Integrating palliative care into the ICU

Palliative care, rapid response teams, and sepsis were a few of the topics covered at the Institute for Healthcare Improvement's 22nd annual National Forum.

Palliative care is often considered separate from other parts of the hospital, something to consider only when a patient is near death. But that kind of thinking can lead to the most severely ill patients getting lost in the system due to confusion over when and whether to initiate palliative care, experts said at a recent conference on quality.

“Part of the difficulty of these patients is ‘Who do they belong to, where do they fit?’,” said Lynn H. Spragens, president of healthcare consulting firm Spragens and Associates, at the Institute for Healthcare Improvement's 22nd annual National Forum in December. “People who don't fit the standard clinical pathways are more likely to get lost. They need more shepherding through by the palliative care team.”

Yet initiating palliative care tends to be reactive instead of proactive at most hospitals, said Ms. Spragens, who works closely with the Center to Advance Palliative Care (CAPC). The palliative care team often is not called in until a patient is dying, instead of being integrated into the care plan.

“The current definition [of palliative care] is really driven by a Medicare benefit structure from the 1980s, where you have to have a six-month prognosis,” she said. “The result of that is that often people are referred to hospice way too late because it's only clear in the rear view mirror that they are near the end of life.”

The reality is that there is rarely a clear-cut point in time when a patient crosses over from seriously ill to dying, she said. Patients with serious illnesses such as chronic heart failure may have concurrent needs for life-prolonging treatment and palliative care for a number of years.

“The relative balance of curative treatment and comfort shifts over time,” said Ms. Spragens. “At some point it is appropriate to have people access hospice, but that becomes a more natural, less disruptive access point when you've done a good job of introducing palliative care concepts, clarifying goals of care, and developing joint plans of care earlier.”

Barriers and tips in palliative care

More than half of hospitals in the U.S. have some type of palliative consult service, said Ms. Spragens, and they vary widely in size and function. Inpatient consult is the most common type, but palliative care is also provided through telemedicine, outpatient clinics, inpatient units and provider home visits. Other programs are based in the community, including hospices.

The CAPC has launched initiatives to help hospitals integrate palliative care into the intensive care unit (ICU) and emergency department (ED), said Amber B. Jones, a CAPC consultant and co-presenter at the session. The underlying principle is that palliative care should be part of comprehensive critical care for all patients beginning at ICU admission, regardless of prognosis.

Planning for discharge is a major challenge of implementing a palliative care program, said Ms. Jones. About one-third of chronically ill patients are discharged with no follow-up arrangements, according to a March 2008 study in the New England Journal of Medicine. The study also noted poor communication between hospitalists and primary care physicians (PCPs), with fewer than half of PCPs being given discharge information and only 3% of PCPs involved in discharge planning.

Ms. Spragens gave tips to implement or improve an inpatient palliative care program, such as doing a needs assessment of the ICU and ED regarding palliative care, adopting the National Quality Forum's “preferred priorities “ and launching a pilot program addressing unmet meets with specific inpatient populations such as congestive heart failure, dialysis or dementia.

CAPC also offers practical tools on its Web site, including the IPAL-ICU resource center for assisting hospitals in integrating palliative in the ICU; leadership training; an online discussion forum; and the National Palliative Care Registry, which has national data on hospital programs.

Measuring the effectiveness of rapid response teams

Other topics of interest to hospitalists at the IHI conference included measuring the effectiveness of rapid response teams and fighting sepsis.

Establishing a rapid response team (RRT) is only the first step toward reducing a hospital's mortality rate, said IHI presenter Michael E. Westley, ACP Member, medical director of critical care at Virginia Mason Medical Center in Seattle. A bigger challenge is figuring out whether one's team is effective.

Hospitals must follow up by continuously assessing the criteria for triggering an RRT call and judging whether that triggering process reliably identifies all patients at risk for dying. “What criteria are you using to mobilize your team,” said Dr. Westley, “and how reliable is the response?”

It's crucial to keep track of data in order to answer those questions. Hospitals should collect data on the number of RRT calls per 1,000 admissions/discharges and review all codes for potential failure to trigger the RRT, he said.

At Virginia Mason, for example, Dr. Westley and his team showed that by following a protocol for triggering RRT calls, the number of unscheduled transfers to the ICU preceded by an RRT call increased by 10% between 2006 and 2010, while missed RRT calls (patients that should have triggered the RRT but didn't) decreased from 90% to 25%.

Hospitals should measure the time from an RRT call to ICU admission because RRTs typically speed up the transition from hours to minutes, he said. Consider, too, that RRTs can have benefits beyond mortality reduction, said Dr. Westley, such as facilitating flow within and between units and providing support for the bedside team before the primary care physician arrives.

“The value is in getting the patient to treatment, or transferring him to the appropriate level, faster,” he said. “With STEMI (ST-segment elevation acute myocardial infarction), stroke or sepsis, there is a need for speed.”

Fighting sepsis

It's easy to classify acute myocardial infarction, stroke or trauma as urgent when patients arrive in the ED. But sepsis, which claims more lives than any of the other three, according to national statistics, often goes undiagnosed until it's too late to save the patient.

“Stroke and MI (myocardial infarction) are urgent, and they appear urgent,” said presenter Sean R. Townsend, MD, vice president for quality and safety at California Pacific Medical Center, one of four presenters in a session on reducing sepsis mortality. In contrast, it is often not apparent when a patient is in the early stages of sepsis.

In recognition of the problem, IHI has partnered with the Surviving Sepsis Campaign, (an initiative of the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine) to improve sepsis treatment and reduce associated mortality.

The collaborative enlisted 15 hospitals of various sizes to focus on patients admitted to the ICU from the ED with severe sepsis or septic shock. The goal is to increase compliance to at least 75% on key components of the severe sepsis bundle, including serum lactate collection, obtaining blood cultures before administering antibiotics, delivering antibiotics within three hours of recognition of severe sepsis, and providing adequate fluid resuscitation if a patient is hypotensive.

Data collected since the collaborative began in November 2009 until August 2010 show an overall slight increase in compliance with the basic sepsis bundle and an almost 20% overall decrease in sepsis mortality, said presenter Terry P. Clemmer, MD, director of critical care medicine at Salt Lake City-based LDS Hospital, part of Intermountain Healthcare.

The key to success, said Dr. Clemmer, is to “make it simple, concentrate on a focused population, and push it to high reliability using rapid cycle testing.”