PROJECT LEAD: Jennifer Harris, MD

EXECUTIVE SPONSORS:

Maria Raven, MD, MPH, MS, Chief of Emergency Medicine at UCSF Medical Center, Professor and Vice Chair, Department of Emergency Medicine

Additional executive sponsors TBD

ABSTRACT:  

      Many patients with advanced age and life-limiting illness arrive to Emergency Departments with severe illness.    Often, both patients and providers find themselves at a crossroads where critical decisions about next steps in health care need to be made promptly.  Providers feel uneasy making recommendations to patients they barely know.  Patients and family members feel overwhelmed by all the possible options and the weight of making life and death decisions.    As a result, sometimes providers and patients charge ahead with aggressive care because it is sometimes easier just to quickly intubate someone than it is to have a conversation about whether intubation would help them to achieve a desired outcome.  

     However, it is not hard to see that this approach has the potential to be detrimental to patients and their loved ones and can strain ICU and inpatient hospital capacity.   In an article entitled “Economic implications of end-of-life care in the ICU,” the authors note “According to Medicare claims data, ICU use in the last 30 days of life increased between 2000 and 2009 despite public opinion surveys reporting that most patients would prefer to die at home, if diagnosed with a terminal illness.”

     Given the potential to improve care, Emergency Departments around the country have evaluated bringing goals of care (GOC) conversations into the Emergency Department.   For example, Northwell Health, New York’s largest healthcare provider, provided structured guidance and training to ED providers and emphasized establishing GOC in the ED.   According to unpublished data presented at the GEDC, those patients who had GOC addressed in the ED had shorter inpatient length of stay as well as lower readmission rates.   Dr. Corita Grudzen from NYU has also been studying the role of end of life conversations in the ED.   She writes that “a Center for Medicare and Medicaid Innovation project that ED-based primary palliative care innovations reduced the percentage of geriatric ED admissions to the ICU from 2.3% to 0.9%.”   Dr. Grudzen is currently conducting a large, national study to further evaluate the impact of primary palliative care conversations by Emergency Physicians.    UCSF took part in this study with site champions at both Parnassus and ZSFG campuses.  

     My proposal would be to implement a concrete scripted tool offering specific guidance and language to regularly walk providers through end of life conversations.   This proposal would align with all the UCSF True North Pillars. 

TEAM:

This project is supported by:

Maria Raven, MD, MPH, MS, Professor and Vice Chair, Department of Emergency Medicine, Chief of Emergency Medicine at UCSF Medical Center

Susan Lambe, MD, Associate Professor of Emergency Medicine, Medical Director for Quality and Case Review, Emergency Medicine Medical Director for Patient Safety, Adult Services, UCSF Health

Laura Schoenherr, MD, Associate Professor, Associate Division Chief of Inpatient Palliative Care Services

Tina Chen, MD, MS, Associate Clinical Professor, Division of Pulmonary and Critical Care Medicine, UCSF

Kathleen Liu, MD, PhD, Professor of Medicine and Critical Care, Medical Director of the Medical Intensive Care Unite and the Apheresis/Hemodialysis Unit

Molly Kantor, MD, Associate Clinical Professor, Division of Hospital Medicine,  Associate Medical Director of Adult Patient Safety, Assistant Director of Quality and Safety for the Division of Hospital Medicine, Lead for Inpatient Advanced Care Planning Improvement Work Group

Tawnya Napoli, MS, RN, AGNP-BC, CCRN, CHPN, Palliative Care Advanced Practice Specialist, Center for Nursing Excellence and Innovation, UCSF

Karen Martinez BScN, RN, CEN, Assistant Unit Director, Emergency Department

PROBLEM:

• Patients with a history of serious illness often present to the Emergency Department with critical illness and at high risk for poor health outcomes.   Despite frequent contact with health care, often their health care goals and priorities have not been addressed or documented previously.  
• ED providers are left trying to have delicate conversations about goals of care in a very limited amount of time.    This is quite stressful as providers have varying levels of experience and training in having these conversations. 
• When dealing with such a sensitive topic, it is hard to think of the right way to share information and ask questions to help make life and death decisions quickly.     When these conversations go poorly, they can result in goal discordant care and be extremely distressing for patients and their loved ones.
• Providers without adequate training often fall back on medical jargon leaving patients and families confused about what different interventions mean and whether they could be helpful to the patient.
• ICU care is very expensive and can burden patients and their families with large medical bills.   This is particularly unfortunate if ICU level care would not help the patient achieve a desired outcome.
• ICU resources are limited and boarding ICU patients in the Emergency Department limits our ability to deliver emergent care to new patients.
• Delivery of futile care and lack of time/training to have meaningful and effective GOC conversations contribute to provider burnout

TARGET:

• To use a script, such as the “Rapid Code Status Conversation Guide,” to standardize how providers have goals of care conversations so that we can deliver goal concordant care to our patients.   This can help avoid unnecessary and invasive care that is not within those goals.  
• The ED would be an ideal place to implement this tool, but it could also be useful to physicians, APPs, and RNs working in other inpatient settings.  
•  Possible indirect measurements may be reduction in ICU admissions, decreased ICU and/or hospital length of stay, and fewer hospital admissions.  

GAPS:

• Currently, in our hospital system, we don’t have standardized use of a concrete tool to guide code status discussions that providers can use in acute settings where they may have only a few minutes to help patients and their loved ones make critical life and death decisions.   Most existing frameworks to address goals of care are meant for situations where the patient and provider have time to have a lengthy in-depth conversation.  
• With a new crop of resident learners each year, it is challenging to implement adequate training around how to have a GOC conversation.  After these training sessions, even seasoned providers may not feel confident using their new communication skills as they may do it infrequently or feel they don’t have enough time.  

INTERVENTION:

• We will create a concrete script (or use a pre-existing tool such as Brigham and Women’s hospital EM MD Dr. Kei Ouichi and Dr. Naomi George's “Rapid Code Status Conversation Guide”) that walks providers through a goals of care conversation focused on a desired outcome rather than offering a menu of intervention possibilities.    (Click on link below to view this guide).
• The script will explain the urgency of the current situation, elicit “what matters most” to the patient and/or their loved one(s), and ultimately make a recommendation for next steps for care based on the patient’s own values and priorities. 
• It could be used after brief explanation and providers would get hands on frequent experience (and hence more comfort) rather than hoping to remember all the simulated conversations and tips from a lengthy training session.      
• This could also be a tool used by trainees on inpatient and critical care services as sometimes conversations started in the ED require further discussion in the hospital.

PROPOSED EHR MODIFICATIONS: None 

RETURN ON INVESTMENT:

• Average cost per day of ICU stay at Parnassus is $5500
• Average LOS in ICU is 8 days
• In 2023, there were approximately 225 adult inpatients admitted to Critical Care Medicine
• Total average cost of these ICU stays = $5500 x 8 x 225 = $9,900,000
• If having regular GOC conversations could decrease ICU LOS by 10% (a conservative estimate), this would mean savings of $990,000. 
• Preventing just one ICU admission per month could lead to cost saving of $528,000
• Decreased length of stay on hospital floors with cost of $1500 per day could also contribute to additional savings.  
• This project should have very low overhead so that decreased utilization should be captured as savings

SUSTAINABILITY:

• Championing and standardizing GOC conversations into our regular workflows can become an increasingly familiar part of our patient interviews along with HPI, PMHx, meds, etc.    Providers can provide care with a more integrated and holistic view of the patient’s healthcare goals.  

BUDGET:

• Salary support for provider champions – estimate $40,000
• Printing/laminating materials – estimate $5,000
• Incentive gift cards to help encourage providers to incorporate this conversation guide into their practice – estimate $5,000