Palliative Care Quality Network Research Articles

The Pediatric Palliative Care Quality Network: Palliative Care Consultation and Patient Outcomes.

Quality benchmarking in pediatric palliative care (PPC) helps identify gaps in care and guides quality improvement. Our study objective was to characterize inpatient PPC referral processes, interdisciplinary PPC delivery, and patient outcomes from a multisite PPC data repository. Cross-sectional, administrative data analysis of 1587 PPC inpatient encounters at 5 US hospitals enrolled in the Pediatric Palliative Care Quality Network (2016-2022). PPC clinicians submitted data to a national repository for key quality indicators. Program and referral characteristics, care processes, and outcomes were examined descriptively. Time to referral, time on PPC service, and total hospital length of stay were compared by discharge disposition (alive or dead). Programs were in service for 13 (range 6-17) years on average. Most encounters involved children >1 year old (77%). Common diagnoses were solid tumor cancer (29%) and congenital or chromosomal conditions (14%). Care was often provided by ≤2 PPC team members (53%) until discharge (median = 7d, interquartile range 2-23). There were often multiple reasons for PPC referral, including psychosocial support (78%), goals of care discussions/advance care planning (42%), management of non-pain symptoms (34%), and pain (21%). Moderate-severe symptoms improved by second assessment for pain (71%), dyspnea (51%), fatigue (46%), and feeding issues (39%). Referrals to PPC were made early during hospitalization for psychosocial and physical symptom management. Moderate-severe symptom distress scores at initial assessment often improved. Findings highlight the need to ensure interdisciplinary PPC team staffing to meet the complex care needs of seriously ill children.

Hispanic/Latinx and Spanish Language Concordance Among Palliative Care Clinicians and Patients in Hospital Settings in California

Background: Members of racial or ethnic minority groups utilize palliative care (PC) services less than non-Hispanic White patients and multiple factors contribute to this disparity. The impact of racial, ethnic, and language (REL) concordance between patients and clinicians has been demonstrated in general medical populations, but not in PC populations. We characterized the racial and ethnic composition and languages spoken of California PC clinicians and patients to examine clinical impacts of REL concordance. Methods: Using Palliative Care Quality Network data, 15 inpatient teams were identified in California that had collected data on patient race/ethnicity and language. Patient and clinician data were analyzed using means and medians for continuous variables, and chi-squared tests to explore similarities and differences between clinician and patient data. Results: 51 clinicians from nine teams completed the survey. The largest non-White and non-English speaking groups among patients and clinicians identified as Hispanic/Latinx (31.5% of patients, 16.3% of clinicians) and as Spanish speakers (22.6% of patients, 7.5% of clinicians). There was a significantly higher proportion of Hispanic/Latinx patients compared to clinicians (p-value 0.01), with Southern California demonstrating the largest difference (30.4% of patients vs. 10.7 % of clinicians, p-value 0.01). Similar proportions of patients and clinicians reported Spanish fluency (22.6% vs 27.5%, p-value 0.31). Discussion: We found significant differences in the racial/ethnic distributions of Hispanic/Latinx patients and clinicians in California, prompting consideration of whether a lack of representation of Hispanic/Latinx clinicians relative to the patient population may contribute to lower palliative care utilization among Hispanic/Latinx patients.

Utilization and Delivery of Specialty Palliative Care in the ICU: Insights from the Palliative Care Quality Network (GP723)

Utilization and Delivery of Specialty Palliative Care in the ICU: Insights from the Palliative Care Quality Network (GP723)

Utilization and Delivery of Specialty Palliative Care in the ICU: Insights from the Palliative Care Quality Network

