Abstracts

1. Seamless Integration of Pediatric Palliative Care into the ICU

Team Contact:

Sarah Friebert, MD

Topic area: Pediatrics, ED, ICU or Outpatient Programs

Description:

The pediatric intensive care unit (PICU) is a point of entry for critically or chronically ill children into health care. PICU admissions are also natural times for advance care planning for those with life-threatening illness. Nevertheless, Palliative Care (PC) has historically not been well accepted in PICUs due to many barriers. Since PC was established at Akron Children's Hospital (ACH), a close collaboration has developed, resulting in higher utilization of PC. Hypothesis: Seamless integration of palliative care can occur between PC and a PICU. Methods: To examine trends in PC consultation, we undertook a 5-year retrospective analysis from 2005 through 2009. Results: During the study, the PICU had 6120 admissions; PC was consulted for 695 admissions (11.3%), divided among 423 patients. For patients concurrently managed by PC, specific diagnoses varied, including acute (drowning, trauma) and chronic (MRCP, congenital heart disease). Over 5 years, a linear increase in concurrently managed cases has occurred. Thus far, 208 of the 423 shared patients have died. Expertise from PC is sought by the PICU for reasons including: pain and symptom management; facilitation of family meetings; management of end of life; and provision of seamless care after PICU discharge. Conclusions: PC consults are increasing, likely because of the expertise PC brings to the care of children with life-threatening illness in the PICU. Collaboration occurs not just at end of life, as evidenced by the fact that 215 co-managed patients remain alive. Future studies include determination of patient/family satisfaction and reasons for non-utilization of PC expertise.

2. Start with a Team: It's the Vehicle & the Destination

Team/Contact Information:

Bridges: The Palliative Care Team of Arnold Palmer Medical Center

Angela Donahue, Pediatric Critical Care Nurse Practitioner

Topic: Team-based Internal Marketing Strategy to Overcome Institutional Obstacles

Description:

Inspired by the ideal of transdisciplinary care and informed by the challenges faced by solo pioneers in building programs, Bridges: the Palliative Care Team of Arnold Palmer Medical Center was co-created by a team without the benefit of physician leadership. Equipped with the skills garnered from the Center to Advance Palliative Care's Palliative Care Leadership Center, Akron Children's Hospital, this team has gained administrative support, secured funding and cultivated a culture that is demanding a palliative care service.

“The Medium is the Message” ∼ Marshall McLuhan. Communicate teamwork through teamwork. Avoiding the pitfalls of solo personality efforts, teams promoting the advantages of palliative care allow for others to more readily envision a team approach to delivery.

3. Educating Nurses to Provide Palliative Care to Veterans

Team/Contact Information:

Contact Person: Betty Ferrell, PhD, FAAN, FPCN, Research Scientist, Principal Investigator of the ELNEC Project, City of Hope, Population Science Bldg. #173, 1500 East Duarte Road, Duarte, CA 91010-3000

Topic: Marketing and Education

Description:

In 2010, the Department of Veterans Affairs (VA) awarded the City of Hope a three-year contract to educate nurses on how to provide better palliative care for Veterans with life-threatening illnesses. The first two of six national train-the-trainer courses were held in August 2010 in Pasadena, CA and Washington, DC, with over 250 nurses and other members of the interdisciplinary attending, representing all 22 Veterans Integrated Service Networks (VISN). The 1000-page curriculum was developed through the End-of-Life Nursing Education Consortium (ELNEC), a national nursing education initiative administered by the City of Hope and the American Association of Colleges of Nursing (AACN), along with a VA workgroup of healthcare providers. After completing the two-day train-the-trainer course, nurses will be equipped with materials to return to their institution and train others. Each participant's VA institution will also have access to all of the ELNEC-For Veterans modules through the Hospice Education Network (HEN), which will provide lectures by the national faculty, available 24/7 via web-based video streaming.

No other healthcare provider spends more time with these Veterans and their families than the nurse. The expertise gained at these courses promises to improve the quality of palliative care for thousands of veterans in 153 Department of Veterans' Affairs Medical Centers across the U.S. Efforts are being made to also reach out to community nursing homes, long-term care facilities, hospices, and non-VA acute care facilities who care for approximately 96% of all Veterans.

