase. Design: We reviewed consecutive patients referred to our IPC team. Setting/Subjects: Eligibility criteria included (1) taking opioid medication; (2) having ≥2 consecutive visits with the IPC team; and (3) an Edmonton Symptom Assessment Scale (ESAS) pain score ≥4 at consultation. Measurements: We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, and oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids; antiepileptics-gabapentin and pregabalin; benzodiazepines; and neuroleptics), and achievement of CIP. Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (p = 0.003), less opioid rotation (p = 0.005), and lower symptom distress scale of ESAS (p = 0.04). Conclusions: Nearly half of the patients achieved CIP without MEDD increase, suggesting that the multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.

Factors associated with improvement in uncontrolled cancer pain without increasing opioid daily dose among patients seen by an inpatient palliative care team.

9 Background: Increasing total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase. The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase. Methods: We reviewed consecutive patients referred to our IPC team. Eligibility criteria included: 1) taking opioid medication; 2) having ≥ 2 consecutive visits with the IPC team; 3) Edmonton Symptom Assessment Scale (ESAS) pain score ≥ 4 at consultation. We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids, benzodiazepines, and neuroleptics), and achievement of CIP. Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (P = 0.003), less opioid rotation (P = 0.005), and lower symptom distress scale of ESAS (P = 0.04). Conclusions: Nearly half of patients achieved CIP without MEDD increase, suggesting that multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.

The Effect of a Standardized Triage Process on Efficiency and Productivity of an Inpatient Palliative Care Team.

Studies have shown that palliative care involvement delivers a multitude of benefits to patients and caregivers. The existing palliative care workforce is inadequate to meet growing demand. Innovative strategies to triage inpatient consults are necessary. To describe the implementation of a new palliative care triage process and to demonstrate its impact on efficiency, teamwork, and patient care. A quasi-experimental study design, comparing clinical consult data from a 6-month period before and a 6-month period after implementation of the novel consult triage model. Across the 2 study periods, consult demand increased by 44% while the physician staffing (full time equivalent [FTE]) decreased by 38%. Penetration rate per clinical FTE increased (from 1.9%-2.4%; P = .004). Monthly physician work relative value units (RVUs) per FTE increased from 909 to 1678. Physician encounters with hospitalized patients increased from 284 to 353, and total team visits increased from 596 to 891 (P < .001). Average time to consult decreased by 2.4 hours (P = .54). An efficient and streamlined consult triage process had a positive impact on our palliative care team's ability to reach patients. We were able to generate more physician visits and RVUs despite a decrease in physician clinical time, and our penetration rate per physician clinical FTE improved. Our findings highlight the importance of thoughtful and appropriate triage, not to mention teamwork, in helping to augment patient access to palliative care.