ContextPalliative care (PC) benefits critically ill patients but remains underutilized. Important to developing interventions to overcome barriers to PC in the ICU and address PC needs of ICU patients is to understand how, when, and for which patients PC is provided in the ICU. ObjectivesCompare characteristics of specialty PC consultations in the ICU to those on medical-surgical wards. MethodsRetrospective analysis of national Palliative Care Quality Network data for hospitalized patients receiving specialty PC consultation January 1, 2013 to December 31, 2019 in ICU or medical-surgical setting. 98 inpatient PC teams in 16 states contributed data. Measures and outcomes included patient characteristics, consultation features, process metrics and patient outcomes. Mixed effects multivariable logistic regression was used to compare ICU and medical-surgical units. ResultsOf 102,597 patients 63,082 were in medical-surgical units and 39,515 ICU. ICU patients were younger and more likely to have non-cancer diagnoses (all P < 0.001). While fewer ICU patients were able to report symptoms, most patients in both groups reported improved symptoms. ICU patients were more likely to have consultation requests for GOC, comfort care, and withdrawal of interventions and less likely for pain and/or symptoms (OR-all P < 0.001). ICU patients were less often discharged alive. ConclusionICU patients receiving PC consultation are more likely to have non-cancer diagnoses and less likely able to communicate. Although symptom management and GOC are standard parts of ICU care, specialty PC in the ICU is often engaged for these issues and results in improved symptoms, suggesting routine interventions and consultation targeting these needs could improve care.

Inpatients With Dementia Referred for Palliative Care Consultation: A Multicenter Analysis.

Specialty palliative care (PC) may benefit patients with dementia by aligning treatment with goals and relieving symptoms. We aimed to compare demographics and processes and outcomes of PC for inpatients with dementia with those with systemic illnesses or cancer. This multicenter cohort study included standardized data for hospitalized patients with a primary diagnosis of dementia, systemic illnesses (cardiovascular, pulmonary, hepatic, or renal disease), or cancer among the 98 PC teams submitting data to the Palliative Care Quality Network from 2013 to 2019. Of 155,356 patients, 4.5% (n = 6,925) had a primary diagnosis of dementia, 32.5% (n = 50,501) systemic illness, and 29.2% (n = 45,386) cancer. Patients with dementia were older (mean 85.5 years, 95% confidence interval [CI] 85.3-85.6) than those with systemic illnesses (mean 73.2, 95% CI 73.0-73.3) or cancer (mean 66.6, 95% CI 66.4-66.7; p < 0.0001). Patients with dementia were more likely to receive a PC consult within 24 hours of admission (52.3% vs systemic illnesses 37.4%; cancer 45.3%; p < 0.0001), more likely to be bed-bound (vs systemic illnesses odds ratio (OR) 2.23, 95% CI 2.09-2.39, p < 0.0001; vs cancer OR 3.45, 95% CI 3.21-3.72, p < 0.0001), and more likely to be discharged alive (vs systemic illnesses OR 2.22, 95% CI 2.03-2.43, p < 0.0001; vs cancer OR 1.51, 95% CI 1.36-1.67, p < 0.0001). Advance care planning/goals of care (GOC) was the primary reason for consultation for all groups. Few patients overall had advance directives or Physician Orders for Life-Sustaining Treatment before consultation. At the time of referral and at discharge, patients with dementia were more likely to have a code status of do not resuscitate/do not intubate (DNR/DNI) (62.6% and 81.0% vs 38.7 and 64.2% for patients with systemic illnesses and 33.4% and 60.5% for patients with cancer; p < 0.0001). Among the minority of patients with dementia that could self-report, moderate-to-severe symptoms were uncommon (pain 6.4%, anxiety 5.8%, nausea 0.4%, and dyspnea 3.5%). Inpatients with a primary diagnosis of dementia receiving PC consultation were older and more functionally impaired than those with other illnesses. They were more likely to have a code status of DNR/DNI at discharge. Few reported distressing symptoms. These results highlight the need for routine clarification of GOC for patients with dementia.

Doing More with the Same: Comparing Public and Private Hospital Palliative Care within California.