4. Eight Domains: Eight Opportunities

Topic: Marketing and Education

Team/Contact Information:

Colleen Apostol, RN, CHPN, OCN (key contact)

Description:

Using the Eight Domains of Palliative Care to Promote a New Palliative Care Program:

The Duffey Pain and Palliative Care Service became operational in late 2007. One of the many challenges faced while introducing and integrating our new program was demonstrating the value our service would bring to patient care.

The Clinical Practice Guidelines for Quality Palliative Care, established by the National Consensus Project (NCP) identify eight domains of quality palliative care. Within the NCP document are outcomes and criteria for achieving them.

In an effort to familiarize the Cancer Center's nursing staff with palliative care and our service, nurses on the palliative care team used the eight domains to design a series of in-services. Each month, for eight months, one of the domains was used as the topic for an interactive educational presentation. As the domains were explored, different members of the interdisciplinary team joined the palliative nurses as primary presenters. For instance, our team's social worker presented Domain 4, and members of our diverse pastoral care staff assisted with Domains 5 and 6.

Our strategy to encourage attendance was four-fold: 1) the length of presentation kept to 15-20 minutes, 2) presentations were held on each of the nursing care units, 3) we scheduled times that were least disruptive for the busy units, 4) provided attendees with documentation for their developmental resumes'.

Update- A total of 204 nurses were in attendance over the 8 month period. Unit nurses were engaged, and the process for patient referral was solidified and reinforced.

5. Nurse Practitioner Led Palliative Care Program

Team/Contact Information:

Meg Randle, GNP, CHPN

Topic area: Integrating with existing programs

Description:

A collaborative and interdisciplinary team that offers

Billable Nurse Practitioner inpatient service

Results : > 20% increase in number of consults from year to year. Initially 206 patients before full program integration then in 2008, 305 patient consults; 2009, 385 pts consults; and 2010, 465 palliative consults.

6. Extending the Scope of Pediatric Palliative Care

Team/Contact Information:

Kathy Davis, PhD, MSEd

Topic: Expanded inpatient and outpatient services

Description:

The American Academy of Pediatrics (AAP) and the World Health Organization (WHO), in their respective definitions of pediatric palliative care (PPC), suggest that services should commence at the time of diagnosis of a child with a life limiting condition. Despite these definitions, pediatric palliative care has traditionally been reserved for children nearing the end-of-life; those who are transitioning from curative treatment to hospice care. In the Department of Pediatrics at the University of Kansas Medical Center, a unique program is working to ensure that palliative supports begin at the time of diagnosis, and continues through cure, transition to adult care, or end-of-life care. The KU Kids Healing Place provides care for the physical, psychological, social, spiritual and educational needs of children with life limiting conditions, as well as traditional palliative care for youngsters nearing the end of life. The program initiates services within the hospital, and extends them into the natural environments of the youngster. As health care providers partner with schools, child care programs, extracurricular activities, athletics, places of worship and more, a system of support is developed that enables young people, regardless of health status, to continue to grow and develop normally. School professionals, peers, child care providers, coaches, clergy and other community members receive education and training which enables them to provide ‘palliative care’ in every facet of the youngster's world. This poster presentation will chart the development of this innovative model of pediatric palliative care, from inception to implementation.

7. Growing Pediatric Programs using Social Media

Team/Contact Information:

Topic: Marketing and Education

Description:

Cocktail parties and family gatherings do not typically provide the appropriate venue to ‘spread the word’ about pediatric palliative care. In addition, sharing information and resources about PPC may be difficult to accomplish among providers who are engaged in patient care, research and other scholarly activities. How, then, do busy professionals develop networks, inform stakeholders, communicate with colleagues, and build a comprehensive community around PPC? Social media, of course! Facebook, Twitter and blogging are not just for sharing photographs or informing friends and family about your current activities. In addition, these social media forums offer terrific opportunities to develop pediatric palliative care networks, inform families and other stakeholders, share the most current information, and advance pediatric palliative care programming. Although many health care disciplines are experiencing significant growth in the world of social media, pediatric palliative care is still in its infancy in the world of social media. There are very few professionals communicating in social media venues regarding pediatric palliative care, and the opportunity to develop along these lines is now. This poster will outline the social media development of the KU Kids Healing Place at the University of Kansas Medical Center, Department of Pediatrics. The presentation will describe how social media has been used to provide support to patients and family members, market the program, inform colleagues on a variety of topics, share information with others with similar interests, and provide education to a wide range of stakeholders.

