Consults in the Emergency Department: … It’s Not the Same

1. Consults in the Emergency Department: …It’s Not the Same The IPAL-EM Project is supported by the Center to Advance Palliative Care and the Olive Branch Fund Thursday, October 18, 2012 Audio Conference 1:30 – 2:30 PM EDT • Tammie E. Quest, MDDirector, IPAL-EM Project • Director, Emory Palliative Care Center • Emory University School of Medicine • Atlanta, GA • E-mail: tquest@emory.edu  2012 Center to Advance Palliative Care

2. Disclosures • No industry relationships to disclose • Tammie Quest, MD – consultant to CAPC for the IPAL-EM project

3. Learning Objectives Describe key elements of ED practice/culture that palliative care consultants need to be aware of. Review 10 steps of effective palliative care consultations in the ED. List three methods for improving palliative care–ED relationships.

4. Clinical Case • 62 yo woman with COPD, CHF, Stage IV CKD presents to the ED with dyspnea. The patient states she does not want LST, she does not want to go to the ICU and she is saying “she’s tired.” The husband is insisting on ICU and aggressive therapy, the daughters want to honor the patient’s wishes. • The ED calls the palliative care consultant: • “Can you help me with this family, they are all screaming at each other and I don’t know what to do”. • “Her sat is 85% and she is short of breath. I need to decide if I am going to intubate her.” What do you want to know, how do you respond?

5. ED–Palliative Care Collaboration • ED staff members recognize that asking a palliative care clinician to come to the ED can help in . . . • Attempting to rapidly achieve consensus about goals of care • Assisting with challenging symptom management problems • Developing creative disposition plans • Freeing up the ED staff to attend to other patients

6. ED–Palliative Care Collaboration • Focus on throughput-output phase • Palliative care clinicians recognize that ED clinicians have operational needs to keep the flow of patients moving as expeditiously as possible.

7. Consultations in theEmergency Department • Core concept of “input-throughput-output” • Consultants effect throughput and output phases. • 20–40% of ED patients required a consultation to manage disposition. • Up to 68% of patients consulted may be admitted. • ED consultation time targets: 30–45 minutes based on the nature of the problem Vosk A. Ann Emerg Med. 1998 Nov;32(5):574–77 Hexter DA. ACEP: Foresight. 2002 Feb;53

8. Understanding Patient Flow in theEmergency DepartmentInput-Throughput-Output

9. Categories of ED Consults Consultation for admission (most common) Consultation for opinion only, where the patient can be discharged but an opinion is needed for specific investigations or outpatient arrangements Consultation for treatment or special procedure, where a consultant assists with management of a specific problem Consultation for “transfer of care,” where a consultant takes over care of the patient Consultation for outpatient referral of patient sent for outpatient follow-up Lee RS et al. Emerg Med J. 2008 Jan;25(1):4–9

10. Common Reasons for Delaysin ED Consults • Delays in consultation response times • inconvenience • competing priorities • lack of financial incentives • shortage of physicians • failure to enforce rules regarding policies on consultants Weston K. Clinical Initiatives Center/The Advisory Board Company: ED Watch. 2000;4

11. What Is a Successful Consultation ? You have met one or more of the following needs of your referring clinician: • Answered a question • Provided leadership in decision making • Improved symptom control • Provided knowledge about prognosis • Assisted in disposition planning • Provided emotional support • Improved clinician efficiency

12. Principles of Consultation EtiquetteAdapted from: Goldman L, Lee T, Rudd P. Arch Intern Med. 1983 Sep;143(9):1753–55 1. Determine the question 2. Establish urgency 3. Gather additional data 4. Brevity 5. Specificity 6. Plan ahead 7. Honor turf 8. Teach with tact 9. Personal contact 10. Provide follow-up

13. 1. Determine the Question Ask the ED clinician how you can best help him/her; what question(s) you can answer? • Symptom control issue? • How to proceed clinically based on goals? • Acceptability/indication for an urgent/emergent intervention (e.g., should we intubate, place central line, initiate emergent dialysis, etc.) • Disposition issue?

14. 1. Determine the Question (cont.’d) • Define the action steps needed by the consultant: • Leadership for disposition planning? • Order writing for symptom control? • Leadership for sensitive communication with patient/family?

15. 2. Establish Urgency Requests for consultation can be divided into two levels of urgency based on the request from the ED clinician: • Emergent • Respiratory failure, decision needed whether to intubate or not • Pain out of control • Urgent • Patient is medically stable; question of hospice appropriateness and direct hospice referral from ED

16. 2. Establish Urgency (cont.’d) • Who will arrive and when • Determine which palliative care team member can best meet the request. • Be honest about your availability and who will come. • “I feel like our social worker could get started; she can be there in 20 minutes. Is that soon enough?” • If unable to meet the requested need, offer alternative options to assist the ED staff.

17. 3. Gather Additional Data • Consultants are most effective when they are willing to create their own impressions from all available data. • This likely will require more input than the ED already has from . . . • Family and primary physician • Medical record review • Pharmacy records

18. 4. Brevity • Much of the consultant’s helpfulness is in the 2- to 4-minute verbal review of recommendations immediately after the consult. • It is very helpful to let the ED provider know you will supply documentation to assist in his/her dictation/electronic report. • The disposition plan and follow-up plan should be explicit.