Background: Public and private hospitals treat different patient populations, which may impact resources to deliver palliative care (PC). Objectives: Compare public and private hospital PC service structures, processes, and treatment outcomes. Design: Retrospective data analysis of the Palliative Care Quality Network between 2018 and 2019. Settings/Subjects: Six public and 40 private California hospitals provided PC consultations to 4244 and 38,354 adults, respectively. Measurements: PC team and patient characteristics, care processes, and treatment outcomes. Results: Public and private hospital PC services had similar full-time equivalent/100 beds (1.2 vs. 1.4, p = 0.4). Public hospital patients were younger (65.2 vs. 73.5, p < 0.001), less likely to be non-Hispanic Caucasian (22.5% vs. 57.5%, p < 0.001), or English speaking (51.1% vs. 79.9%, p < 0.001). Public hospital patients had more moderate/severe pain (21.3% vs. 19.3, p < 0.03), anxiety (12.4% vs. 9.2%, p < 0.001), nausea (6.5% vs. 4.7%, p < 0.001), and dyspnea (11.0% vs. 8.6%, p < 0.001). Both hospitals equally improved pain (70.9% vs. 70.5%, p = 0.83) and nausea (82.0% vs. 87.6%, p = 0.09), but public hospitals were less effective at improving anxiety (67.3% vs. 78.4%, p = 0.002) and dyspnea (58.4% vs. 67.9%, p = 0.05). Although there was no difference in hospital length of stay (public = 10.2 days vs. private = 9.5 days, p = 0.07), public hospitals conducted more patient visits (2.6 vs. 1.8, p < 0.001). They also more often clarified code status (87.7% vs. 84.4%, p < 0.001) and surrogate decision maker (94.9% vs. 89.9%, p < 0.001). Conclusions: Public hospital PC teams treat a more diverse symptomatic population. Yet, they achieved comparable outcomes with similar staffing to private hospitals. These findings have important ramifications for policy makers and public institution leaders.

121 Embedding Palliative Consultants in the Emergency Departmet Creates Significant Value for Healthcare Systems

A vast majority of patients with serious illness present to emergency departments (EDs) in their last year of life with unmet palliative needs. ED-requested palliative care (PC) consults have been shown to reduce hospital length-of-stay and costs. As integrated care delivery models evolve, many health systems are considering how to best deploy PC resources and protocols to the ED to facilitate earlier engagement. Our objective was to demonstrate the financial and operational viability of embedding a palliative consultant in the ED. This single-site hospital with 42,000 annual ED visits featured a mature PC team, with historically high ICU/ward but minimal ED engagement. Institutional alignment was acquired from key stakeholders (ED, PC, ICU, hospitalists, administration) to fund a new ED-embedded PC consult service. A single PC physician or nurse practitioner was co-located in the ED fishbowl between the hours of 11am-7pm daily, initially weekdays and expanded to weekends after 10 weeks. ED consults were both proactively identified by PC and actively requested by ED clinicians. Clinical and financial data from 08/2020-04/2021 were tracked through the electronic health record, Palliative Care Quality Network registry, and McKesson Horizon Performance Manager. Over 8.5 months, the ED-embedded PC service saw 565 consults. Of these, 46% had a code status change, 8% admitted to a lower level of care, 9% avoided hospitalization, and 13% newly referred to hospice. ED consult volume was consistent month-over-month. ED length-of-stay did not appreciably lengthen. None of these cases were related to COVID-19. Importantly, this additional consult team did not cannibalize inpatient consult volume from usual practice. Compared to inpatient PC consults, median hospital length-of-stay decreased from 10.8 days to 3.3 days (p<0.001). Likewise, median direct costs per hospitalization decreased from $17,726 to $4,617, a 75% reduction or $13,019 per hospitalization (p<0.001). Annualized direct cost avoidance will be $6.5M. Subsequently, the ED provider group volunteered to include ED-palliative consults as a performance metric in their compensation model. ED-embedded palliative consultants are a high cost but even higher-reward intervention. For this hospital, return on investment will exceed 15x. True impact is likely even greater given analyses were not compared against all-comers, and did not account for future deferral of ED revisits and healthcare utilization from earlier introduction into outpatient palliative and hospice services. ED-palliative partnerships significantly advance the quadruple aim and position the ED to lead change in healthcare systems which increasingly prioritize value-based care.

