Evaluation of a Palliative Outreach and

Consult Team:

Romayne Gallagher MD, CCFP, Palliative Care Program Providence Health Care

Vancouver, BC

Palliative care improves quality

Compared to conventional care, palliative care is associated with:

• Reduction in pain and non-pain symptoms • Improved patient/family satisfaction • Reduced hospital length of stay and cost Jordhay et al Lancet 2000; Higginson et al, JPSM, 2003; Finlay et al, Ann

Oncol 2002; Higginson et al, JPSM 2002.

Late Referral Decreases Quality • 237 bereaved family members of hospice patients

asked about timing of the referral • 13.7% reported referral “too late”

• Compared to family members referred early or at

the right time, these respondents reported Lower satisfaction More unmet needs Lower confidence More concerns about coordination

Schockett, Teno, Miller, Stuart. JPSM 2005

Prior to POCT launch

• MD to MD consultation • MD only team • Availability of 24/7 coverage only at SPH • Not involved in outpatient clinics • Palliative Care Unit seen as a place to send

people to for end of life care

Removing Barriers Consults: • Nurses and physicians on team

• Access to social worker

• Anyone (including patient and family), any discipline can refer

• Early referrals and hallway consultations encouraged

• 24/7 coverage of whole organization

Removing Barriers Outreach: • Attending rounds • Working with out patient clinics • Increasing visibility • Education

Building capacity • Palliative Immersion Project • Education for medical students and

residents • Orientation for nurses • RN training on using SBAR • Terminal care orders on SCM • Palliative Care tools and info on Intranet

There has been a 50% increase in the annual number of patients consulted by palliative care at SPH since the implementation of the POCT in 2008.

331

501 497

251

158 157

72

0

100

200

300

400

500

600

2007 2008 2009 2010-YTD 2008 2009 2010-YTD

Num

ber o

f con

sulte

d pa

tient

s

Number of consulted patients - Acute care

Number of consulted patients

SPH MSJ

Decline in average number of days to consult from an average of 14.3 days in 2008 to 12.4 days in 2010-YTD for SPH and from 13.2 in 2008 to 9.5 days in 2010-YTD for MSJ.

14.313.1 12.4 13.2

11.19.5

02468

101214161820

2008 2009 2010 - YTD 2008 2009 2010 - YTD

Avg

time

to co

nsul

t

Average number of days to 1st palliative care consult

Avg time to consult

SPH MSJ

For SPH, the number of palliative care consults per 100 admissions has increased from 2.6 in 2007 to an average of 4.0 post-POCT implementation. The consult rate at MSJ is 4.3 consults per 100 admissions.

2.6

3.9 3.94.3 4.3 4.3

4.6

0.00.51.01.52.02.53.03.54.04.55.0

2007 2008 2009 2010-YTD 2008 2009 2010-YTD

Cons

ult r

ate

Number of palliative care consults per 100 admissions

Consult rate

SPH MSJ

For SPH, the average number of critical care days spent by patients consulted by palliative care has decreased slightly each year since the implementation of POCT while the rate of transfers to critical care have remained relatively stable.

1.3

1.0

0.8

0.3

0.6

0.1

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

2008 2009 2010 - YTD 2008 2009 2010 - YTD

Avg.

num

ber o

f crit

ical c

are

days

Average number of critical care days spent by patients with palliative care consult

Avg. number of critical care days

SPH MSJ

Residential Care Medication Review • Compared with 2005 there is a tripling of

the morphine equivalent amount of opioid used

• Decrease in hazardous NSAID use for pain management

• Increase in appropriate end of life medication orders

Pharmacy data in residential care Total opioid usage in morphine equivalents

– 2004: 491967 2009: 1624604 Tylenol #3

– 2004: 45080 2009: 864.4 Morphine

– 2004: 45165 2009: 14290 Large increase in methadone, oxycodone, hydromorphone,

sufentanil Fentanyl patch mostly unchanged

Pharmacy data in residential care • Acetaminophen

– 2004: 357673 2009: 597202 • Celecoxib:

– 2004: 2593 2009: 48 • Increase in short term use of naproxen and

ibuprofen • Reduction in docusate, increase in lactulose • Increase in lower doses of neuroleptics • Increase in scopolamine

Palliative Care Companion

Podcasts

POP Tool e

Terminal Care Orders

Where do we go from here? Bereaved Relative Study

– After-death bereaved relative telephone interview – Taking these results and acting on gaps in education

and support of families

Pilot project to screen patients coming into acute care – Identify patients needing palliative approach or

palliative services earlier

Palliative Care Awareness Week