8. ‘Goals of Treatment’ Enhance Long Term Communication

Team/Contact Information:

Topic: Enhancing Communication Systems

Description:

Documenting long term treatment goals and decisions is particularly important for patients with advanced illness. Yet, even when long term goals are discussed, they are often unavailable during subsequent hospitalizations leading to redundant or duplicative conversations or treatment. We worked with the Medical Records and information systems departments to establish a new dictation type that is specifically designed to capture this information and make it available widely across the network. Called ‘Goals of Treatment’ (GOALTX), the note appears in the transcription section of the hospital computerized medical record where all H&P's, operative notes and discharge summaries are stored. It is available to all hospital staff and all referring community physicians. The template includes: summary of case, decision making capacity and surrogates, and prompts for CPR status, treatment plan including appropriate diagnostics and comfort measures if any. To date, XXX have been completed and they are widely recognized throughout the network. Now, with its legitimacy established, there are plans to make it part of quality initiatives such as requiring a GOALTX for all patients with complex illness, such as metastatic malignancies, or advanced organ failure with multiple hospital readmissions. Templates, examples, policies and usage data will be presented.

9. “Using Scorecards to Monitor Program Performance”

Team/Contact Information:

Topic: Measurement, Quality Improvement or Clinical Outcomes

Description:

Monitoring and communicating the complex array of data required to assure clinical, operational, financial and quality performance is a crucial key to the success of a palliative medicine program. Our team developed a one-page score card for both the in-patient and out-patient services, to assemble and display relevant outcomes in a succinct and timely manner. This report is used both as an internal barometer and distributed to key network leaders to demonstrate ongoing benefits of needs of the palliative medicine services.

The measures were selected to help identify opportunities in both process and outcomes for the palliative care program based on the 5 pillars of our institutional quality improvement program: finance, growth, service, quality and people.

The completed scorecard serves well as a communication and management tool, but the process of creating it; i.e. assessing all the myriad data sources and measurement options, was crucial in uncover incomplete or inaccurate data, data that could be better represented, and opportunities for growth and improvement.

10. SYMPAQ Clinic: Palliative Care Clinic Gets a New Name

Team/Contact Information:

Key Contact:

Topic: ED, ICU or Outpatient Programs

Description:

To complement the Mayo Clinic Rochester inpatient Palliative Care consult service active since January 2003, we started a referral-based outpatient Palliative Care Clinic in July 2008. Initially, referral volumes were low. Needs analysis identified stigma with the word “palliative” as a major deterrent to timely referral. In an 8-month pilot (reported elsewhere) patients with cancer-related pain referred to Cancer Pain Clinic (staffed by Anesthesia Pain consultants) were randomized to either Palliative Medicine or Anesthesia Pain clinic based on availability. The pilot demonstrated non-inferior pain management by Palliative Medicine, but clinically significant improvement in several non-pain symptoms and several quality of life parameters with Palliative Medicine over Anesthesia Pain Consultation. To more accurately reflect our clinic's mission, we changed the name to SYMPAQ (Symptom Management, Pain and Quality of Life) Clinic in June 2010. The SYMPAQ Clinic continues to be staffed by board-certified hospice and palliative medicine physicians from our group, and the clinic maintains the identical focus as the “Palliative Care Clinic.” However, the name change has led to increased and earlier referrals (as similarly demonstrated by other centers (i.e. M.D. Anderson)). The clinic is now co-located with the Anesthesia Pain Clinic, thus facilitating interdisciplinary, collegial exchange and collaboration to improve patient-centered care and outcomes. Members of both Anesthesia Pain and Palliative Medicine groups are involved in triage of referred patients to appropriate clinicians. Patient referral volume to the Palliative Medicine fellow's outpatient continuity clinic, as well as the attending-only outpatient clinic has doubled in one year, in part resulting from these changes.

11. Novel Program to Promote Competency & HPM Boarding

Team/Contact Information:

Topic: Marketing and Education

Description:

Hospice and Palliative Medicine (HPM) Certification will require fellowship training after 2012. To accommodate mid-career clinicians desiring HPM certification and to staff and support our growing HPM practice, we developed a novel curriculum and training experience. The ABMS (American Board of Medical Specialties) Learners Program has provided structured clinical and didactic HPM training outside of formal fellowship and leads to HPM-board eligibility.