Comparing the Palliative Care Needs of Patients Seen by Specialty Palliative Care Teams at Home Versus in Clinic

ContextUnderstanding the unique needs of patients seen in clinic versus at home can help palliative care (PC) teams choose how to maximize available resources. ObjectivesTo compare the characteristics and PC needs of patients seen by PC teams in clinic versus at home. MethodsWe analyzed data from the Palliative Care Quality Network between August 2016 and September 2019 and compared demographics, diagnosis, reason for referral, PC needs, functional status, self-reported symptoms, and patient-reported quality of life. ResultsCompared to patients receiving PC in clinic, patients receiving PC at home were more likely to be of age 80 years or older (odds ratio [OR] 7.5, 95% CI 5.0, 10.9, P < 0.0001), have lower functional status (mean Palliative Performance Scale score 53% vs. 68%, P < 0.0001), and were less likely to screen positive for needing pain management (OR 0.31, 95% CI 0.22, 0.42, P < 0.0001) or other symptom management (OR 0.61, 95% CI 0.41, 0.90, P = 0.01). Patients receiving care at home were more likely to be referred for care planning (goals of care discussions or advance care planning) (OR 11.5, 95% CI 8.3, 16.0 P < 0.0001) and patient/family support (OR 5.9, 95% CI 4.2, 8.3, P < 0.0001). ConclusionPatients seen by PC teams at home had worse function and were more likely to be referred for care planning, while patients seen in clinic had more PC needs related to pain and symptom management. Despite these differences, both populations have significant PC needs that support routine assessment and require appropriately staffed interdisciplinary teams to address these needs.

QOLP-12. EMBEDDING OUTPATIENT PALLIATIVE CARE INTO NEURO-ONCOLOGY CLINIC – RESULTS FROM A ONE YEAR PILOT

Abstract BACKGROUND Glioblastoma (GBM) patients fall within NCCN and ASCO guidelines for early palliative care (PC). However, data suggests they are less likely than systemic cancers to be referred to PC and often later in their illness. This results in potential missed opportunities, both for improving symptom control and earlier completion of important tasks, like advance care planning. Data on how to best incorporate comprehensive PC into routine neuro-oncology (NO) patient care is needed. METHODS We piloted a program embedding a PC physician into UCSF’s NO clinic one half-day per week. NO physicians were encouraged to refer GBM patients within 3 months of diagnosis and other patients with PC needs. PC visits were offered in-person, by telemedicine, or at home. PC physician and NO social worker made joint visits when possible; chaplaincy support was available by telemedicine. Data was collected using Palliative Care Quality Network (PCQN) database and patient satisfaction survey. RESULTS To date, 37 patients have been referred resulting in 103 visits (average 2.8 visits/person): 25% in-person; 68% telemedicine; 6% at home. PC physician and NO social worker met jointly with 46% visits. Median age was 58 years, 41% female, 81% non-Hispanic white, 84% GBM, median 9 months from diagnosis, and 73% receiving first line treatment. Interventions addressed across visits: 94% non-pain symptoms, 76% psychosocial needs; 71% pain; and 70% GOC. Results from satisfaction survey demonstrated 79% would recommend seeing PC embedded in NO to others and highest benefits were attention to practical considerations to staying healthy at home, discussing preferences for future medical care, and help with coping. CONCLUSIONS Embedding PC into NO clinics is a unique model for addressing symptoms and GOC early, is well received by patients and caregivers, and provides opportunities for collaboration and PC physicians to specialize in caring for needs of NO patients.

