Quality measures for palliative care in the emergency department

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The emergency department (ED) offers specific challenges and opportunities for palliative care–related programs and initiatives. ED providers serve an important role in both the initiation and the continuation of palliative care for the seriously ill as ED visits often increase within the last 6 months of life.1 Palliative care is specialized care for the seriously ill that focuses on improving quality of life at any age and at any stage of disease. Palliative care can be provided along with curative treatment in the ED and often improves patient quality of life, symptom control, and transitions of care, without shortening survival or disrupting potential life-prolonging interventions.2, 3 Hospice care is applicable for a subset of seriously ill patients with less than 6 months of expected survival. ED referrals and care transitions from ED to hospice4 may similarly impact patient outcomes and quality of life. However, systematic quality measurements of the impact of ED-palliative care interventions are rare. National organizations such as Center to Advance Palliative Care (CAPC), American Academy of Hospice and Palliative Medicine (AAHPM), and the Hospice and Palliative Nurses Association (HPNA) provide guidance to programs by identifying quality metrics for palliative care.5-7 For example, CAPC categorizes metrics into outcome measures, process measures, and transition plans.5, 6 Measuring What Matters (AAHPM and HPNA) is a consensus recommendation for a portfolio of ten performance measures to guide hospice and palliative medicine programs for assessment and improvement.5, 6 In addition, AAHPM developed an implementation guide for patient-reported outcome performance measures for quality improvement and regulatory reporting efforts.7 These quality measures were designed for hospitalized (>24 h) or hospice patients and are not specific to the ED setting. Therefore, there is little guidance on how to measure quality improvements specifically related to ED palliative care interventions. This gap was explored by a committee on convened by the Palliative Medicine Section of the American College of Emergency Physicians, in 2017, to develop a consensus on best practices for ED palliative care.8 We present the work of this committee to articulate a set of relevant ED palliative care quality measures using an expert consensus approach (Table 1). –No. using surprise question: “Would you be surprised if the patient died in the next year (or during this admission)?” screening positive or “no surprise,” deaths within 30 days –No. using surprise question: “Would you be surprised if the patient died in the next year (or during this admission)?” screening positive or “no surprise,” deaths within 6 months –Percentage or No. of patients measured with __ score (% or No.) for frailty or functional decline (for example CFS, PPS) –Percentage or No. of patients measured with __ score (% or No.) for total disease burden/comorbidities/mortality risk (for example, using CCI) –Percentage or No. of patients measured for spiritual distress or loneliness –Percentage of patients with pain assessment documented (total vs. those screening positive) –Percentage of patients prescribed pain medications or medications for other distressing symptoms (nausea, vomiting, dyspnea, etc.) in ED –Time from X symptom/pain assessment to delivery of medication for symptom/pain relief –Percentage or No. of patients offered spiritual support in ED (spiritual support offered for patients with deaths within 24 h of ED arrival) –Percentage of family members offered spiritual support after ED patient death –Percentage of family members offered grief support after ED patient death –Percentage of family members screened for caregiver strain –Percentage with ED ventilator use; pressor use in patient screened positive for palliative care needs –Percentage of in-hospital ventilator use, pressor support, artificial nutrition, dialysis, etc., use in patient screened positive for palliative care needs in ED –No. of X intervention after palliative care consultation –No. of total deaths and/or ICU/non-ICU or floor deaths within 24, 48, or 72 h of ED admission –No. of deaths (ICU/floor) after ED palliative care consultation within 24, 48, or 72 h of ED admission –Percentage or No. of patients admitted total and/or after palliative care consultation to: –Percentage of ED and/ or in-hospital use of ventilator, pressor support, artificial nutrition, dialysis, etc., after palliative care consultation vs. all total patients receiving ventilator, pressor support, artificial nutrition, dialysis, etc. –Percentage with readmission to the hospital within 30 days (total vs. those with palliative care consultation in ED) –Percentage of repeat ED visits within 30 days (total vs. those with palliative care consultation in ED) –Percentage discharged to home and screened positive for palliative care needs –Percentage discharged to skilled nursing facility/long-term care and screened positive for palliative care needs –Percentage discharged on hospice care –No. of patients who died within 24/48/72 h of ED admission with a documented family meeting (in those with ED palliative care consultations vs. in all patients) –Percentage of patients in target population (e.g., elderly from skilled nursing facility or metastatic solid organ malignancy) with documented screening for palliative care needs –Percentage of patients with documented health proxy or decision maker in medical records (total vs. those who screened positive for palliative care needs) –Percentage of patients with do not attempt resuscitation status (total vs. those who screened positive for palliative care needs) –Percentage with documentation of advance directives/POLST/MOLST (total vs. patients in target population—such as those admitted to ICU) –No. of patients who died within 24/48/72 h of ED admission with documented health proxy or decision maker in medical records –Percentage of completion rate/use of screening tool for palliative care needs –Percentage of patients with X diagnosis who were screened –No. of transfers from a long-term care facility –No. of patients with multiple ED visits and hospitalizations in X time (total vs. those who screened positive for palliative care needs) –Time from ED arrival to completion of palliative care screening –Person completing the screening tool –Percentage or No. of patients screened positive for palliative care needs using X tool –Percentage or No. of patients with X diagnosis screened positive for palliative care needs –Percentage of X order set placed by an ED clinician in those patients who screened positive for palliative care needs –Percentage of X order sets placed by an accepting clinician in those patients who screened positive for palliative care needs –Percentage or No. of patients admitted (ICU/floor) or discharged after screened positive for palliative care needs –No. of ED referrals for palliative care consultation or No. of ED referrals for hospice service –Time from consult to response by palliative care team member or hospice agency staff –ED length of stay for patients with palliative care consult (and/or in those who screen positive for pall care needs) vs. ED length of stay for all patients, all discharged patients, all admitted patients –Hospital length of stay for patients with palliative care consultations in the ED vs. hospital length of stay for all patients –Percentage or No. of canceled palliative care consultations by admitting clinician –Percentage of patients who received pain medications within X hours of arrival to floor/ICU/palliative care unit etc. (in those who screened positive for palliative care needs or received ED palliative care consult) –Percentage of patients who received medications for distressing symptom control within X hours of arrival to floor/ICU/palliative care unit etc. –Time from ED request for palliative care/hospice consultation to final disposition –Percentage or N

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