Five physicians (2 Generalists, 1 Geriatrician, 1 Psychiatrist, and 1 Hematologist) were selected to participate based on interest and aptitude. Participants use 20% clinical effort over a two-year period (2010-2012) to meet ABMS “Practice Pathway A” requirements. Learners actively manage ≥50 terminally ill patients, perform inpatient palliative medicine consultations, and attend interdisciplinary group meetings at local hospices and on inpatient palliative care consult services. These activities meet the ABMS requirement for subspecialty-level exposure. Learners attend HPM Fellowship didactics and participated in a structured “Boot Camp” with 12 hours of intense HPM education in key content areas. Direct feedback with program coordinators is provided semi-annually.

In the first 6 months, learners were precepted by board-certified HPM physicians on approximately 100 new consults and 80 follow-ups. After 10 months, learners will perform consults independently, with HPM-certified physicians available as backup. To our knowledge, non-traditional programs outside of fellowship have not been reported to enhance HPM board passing rate or to improve clinical competency. This approach aims to provide an increase in trained HPM physicians within our institution and further meets staffing demands with our growing services.

12. FootPrints™ at Your Fingertips?

Team/Contact Information:

Topic: Measurement, Quality Improvement or Clinical Outcomes

Description:

In these tumultuous economic times, it is important to consistently prove to hospital administration that the Palliative Care Program is not only providing quality end of life services, but is a cost savings to the hospital. The Center for Palliative Care at The Medical Center of Central Georgia located computer software that makes data collection easy and keeps the palliative team efficient through its communication capabilities. The Numara software, called FootPrints, allows the user to build reports that coincide with the CAPC formulas for determining cost savings. By keeping real time data on every patient, The Center for Palliative Care is able to report actual raw numbers and; therefore, prove indisputably the value of the palliative team.

Through the use of FootPrints, The Palliative Care Interdisciplinary Team members (1 Medical Director, 3 Geriatric Fellows, 4 midlevel providers, 8 counselors/social workers, 8 interns and 2 administrators) are able to communicate effectively making them more efficient in their daily functions. In 2009, the Team provided services to 1,915 patients and families. Because of FootPrints, the Team is able to manage a large volume of data, accessible at any time, which is critical to the programs' existence in harsh economic times.

13. Real-Time Operational and Clinical Dashboard

Team/Contact Information:

Topic: Collecting and Using Data to Achieve Your Program Goals: What Worked and Why

Description:

A real-time web-based dashboard that graphically represents operational, financial, quality, and clinical data in one integrated 360° view of the Section of Palliative Medicine.

Having a 360° view of your palliative care program is critical to demonstrate your impact, measure the quality of the care you deliver, manage your practice, and identify opportunities for improvement. Achieving this view had been nearly impossible until the emergence of the Enterprise Data Warehouse (EDW) at Northwestern. This integrated cross-institutional database provided a platform upon which we were able to create a real-time web-based dashboard that graphically represents operational, financial, quality, and clinical data in one integrated 360° view.

This dashboard has proven to be a critical management tool as the recently re-established Section of Palliative Medicine continues to grow at Northwestern. In addition to providing the team with real-time feedback, this dashboard has facilitated an open dialogue with senior leadership, as they can also view the dashboard at any time.

14. Integrating Automated Data Collection into Your Notes

Team/Contact Information:

Topic: Collecting and Using Data to Achieve Your Program Goals: What Worked and Why

Description:

Fully integrated structured note templates with data entry and automated extraction functionality.

CAPC strongly encourages programs to measure operational, financial, customer, and clinical data, but the later has traditionally necessitated a manual chart review process for extracting and analyzing the data. At Northwestern, we have partnered with our IT department to develop note templates that allow us to document patient assessments and symptom scores concurrently with the clinical note and to subsequently extract and analyze that data automatically. In theory, this means that we will be able to assess clinical data for 100% of the patients we touch without expending countless person-hours to do so, ultimately opening the door to innumerable research opportunities as well as quality of care initiatives.