A Comparison of Hospitalized Patients With Heart Failure and Cancer Referred to Palliative Care

Growing evidence shows that palliative care (PC) improves treatment outcomes in patients with heart failure (HF), but few large-scale studies have prospectively evaluated the processes and outcomes associated with PC consultation for such patients in the real world. To characterize processes and outcomes of PC consultations for hospitalized patients with HF compared with patients with cancer. This cohort study of inpatient encounters at community and academic hospitals in the Palliative Care Quality Network enrolled participants between 2013 and 2017. Of a total of 135 197 patients, 57 272 adults with a primary diagnosis of HF or cancer receiving PC consultation were enrolled. Data analysis was performed from April 2018 to December 2019. Primary diagnosis of HF or cancer. Symptom improvement and changes in care planning documentation after PC consultation. At the time of consultation, patients with HF were older (mean age, 75.3 years [95% CI, 75.0-75.5 years] vs 65.2 years [95% CI, 65.0-65.3 years]; P < .001), had lower Palliative Performance Scale scores (mean, 35.6% [95% CI, 35.3%-35.9%] vs 42.4% [95% CI, 42.2%-42.6%]; P < .001), and were more likely to be in a critical care unit (5808 of 16 741 patients [35.3%] vs 4985 of 40 531 patients [12.5%]; P < .001) or a telemetry or step-down unit (5802 of 16 741 patients [35.2%] vs 7651 of 40 531 patients [19.2%]; P < .001) compared with patients with cancer. Patients with HF were less likely than patients with cancer to be referred to PC within 24 hours of admission (6773 of 16 741 patients [41.2%] vs 19 348 of 40 531 patients [49.0%]; P < .001) and had longer hospitalizations before receiving PC consultation requests (mean, 4.6 days [95% CI, 4.4-4.8 days] vs 3.9 days [95% CI, 3.8-4.0 days]; P < .001). Patients with HF were referred less frequently for symptoms other than pain (1686 of 16 488 patients [10.2%] vs 8587 of 39 609 patients [21.7%]; P < .001), but were equally likely to report improvements in anxiety (odds ratio, 0.85; 95% CI, 0.71-1.02; P = .08) and more likely to report improvements in dyspnea (odds ratio, 2.17; 95% CI, 1.83-2.57; P < .001) compared with patients with cancer. Patients with HF were less likely than those with cancer to be discharged alive (odds ratio, 0.78; 95% CI, 0.64-0.96; P = .02) or to be referred to hospice (odds ratio, 0.50; 95% CI, 0.47-0.53; P < .001). These findings suggest that PC referral comes late for patients with HF and is used primarily to discuss care planning. Practitioners caring for patients with HF should consider involving PC experts earlier for symptom management.

Finding the Strength Within: Increasing Spiritual Screening for Inpatient Consults with a Transdisciplinary Team (TH371A)

•Describe a multi-faceted intervention to increase documentation of spiritual screening for a transdisciplinary inpatient consult team.•Identify the transdisciplinary team as an essential asset of quality improvement endeavors in palliative care settings. The American Academy of Hospice and Palliative Medicine (AAHPM), The National Quality Forum (NQF), and the National Consensus Project (NCP) identify spiritual screening as a core element and quality metric for palliative care (PC) consults. This recommendation is based on research showing that patients want their doctors to discuss spirituality and that these discussions change patients' healthcare decisions. We sought to increase the rate of documented spiritual screening for inpatient consults at our hospital by 10% between September 2018 and May 2019 from the 2017 average screening rate of 69%. After completing a fishbone gap analysis, we developed a 4-part intervention to address factors contributing to low documentation of spiritual screening, including monthly e-mail reminders, announcements at monthly division meetings, posting “meme” reminders in our workroom, and changing the method for documenting in the electronic health record (EHR). Data from the Palliative Care Quality Network (PCQN) was used to monitor rates of documented spiritual screening out of all our team's inpatient consults. Of the 502 inpatient PC consults completed, 413 (82%) had documented spiritual screening during the intervention, representing a significant increase from the 2017 average of 69% (p<0.0001). Over the course of the intervention, there was variability in screening rate from month-to-month (range 73% to 94%). Months with the highest rates of documented spiritual screenings were months when all reminder interventions were in effect. Completion of spiritual screening requires the attention of all providers on the transdisciplinary team. A combination of gentle reminders and streamlining documentation in the EHR resulted in significant increases in rates of documented spiritual screening. Lessons learned from this quality improvement project include involving a transdisciplinary team early in the design process, utilizing the transdisciplinary team's expertise to define best practices, and developing a robust plan for collecting and reporting data.

