Department of Palliative Medicine, Scripps Health, San Diego, California, USA.
J Palliat Med. 2023 May;26(5):646-652. doi: 10.1089/jpm.2022.0245. Epub 2022 Nov 11.
Emergency department (ED)-initiated palliative care consultation facilitates goal-concordant care while stewarding resource utilization. Delivery models are being piloted without clear operational and financial sustainability. To demonstrate that embedding a palliative care consultation service in the ED is clinically meaningful, operationally viable, and yields significant return on investment (ROI). Quasi-experimental study from August 17, 2020 to August 17, 2021. We established an ED-embedded palliative care consultation service at a 350-bed urban community hospital with 45,000 annual ED visits. A singe palliative care provider stationed in the main ED workstation area from 11 am to 7 pm daily. Matched analysis compared ED-embedded consultations against Floor and intensive care unit (ICU) consultations originating from usual practice. ED consultations increased 10x, without cannibalization, to become the hospital's primary source of palliative care consultations. Clinical outcomes were meaningful, with 49% changing code status, 11% admitting to lower level of care, 11% avoiding hospitalization, 17% newly referred to hospice, and 21% newly referred to palliative care clinic. ED length of stay (LOS) did not lengthen, and ED staff strongly agreed that the service was valuable and unobtrusive. Compared with Floor, ED consultations had 8.1 days shorter hospital LOS (3.0 vs. 11.1 days, < 0.01) with $5,974 lower median direct costs for index hospitalization ($6,211 vs. $12,005, < 0.01). Compared with ICU, ED consultations had 4.2 days shorter hospital LOS (3.0 vs. 7.2 days, < 0.01) with $9,332 lower median direct costs for index hospitalization ($14,093 vs. $23,425, < 0.01). ROI was 6.7x net of foregone revenue and labor expenses. This ED-embedded palliative care consultation service was clinically meaningful, operationally viable, and delivered a 6.7x ROI. ED-palliative partnerships present a quadruple aim opportunity to improve care for seriously ill patients.
急诊科发起的姑息治疗咨询有助于实现目标一致的护理，同时管理资源利用。正在试点各种交付模式，但缺乏明确的运营和财务可持续性。为了证明在急诊科嵌入姑息治疗咨询服务具有临床意义、运营可行，并带来显著的投资回报 (ROI)。2020 年 8 月 17 日至 2021 年 8 月 17 日的准实验研究。我们在一家拥有 350 张床位的城市社区医院建立了一个急诊科嵌入式姑息治疗咨询服务，该医院每年有 45000 次急诊科就诊。一名姑息治疗提供者每天上午 11 点至下午 7 点驻扎在主急诊科工作站区域。匹配分析比较了急诊科嵌入式咨询与常规实践中来自 Floor 和重症监护病房 (ICU) 的咨询。急诊科咨询增加了 10 倍，没有蚕食，成为医院主要的姑息治疗咨询来源。临床结果有意义，49%改变了治疗方案，11%转入较低级别的护理，11%避免住院，17%新转介到临终关怀，21%新转介到姑息治疗诊所。急诊科住院时间 (LOS) 没有延长，急诊科工作人员强烈认为该服务有价值且不显眼。与 Floor 相比，急诊科咨询的住院 LOS 缩短了 8.1 天（3.0 天对 11.1 天，<0.01），索引住院的中位数直接费用降低了 5974 美元（6211 美元对 12005 美元，<0.01）。与 ICU 相比，急诊科咨询的住院 LOS 缩短了 4.2 天（3.0 天对 7.2 天，<0.01），索引住院的中位数直接费用降低了 9332 美元（14093 美元对 23425 美元，<0.01）。ROI 为净放弃收入和劳动力费用的 6.7 倍。这个急诊科嵌入式姑息治疗咨询服务具有临床意义、运营可行，并带来了 6.7 倍的投资回报。急诊科-姑息治疗伙伴关系提供了一个四重目标的机会，可以改善重病患者的护理。