19. 5. Specificity • Make very specific recommendations: • Pain: Given prior history of MS Contin 180mg po bid/morphine 30mg 4 times daily and pain is still moderate to severe, recommend 6mg/hr IV/sq morphine with 2mg IV/sq q 10 minutes prn breakthrough pain. • Nausea: Haldol 1mg IV/sq now and q 2 hours up to 4 doses based on lack of response to phenergan. • Anxiety: lorazepam 1mg IV/sq q 6 hours. • Spiritual: Chaplain called to provide Sacrament of the Sick. • Psychosocial: Will need discharge planning as soon as possible; social worker Mary Smith has been contacted to see patient.

20. 5. Specificity (cont.’d) • Make feasible recommendations. • The ED may have policies/protocols for drugs/treatments that differ from those in the inpatient setting. • Before making definitive recommendations, check with ED staff to ensure that your recommendations are feasible without disrupting normal ED operating procedures.

21. 6. Plan Ahead • Be prepared to arrange the follow-up. • As the palliative care expert, you are in the best position to help both the patient/family and the referring clinician “look ahead” to plan for expected problems and who may help. • This is especially important for patients who are not admitted to the hospital but return home or to another care site. • Detail the future problems you anticipate and how to manage these. • Physical and emotional symptoms • Drug/treatment side effects • Family concerns

22. 7. Honor Turf • Appreciate the complexity. “I know that things are very busy here so I want to establish how I can best help.” • Ask what is needed explicitly. Leadership for disposition planning? Order writing for symptom control? Leadership for sensitive communication with patient/family? • Anticipate shift changes. Recognize that the ED is an environment of shift changes. New staff members come every 8–12 hours and may need help understanding the case, context and complexity.

23. 8. Teach with Tact • Every consult is a teaching opportunity; avoid judgment. • Make 1–2 teaching points in a case. • “Sometimes what we find works best is changing the opioid to get pain control. These cases are difficult.” • Place a Fast Fact (www.eperc.mcw.edu) on the chart. • “I have left some quick guides that I use in my practice for symptoms that you might find helpful.” • If requested, send a key reference article to the ED staff following the consultation. • “I can email you something about management of malignant bowel obstruction if you would find that helpful. The topic can be complex.”

24. 9. Personal Contact Find the ED clinician who called you, but understand that he/she may have signed out to shift work. Referring clinicians want to be “kept in the loop” in a timely manner. Any discussion regarding disposition should be discussed with the clinician before the family. When in doubt as to the referring clinician’s actions/plans, ASK.

25. 10. Provide Follow-up • Offer to contact the admitting team/outpatient providers and review your consultation recommendations. • Renegotiate palliative care involvement with the admitting team. • Provide the palliative care physician with a copy of your EMR/dictation and call the palliative care physician from the ED with any major changes in care. • ED clinicians will appreciate follow-up on shared cases. It is comforting to hear there has been continuity of care.

26. Bringing it all together…

27. Enhancing theED–Palliative Care Relationship • To many palliative care clinicians, the ED can seem intimidating due to the rapid pace and seriousness of clinical problems. • To better learn about ED culture and practice, palliative care clinicians can: • spend a half-day in the ED shadowing ED staff. • review ED symptom management policies/protocols. • gather with key ED staff for a one-hour meeting to learn their common needs around care of palliative care patients. • assist ED staff to develop or facilitate ED debriefings following death or troubling encounter.

28. Enhancing theED–Palliative Care Relationship (cont.’d) • Invite ED staff to make rounds with the palliative care team. • Develop collaborative protocols for identification of potential unmet needs of patients typically referred for palliative care services. • Provide an in-service on community hospice resources. • Provide a pocket card with palliative care team members’ contact information.

29. Summary • Understanding the role of the consultant in the input-throughput-output model is key to success. • Understanding the principles of consultation etiquette will enhance the ability of palliative care teams to improve patient care in the emergency department and better meet the needs of ED staff.

30. References Cohn SL. The role of the medical consultant. Med Clin North Am. 2003 Jan;87(1):1–6. Cortazzo JM, Guertler AT, Rice MM. Consultation and referral patterns from a teaching hospital emergency department. Am J Emerg Med. 1993 Sep;11(5):456–59. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983 Sep;143(9):1753–55. Hexter DA. Working with consultants. ACEP: Foresight. 2002 Feb;53. Lee RS, Woods R, Bullard M, Holroyd BR, Rowe BH. Consultations in the emergency department: a systematic review of the literature. Emerg Med J. 2008 Jan;25(1):4–9. Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st- century consultant. Arch Int Med. 2007 Feb 12;167(3):271–75. Vosk A. Response of consultants to the emergency department: a preliminary report. Ann Emerg Med. 1998 Nov;32(5):574–77. Weissman DE. Consultation in palliative medicine. Arch Intern Med. 1997 Apr 14;157(7):733–37. Weston K. Cause for concern: ensuring adequate and timely on-call physician coverage in the emergency department. Clinical Initiatives Center/ The Advisory Board Company: ED Watch. 2000;4.

31. Question & Answer Period • Thank you for joining us today! ABOUT CAPC The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. Located at Mount Sinai School of Medicine, CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious, complex illness.

32. Continue the Discussion on CAPCconnectTM Forum! At the conclusion of this audio conference, we welcome you to continue the discussion with your peers and faculty on CAPCconnectTM Forum! Go to: http://www.capc.org/forums to post your message and comments within the “Palliative Care and Emergency Medicine” discussion topic!