Trends in Hospital-Based Specialty Palliative Care in the United States From 2013 to 2017

Although palliative care (PC) historically focused on patients with cancer and those near the end of life, evidence increasingly demonstrates a benefit to patients with a broad range of serious illnesses and to those earlier in their illness. The field of PC has expanded and evolved rapidly, resulting in a need to characterize practice over time to understand whether it reflects evolving evidence and guidelines. To characterize current practice and trends among patients cared for and outcomes achieved by inpatient specialty PC services in the United States. This retrospective cohort study was performed from January 1, 2013, to December 31, 2017, at 88 US hospitals in which PC teams voluntarily participate in the Palliative Care Quality Network (PCQN), a national quality improvement collaborative. A total of 135 197 patients were referred to PCQN teams during the study period. Initial analyses of the study data were conducted from March 3 to March 21, 2018. Inpatient PC consultation. A total of 23 standardized data elements collected by PCQN teams that provided information about the characteristics of referred patients, including age, sex, Palliative Performance Scale score, and primary diagnosis leading to PC consult; reason(s) given for the consultation; and processes of care provided by the PC team, including disciplines involved, number of family meetings held, advance care planning documentation completed, and screened for and intervened on needs. A total of 135 197 patients were referred to inpatient PC (51.0% female; mean age, 71.3 years [range, 57.8-82.5 years]) and were significantly debilitated (mean Palliative Performance Scale score, 34.7%; range, 14.9%-56.8%). Cancer was the most common primary diagnosis (32.0%; range, 11.3%-93.9%), although rates decreased from 2013 to 2017 (odds ratio [OR], 0.84; 95% CI, 0.79-0.91; P < .001). Pain and other symptoms were common and improved significantly during the consultation period (pain: χ2 = 5234.4, P < .001; anxiety: χ2 = 2020.7, P < .001; nausea: χ2 = 1311.8, P < .001; dyspnea: χ2 = 1993.5, P < .001). Most patients were discharged alive (78.7%; range, 44.7%-99.4%), and this number increased over time (OR, 1.36; 95% CI, 1.27-1.46; P < .001). Compared with 2013, rates of discharge referral to clinic-based (OR, 4.00; 95% CI, 2.95-5.43; P < .001) and home-based PC (OR, 2.63; 95% CI, 1.92-3.61; P < .001) also increased significantly by 2017, whereas referrals to hospice decreased (OR, 0.56; 95% CI, 0.51-0.62; P < .001). Inpatient PC teams cared for an increasing percentage of patients with diagnoses other than cancer and saw more patients discharged alive, consistent with guidelines recommending specialty PC for all patients with serious illness earlier in their illnesses. Most patients with symptoms improved quickly. Variation in practice and outcomes among PCQN members suggests that there are opportunities for further improvements in care.

Outcomes of Palliative Care Consultations for Hospitalized Patients With Liver Disease

ContextAlthough palliative care (PC) has been shown to improve symptoms and end-of-life (EOL) care for patients with cancer, data are lacking on the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease. ObjectivesWe sought to characterize the patterns of use and outcomes of PC consultations for hospitalized patients with liver disease compared with patients with cancer. MethodsWe conducted an observational study using data from the Palliative Care Quality Network (PCQN). The PCQN contains prospectively collected data on 135,197 hospitalized patients receiving PC consultations at 88 PCQN sites between January 2013 and December 2017. The PCQN data set includes patient demographics, processes of care, and patient-level clinical outcomes. ResultsThe cohort included 44,933 patients, of whom 4402 (9.8%) had liver disease and 40,531 (90.2%) had cancer. Patients with liver disease were younger (58.9 years vs. 65.2 years, P < 0.0001) and had higher in-hospital mortality (28% vs. 16.8%, P < 0.0001). Patients with liver disease were more likely to receive PC consultations to address goals of care (81.7% vs. 67.9%, P < 0.0001) as opposed to pain management (10.9% vs. 34.9%, P < 0.0001). Both groups had similar rates of symptom improvement and change in resuscitation preferences after PC consultation. ConclusionHospitalized patients with liver disease were more likely to have a PC referral to address goals of care compared with those with cancer and were more likely to die in the hospital. Despite late PC consultations, patients with liver disease experienced improvement in symptoms and clarification of their goals of care, similar to those with cancer.