After a number of revision cycles focusing on improving usability, the note templates have been successfully adopted by the Palliative Care Team and are now producing data such as symptom score trajectories and assessment frequencies that feed a real-time web-based dashboard.

15. Improving Palliative Care in RI ICUs: a Model for Success

Team/Contact Information:

Topics:

Description:

The RI ICU Collaborative Palliative Care Initiative aims to improve communication and palliative care services and close the gap between the best evidence and care delivery. The goals are to:

This quality improvement initiative provides centralized project management and a structured program design. The Johns Hopkins model for transformational change (engagement, education, execution and evaluation) serves as the program template design. Rapid cycle improvement methods are applied in the implementation of an evidenced based communication bundle, and continuous improvement monitoring.

A shared learning environment that includes education from palliative care experts, best practice sharing, inter-hospital discussion, data measurement support along with unit specific consultation, resulted in high levels of engagement and is expected to demonstrate positive outcomes.

A customized data base was created for data submission, analysis and identification of improvement opportunities. Over 2,300 patients from 17 ICUs were assessed for inclusion in the communication bundle during the second quarter 2010 baseline period. Comparative data will be available by October.

16. Palliative Presence to Increase ED/PC Consults

Team/Contact Information:

Topics: ED, ICU or Outpatient Programs

Description:

Background: 80% of hospital admissions come through the Emergency Department. What effects will a physician trained both in emergency medicine and palliative medicine have if she is stationed in the ED?

Method: 10-month prospective pilot project from October, 2009 to July, 2010 in Level I Trauma Center Emergency Department for 500-bed urban non-profit hospital. Hospital has palliative medicine consultation service consisting of full time MD, full time NP, full time physician fellow with average daily census of 12-18, 4-6 new consultations per day.

Results: In year prior to project, only 3 palliative medicine consultations from the ED. In 10 month pilot project, 163 consultations in the ED (about 0.3% of all Emergency Department Visits). Based on patterns of referral, 40 consultations per month were projected if the project were to continue (M-F 8-5 PM). There was no effect on inpatient consultation service volume, suggesting this is a different patient population. Of the 163 consults, 48 were admitted to hospice and 52% died within 7 days of the consult.

Conclusion: Dedicated palliative medicine presence in the Emergency Department is feasible and productive. Patients come to the ED who, if palliative medicine consultation requested, have a plan of care other than ‘do everything’. Significant variations in referral practices between ED attending physicians suggest there are cultural or ‘tribal’ barriers to incorporation of palliative medicine into routine ED practice.

17. St. Francis Hospital Palliative Care Brochure

Team/Contact Information:

Topics: Marketing and Education

Description:

Helping patients and families understand the benefit of palliative care is a vital aspect of program development. A palliative care program brochure, developed for St Francis Hospital, a 316 bed New York community hospital, defines the benefit of palliative care and outlines what a patient and family can expect during a consult. Concepts of quality palliative care are highlighted, as well as the hospital's magnet status and “Best Hospital” recognition. The brochure intentionally includes language that describes the current services and allows for future program growth. The palliative care NP reviews the brochure during the initial consult and suggests that families refer to the information throughout the hospital stay. Family feedback has been very positive, and is gathered from the mailed satisfaction survey.

Initial design of the brochure began with the involvement of a patient's daughter who offered her time and marketing expertise and worked with the NP to review images, text, colors and layout. This pre-work significantly decreased the initial design and print cost and incorporated the patient/family voice. The brochure, also used to market palliative care to referring clinicians, has been distributed and reviewed at presentations given by the NP to cardiothoracic surgeons, process improvement and ethics committees.

18. Developing Palliative Care in Rural Communities

Team/Contact Information:

Topics: Palliative Care Delivery in Rural Communities

Description:

Although the number of palliative care programs in large hospitals has grown in recent years, residents of rural communities often lack access to palliative care. Rural communities often have a disproportionate number of residents over age 65, a population with multiple chronic illnesses and palliative needs. In order to increase awareness of palliative care and build skills among health care professionals in rural Minnesota, Stratis Health and Fairview Health System collaborated on the Minnesota Rural Palliative Care Initiative to assist ten rural communities to develop and/or strengthen palliative care programs in their communities. The NQF practices provided the framework for building community capacity in palliative care. Information shared will include examples of community based models, and strategies and tools to address barriers and identify community-based solutions to providing rural palliative care.

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