Consults in the Emergency Department: Outcomes and Impact on Referrals Jhosselini Cardenas-Mori, MD; Bernadette Huvane, MSN APRN FNP- BC, Palliative and Hospice Linda R. Mitchell, MD; Carolyn Genereux, LCSW Department of Family and Social Medicine

BACKGROUND • Adults with chronic illnesses have frequent Emergency Department (ED) visits in the last months of life presenting with uncontrolled symptoms and unclear goals of care. [1,2,8] 17 • Previous research supports early Palliative Care (PC) in the ED to improve were quality of life and reduce costs [2,3,4,8] readmitted in 30 days (29%) • Numerous benefits to providing early PC starting in the ED

METHODS 1. Retrospective cohort chart review study. 2. All patients ≥ 18 years of age and older admitted to the 431-bed Weiler Campus at Montefiore Medical Center in Bronx, NY from April 2017 to September 2018. • Weiler ED serves approximately 75,000 visits per year 3. demographic, clinical data and quality indicators were obtained from Figure 2. Hospice referral outcomes the medical record EPIC. 27/103 were 4. Quality indicators include: 5/103 patients were discharged with PC team saw 103 discharged to a. Reason for presentation to the ED hospice services after patients total at ED Inpatient hospice a mean 8.4 day b. Primary, secondary and tertiary reasons for Palliative Care consults; from ED hospital stay c. Number of hospice referrals from the ED d. Documentation of advanced care planning and code status discussions; e. Patients’ length of stay and 30 days readmission f. Mortality

CONCLUSIONS RESULTS 1. Patients receiving palliative care consultation in the ED were at high Table 1. Demographics of patients receiving PC consults in the ED risk for death during admission Demographics Number (%) 2. Five percent of these consults resulted in discharge directly from the ED with hospice services, representing a significant reduction in Age (years) Mean 76.8 burdensome hospital admission and unnecessary costs 18-75 44 (43%) 3. The palliative care service was also able to facilitate code status change >76 59 (57%) and to perform timely palliative extubations for those patients with

comfort-oriented GOC Sex Male 45 (44%) 4. The main limitation of this study is that it is an observational Female 58 (56%) retrospective design and causality cannot be determined

Code Status at ED presentation Full code 67 (65%) Figure 4. Palliative extubations REFERENCES DNR, DNI 31 (30%) performed by PC team At ED: 3/103 1. SmithAK, McCarthyE, WeberE, CenzerIS, BoscardinJ, FisherJ, CovinskyK: Half of older Americans seen in emergency department in last month of life: DNR but not DNI 5 (5%) Most admitted to hospital, and many die there. Health Aff (Millwood) 2012;31:1277–1285. patients 2. Meier, Beresford. Fast Response is Key to Partnering with the Emergency Department Journal of Palliative Medicine. June 2007, 10(3): 641-645. Primary reason for presenting to ED 3. American College of Emergency Physicians: Campaign. American College of Emergency Physicians. www.acep.org/Clinical---Practice- Palliative Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign. Altered mental status 35 (33%) 4. LambaS, NagurkaR, WaltherS, MurphyP: Emergency-department-initiated palliative care consults: A descriptive analysis. J Palliat Med 2012; 5:633–636. Shortness of breath 43 (42%) extubation 5. WeissmanDE: Consultation in palliative medicine. Arch Intern Med 1997;157:733–737. After admission: 6. Mierendorf SM, Gidvani V. Palliative Care in the in the Emergency Department. The Permanente Journal. 2014;18(2):77-85. doi:10.7812/TPP/13-103. Uncontrolled cancer pain 13 (13%) 7. Penrod JD Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010 Aug;13(8):973-9 8. George, Naomi et al Palliative Care and Assessment in the Emergency Department: A Systematic Review Journal of Pain and Symptom Others 12 (12%) 8/103 patients Management , Volume 51 , Issue 1 , 108 - 119.e2