Development of the Pediatric Palliative Care Quality Network.

Development of the Pediatric Palliative Care Quality Network.

Inpatients with neurologic disease referred for palliative care consultation.

To compare characteristics and needs of inpatients with neurologic disease to those with cancer referred for palliative care (PC) consultation. This prospective cohort study used data collected by the Palliative Care Quality Network from January 2013 until December 2016. We compared demographics, reasons for consultation, discharge disposition, Palliative Performance Scale (PPS) score, and outcomes of care among patients with a primary diagnosis of neurologic disease vs cancer. The most common reason for PC consultation in all patients was assistance with goals of care and advanced care planning. PC consultation was less often requested for pain and symptom management in patients with neurologic disease compared to patients with cancer (13.7% vs 43%, odds ratio 0.3) and more often for assistance with transition to comfort measures only and withdrawal of life-sustaining treatment (19.1% vs 7.1%, odds ratio 1.3). Patients with cancer had higher PPS scores (42.1% vs 23.4%) and were more likely to be discharged home from the hospital, while patients with neurologic disease were more likely to die in hospital. Patients with neurologic disease as a reason for PC consultation are more in need of end-of-life care planning and more likely to die in the hospital than those with cancer, suggesting that targeted approaches may best address the needs of each patient population. Our results can direct further research and education in neuropalliative care.

Trends in Hospital-Based Specialty Palliative Care: Insights from a National Palliative Care Quality Improvement Collaborative (S866)

1.Describe at least two trends in processes of care provided by inpatient palliative care (PC) teams over time.2.Describe one major change in a clinical outcome achieved by inpatient PC teams over time.3.Discuss how these trends relate to evolving expectations of and norms within the field. The field of palliative care (PC) is growing and evolving rapidly in response to increased demand and recognition of its benefits. Describe how processes of care and outcomes achieved by inpatient PC teams have changed over time. Data for this study were extracted from the Palliative Care Quality Network database on 03/06/2018 and pertain to 135,197 patients referred to 88 inpatient PC consult teams between 01/01/2013 and 12/31/2017. The most common diagnoses leading to inpatient PC consult were cancer (32.0%, range between teams: 11.3%–93.9%), cardiovascular disease (13.2%, 0%–29.0%), and pulmonary disease (11.3%, 0%–26.0%). The percentage of referred patients with cancer decreased between 2013 and 2017 (39.0% to 30.0%, p<0.0001), while there was an increase in the percentage of patients with cardiovascular disease (12.0% to 14.0%, p<0.0001) and pulmonary disease (10.0% to 12.0%, p<0.0001). Most patients were discharged from the hospital alive (78.7%, range between teams: 44.7%–99.4%), and the percentage of patients discharged alive increased over time (75.0% to 80.0%, p<0.0001). Between 2013 and 2017, there was a substantial decrease in hospice referrals (46.0% to 31.0%, p<0.0001) and an increase in referrals to clinic-based (2.0% to 4.0%, p<0.0001) and home-based PC services (2.0% to 4.0%, p<0.0001). There is wide variation in practice across inpatient PC teams. Overall, teams are seeing more patients with diagnoses other than cancer and are doing so earlier in the course of illness, which may account for lower rates of hospice referral. Teams are connecting slightly more patients with outpatient PC services at the time of hospital discharge.

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

•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.

