Carol A. Luhrs

Hospital-Based Palliative Care Consultation: Effects on Hospital Cost

CONTEXT Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs. OBJECTIVE To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease. DESIGN, SETTING, AND PATIENTS An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006. MAIN OUTCOME MEASURES We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome. RESULTS The average daily total direct hospital costs were

Family meetings made simpler: a toolkit for the intensive care unit.

464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p < 0.001). COMMENTS Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.

End-of-life care pathways.

Although a growing body of evidence has associated the intensive care unit (ICU) family meeting with important, favorable outcomes for critically ill patients, their families, and health care systems, these meetings often fail to occur in a timely, effective, and reliable way. In this article, we describe 3 specific tools that we have developed as prototypes to promote more successful implementation of family meetings in the ICU: (1) a family meeting planner, (2) a meeting guide for families, and (3) a family meeting documentation template. We describe the essential features of these tools and ways that they might be adapted to meet the local needs of individual ICUs and to maximize acceptability and use. We also discuss the role of such tools in structuring a performance improvement initiative. Just as simple tools have helped reduce bloodstream infections, our hope is that the toolkit presented here will help critical care teams to meet the important communication needs of ICU families.

End-of-Life Nursing Education Consortium (ELNEC)–For Veterans: An Educational Project to Improve Care for All Veterans With Serious, Complex Illness

Purpose of reviewTo summarize recent research findings about the use and effects of integrated care pathways for end-of-life care. Recent findingsIntegrated care pathways designed for patients at the end of life include the Liverpool Care Pathway, used widely in the UK, and Palliative Care for Advanced Disease, developed in the USA. There is general consensus in the current literature that integrated care pathways improve standardization, continuity and collaboration among the interdisciplinary team. Although recent studies on integrated care pathways for dying patients have been predominantly descriptive, previous studies demonstrate improved symptom assessment, documentation of care goals, compliance with standardized guidelines and pain control. SummaryThe use of integrated care pathways for dying patients has the potential to improve care by promoting best practice and standardizing care. In addition, these pathways may improve documentation and provide a mechanism for measuring patient outcomes. Although recent studies on the use of these integrated care pathways are descriptive, some publications have demonstrated improved patient outcomes and processes of care. As their use expands, more studies on the effects and outcomes of these care pathways are anticipated.

Improving Family Meetings in Intensive Care Units: A Quality Improvement Curriculum

Because only 4% of veterans die in Veterans Affairs (VA) facilities, the Department of Veterans Affairs Hospice and Palliative Care Program partnered with the End-of-Life Nursing Education Consortium (ELNEC) to develop veteran-specific curricula and train-the-trainer courses. The goal was to educate and empower nurses to improve care for all veterans with serious illnesses. The partnership resulted in the development of 2 curricula that were disseminated through 6 national train-the-trainer courses. More than 730 participants attended, representing VA facilities and community providers from all 50 states and Puerto Rico and the District of Columbia. Since the training, 72 ELNEC–For Veterans courses have been offered in VA facilities and 17 courses in community settings. Attendees have taken what they have learned to promote palliative care education in their own facilities, help to change systems of care, collaborate with other institutions, develop bereavement services, and promote self-care for staff caring for dying veterans. With the funding for the initiative complete, the attendance and commitment of nurses and multiple other disciplines from within VA and community agencies highlight the importance of the ELNEC–For Veterans curriculum and education. Although they are aware of many barriers, their commitment to provide this education either “live” or through online education has been stellar. While the funding from the VA for this project has ceased, nurses have been provided a plethora of resources to be used to improve care for all veterans and their families. A change of culture has begun, as nurses have been educated to promote and advocate for excellent palliative care for all veterans.

The Use of Toolkits for Palliative Care Quality Improvement: The VA's “Strive for 65 Implementation Package” (SA500)

Background Family meetings in the intensive care unit are associated with beneficial outcomes for patients, their families, and health care systems, yet these meetings often do not occur in a timely, effective, reliable way. Objective The Department of Veterans Affairs Comprehensive End‐of‐Life Care Implementation Center sponsored a national initiative to improve family meetings in Veterans Affairs intensive care units across the United States. Process measures of success for the initiative were identified, including development of a curriculum to support facility‐based quality improvement projects to implement high‐quality family meetings. Methods Identified curriculum requirements included suitability for distance learning and applicability to many clinical intensive care units. Curriculum modules were cross‐mapped to the “Plan‐Do‐Study‐Act” model to aid in planning quality improvement projects. A questionnaire was e‐mailed to users to evaluate the curriculums effectiveness. Results Users rated the curriculums effectiveness in supporting and achieving aims of the initiative as 3.6 on a scale of 0 (not effective) to 4 (very effective). Users adapted the curriculum to meet local needs. The number of users increased from 6 to 17 quality improvement teams in 2 years. All but 3 teams progressed to implementation of an action plan. Conclusion Users were satisfied with the effectiveness and adaptability of a family‐meeting quality improvement curriculum to support implementation of a quality improvement project in Veterans Affairs intensive care units. This tool may be useful in facilitating projects to improve the quality of family meetings in other intensive care units.

Patient Rated Weight Loss, Karnofsky Performance Status, and Prognosis: A Recursive Partitioning Algorithm (410-B)

with the highest potential for impact upon the field of hospice and palliative medicine. A hand search of leading journals highly relevant to the practice of hospice and palliative care was supplemented with a search of evidencebased reviews, a targeted keyword search, and conversations with experts in the disciplines of medicine, nursing, and social work. Journal articles were reviewed for both study quality and potential for immediate impact on the field of hospice and palliative care. There was a selection bias against descriptive studies, pilot studies, pre-clinical studies, retrospective studies, open-label trials, case-series, instrument validation studies, and confirmatory analyses.

Training nurses for interdisciplinary communication with families in the intensive care unit: an intervention.

Objectives 1. Recognize that wounds have significant negative impact on a person’s quality of life and wound pain is reported as the most distressing symptom. 2. Discuss the medications that have been studied in clinical trials as topical agents aimed at reducing pain in the wound. 3. Recognize Dermafill Cellulose Wound Care Dressing as a cost-effective treatment option for the management of wound pain in the hospice and palliative care setting. Background. There is growing evidence that wounds have significant negative impact on a person’s quality of life and wound pain is reported as the most distressing symptom. When reviewing evidence-based literature, the focus of the majority of studies is relief of pain during dressing changes as patients report the pain at time of dressing removal as the greatest pain related to the wound. The few studies that focused on overall wound pain reduction in the wound had limited success of pain reduction. Case description. A 67-year-old male admitted to hospice with end-stage cardiac disease presents with a painful leg wound as a result of ‘‘bumping into the coffee table.’’ Patient lives at home with his caregiver-wife. The patient has no known allergies. Patient’s chief complaint is pain and inability to ‘‘do anything because of this darn leg!’’ Patient rates pain at an 8 on the 0-10 scale with the pain escalating to a 10 when manipulated or touched. Patient currently takes oral pain medication without relief from pain. During this presentation, we will review past treatments, potential future treatment options, and conclude by presenting the treatment option we chosedDermafill, which reduced patient’s pain to a 0 on the 0e10 scale without any oral pain medications. Patient was able to walk without pain and reported a significant increase in his quality of life because of this product. Conclusion. The presenter recognizes Dermafill Cellulose Wound Care Dressing as a cost-effective treatment option for the management of wound pain in the hospice and palliative care setting. It is a valuable dressing in the treatment of wound pain. Physicians and nurses can perform weekly assessments without removing the dressing: eliminating the need for frequent and painful dressing changes in our patients.