Palliative Medicine Consultation in a Long Term Acute Care (LTAC) Hospital

Marissa C. Galicia-Castillo, MD, FAAHPM1; Deborah Morris, MD, FAAHPM1; Linda Christy, NP2, David Ricks2

1Eastern Virginia Medical School, 2Lake Taylor Transitional Care Hospital

Marissa Galicia-Castillo, MD, FAAHPMEastern Virginia Medical SchoolNorfolk, VirginiaEmail: galicimc@evms.eduWebsite: www.evms.eduPhone: 757-446-7040

Contact1DJ Lamas, RL Owens, RN Nace, AF Massaro NJ Pertsch, J Gass, RE Bernacki, S Block, Opening the Door: The Experience of Chronic Critical Illness in a Long-Term Acute Care Hospital, Soc Crit Care Med. 2017 Apr; 45 (4): e357- e362. 2PA Harris, R Taylor, R Thielke, J Payne, N Gonzalez, JG. Conde, Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support, J Biomed Inform. 2009 Apr;42(2):377-81.3PA Harris, R Taylor, BL Minor, V Elliott, M Fernandez, L O’Neal, L McLeod, G Delacqua, F Delacqua, J Kirby, SN Duda, REDCap Consortium, The REDCap consortium: Building an international community of software partners, J Biomed Inform. 2019 May 9 [doi: 10.1016/j.jbi.2019.103208]

References

The growth of Palliative Medicine services in the inpatient and outpatient

settings have been well documented. There are no Palliative Medicine

services noted in a long term acute care (LTAC) hospital in the literature. An

LTAC hospital is a facility that specializes in treatment of patients who have

serious medical conditions that require ongoing specialized care, such as

ventilator support, but no longer requires intensive care or extensive

diagnostic procedures. We found only one study that has researched patients

in this setting that described the experience of patients and their surrogates in

this setting.1 We describe the patient population and observations after the

establishment of a Palliative Medicine consultation service (Supportive Care

Medicine team) in an LTAC hospital.

Introduction

The Supportive Care Medicine Team is comprised of the following members:

• Part-time Board Certified Palliative Medicine physician from EVMS

• Palliative Medicine Fellow

• Part-time Nurse Practitioner from Lake Taylor

• Directors of Nursing from the hospital level and long term care/skilled levels

• Vice President of Patient Services

• Chaplain

• Social workers from hospital level and long term care/skilled levels

Study data were collected and managed using REDCap electronic data

capture tools hosted at EVMS.2,3 REDCap (Research Electronic Data Capture)

is a secure, web-based software platform designed to support data capture for

research studies, providing 1) an intuitive interface for validated data capture;

2) audit trails for tracking data manipulation and export procedures; 3)

automated export procedures for seamless data downloads to common

statistical packages; and 4) procedures for data integration and interoperability

with external sources.

Design and Methods

The LTAC hospital setting is not well studied. This description is an attempt to

provide initial exploration of the patient population in an LTAC hospital who

received consultation from our Supportive Care Medicine (Palliative Medicine)

service. During the implementation of this service, primary focus was on the

LTAC level; however, requests were made to see patients in the skilled

nursing facility/long term care, which was a different level of care. Change in

code status and the place of death were observed to be areas on interest.

Further research is needed to understand the impact of a Palliative Medicine

Consultation Service not only in the LTAC hospital, but also the long term care

and skilled nursing levels.

Discussion

Supportive Care Medicine Team

During the development of the service, the name was discussed by the

members of the team and stakeholders. Consensus was made to call the

service the Supportive Care Medicine Team. Many of the patients and

families who were coming to the LTAC hospital level have had multiple

interactions with the originating hospital’s Palliative Medicine teams. Many of

the patients had Palliative Medicine teams sign off of the case in the

originating hospital. In an effort to ensure a “fresh start” for new patients, the

name Supportive Care Medicine was chosen to highlight the focus on the

supportive nature of the service.

Supportive Care Medicine Name

LTTCH is a free-standing, long-term acute care hospital. This facility is a 296-

bed hospital with 104 hospital level beds (25 pediatrics), 60 intermediate care

(long term care, LTC), and 132 skilled nursing facility (SNF) beds.

Lake Taylor Transitional Care Hospital

Consultation• A formal request is required from Attending physicians prior to consulting

with the patient and family

• Consults are initially seen by the physician or nurse practitioner

• For patients who do not have decision making capacity, contact is made

with the patient’s medical power of attorney to clarify goals of care

• Chaplain support provided

• Attending physicians are updated

• Team meets weekly to discuss all patients on the service

0

10

20

30

40

50

60

70

80

90

100

Tracheostomy Ventilator PEG Dialysis

Medical Devices present in LTAC Hospital Level

0%

10%

20%

30%

40%

50%

60%

70%

ACP dDNR POST

Available Documentation

LTAC LTC/SNF

0%

10%

20%

30%

40%

50%

60%

70%

80%

White Black Asian Other

Race

LTC/SNF LTAC

0%

10%

20%

30%

40%

50%

60%

70%

80%

Male Female

Gender

LTAC LTC/SNF

0%

10%

20%

30%

40%

50%

60%

70%

80%

Full DNR DNR/DNI Comfort

Code Status

LTAC On admission LTAC After consultation

LTC/SNF On admission LTC/SNF After consultation

As of October 18, 2019, we completed 105 consults, with 75 in the LTAC level

(72%) and 30 in the long term care/skilled nursing level (29%). In the LTAC,

65% of patients were male.

• The average age was 62 with a range from 24 to 84.

• Majority (99%) of these patients came from the acute care hospital.

95% had a tracheostomy; 84% on ventilator; 93% PEG; 14% on dialysis

• Upon initial admission to the LTAC:

25% had an advance care plan (ACP);

73% were Full code; 3% DNR; 2% DNR/DNI; 8% Comfort Care.

• After a Palliative Care consultation:

40% were Full code; 29% DNR; 7% DNR/DNI; 24% Comfort Care.

• Disposition:

45% currently residing at the facility; 11% transferred to a different facility;

2.6% went home; and 41% died.

Of the patients who died, 50% stayed at the LTAC and 50%

transferred to an acute care hospital.

Results

CA

PC

Annu

al sessio

n 1

1/1

4/2

01

9

0%

20%

40%

60%

80%

100%

LTAC LTC-SNF

Site of Death

LTAC Acute Care Hospital