Care Planning for Inpatients Referred for Palliative Care Consultation

Care planning is a critical function of palliative care teams, but the impact of advance care planning and goals of care discussions by palliative care teams has not been well characterized. To describe the population of patients referred to inpatient palliative care consultation teams for care planning, the needs identified by palliative care clinicians, the care planning activities that occur, and the results of these activities. This was a prospective cohort study conducted between January 1, 2013, and December 31, 2016. Seventy-eight inpatient palliative care teams from diverse US hospitals in the Palliative Care Quality Network, a national quality improvement collaborative. Standardized data were submitted for 73 145 patients. Inpatient palliative care consultation. Overall, 52 571 of 73 145 patients (71.9%) referred to inpatient palliative care were referred for care planning (range among teams, 27.5%-99.4% of patients). Patients referred for care planning were older (73.3 vs 67.9 years; F statistic, 1546.0; P < .001), less likely to have cancer (30.0% vs 41.1%; P < .001), and slightly more often had a clinical order of full code at the time of referral (54.6% vs 52.1%; P < .001). Palliative care teams identified care planning needs in 52 825 of 73 145 patients (72.2%) overall, including 42 467 of 49 713 patients (85.4%) referred for care planning and in 10 054 of 17 475 patients (57.5%) referred for other reasons. Through care planning conversations, surrogates were identified for 10 571 of 11 149 patients (94.8%) and 9026 patients (37.4%) elected to change their code status. Substantially more patients indicated that a status of do not resuscitate/do not intubate was consistent with their goals (7006 [32.1%] preconsultation to 13 773 [63.1%] postconsultation). However, an advance directive was completed for just 2160 of 67 955 patients (3.2%) and a Physicians Orders for Life-Sustaining Treatment form was completed for 8359 of 67 955 patients (12.3%) seen by palliative care teams. Care planning was the most common reason for inpatient palliative care consultation, and care planning needs were often found even when the consultation was for other reasons. Surrogates were consistently identified, and patients' preferences regarding life-sustaining treatments were frequently updated. However, a minority of patients completed legal forms to document their care preferences, highlighting an area in need of improvement.

Identifying Opportunities to Improve Pain Among Patients With Serious Illness

ContextPain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams. ObjectiveIdentify characteristics associated with pain and pain improvement among inpatients referred to PC. MethodsThirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement. ResultsOf patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P < 0.0001), women (P < 0.0001), patients with cancer (P < 0.0001), and patients in medical/surgical units (P < 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P < 0.0001), nausea (P < 0.0001), and dyspnea (P < 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team's second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P < 0.0001). Improvement in pain was associated with improvement in anxiety (OR = 2.9, P < 0.0001) and dyspnea (OR = 1.4, P = 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P = 0.003). ConclusionPain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement.

The Palliative Care Quality Network: Improving the Quality of Caring.

Describe the establishment of the palliative care quality network (PCQN) with guidance on how teams can develop similar collaborations. In the current healthcare environment, palliative care (PC) teams must be able to demonstrate value and provide efficient care while supporting the clinicians who provide that care. The PCQN is a national quality improvement (QI) collaborative comprised of specialty PC teams from a diverse range of hospitals across the United States Results: PCQN members identified five core activities to support PC teams. 1) Collection of standardized data: 23 core items and 22 optional data elements document patient demographics, consultation characteristics, processes of care, and clinical outcomes. 2) Data analyses with benchmarking including reports generated in real time providing summary, trend, member comparison, and cross-tab analyses. 3) QI collaborative; QI initiatives have addressed pain management, surrogate decision-making, spiritual screening, and anxiety assessment. 4) Education and personal development provided through monthly conference calls, a listserv, PCQN website, and twice-yearly conferences. 5) Financial analysis; a software program enables PC teams to calculate the financial impact of the care provided. The central tenet of the PCQN is to improve quality of care for patients with serious illness and their families, increase the efficient use of healthcare resources, and support growth and sustainability of PC programs. Building and tending to this community takes time to ensure engagement of all members and remain responsive to evolving needs of patients, families, PC teams, and stakeholders.