Applying palliative care principles to transform geriatric emergency care may reduce hospital admissions

Applying palliative care principles to emergency departments may reduce the number of geriatric patients admitted to intensive care units, possibly extending lives and reducing Medicare costs, according to a three-year analysis by Mount Sinai researchers set to be published in the May edition of Health Affairs, which can be found online.

"Data show that more than half of Americans ages 65 and older are seen in the emergency department in the last month of their lives, and that the number and rate of admissions to intensive care units among older adults who are seen in the ED have also increased," said Corita Grudzen, MD, the lead author of the study and former Mount Sinai Health System physician. "Our findings suggest that early palliative care inpatient consultation can improve care for older patients, decrease hospital lengths-of-stay and costs, and even extend life. The potential for this approach to improve the quality and value of geriatric emergency care warrants continued study."."

The changes in emergency care examined in this preliminary analysis were developed through Mount Sinai's Geriatric Emergency Department Innovations in Care Through Workforce, Informatics and Structural Enhancements program, also known as GEDI WISE.

Under the GEDI WISE model, which was developed by a multidisciplinary team led by Lynne D. Richardson, MD, Professor of Emergency Medicine and of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, changes in ED staff training and practice (workforce enhancements) were introduced at The Mount Sinai Hospital, including role redefinition and education in palliative care principles. As part of the training:

• ED triage nurses learned to screen patients aged 65 and older to identify those at high risk of ED revisit and hospital readmission

• ED nurse practitioners learned to identify high-risk patients suitable for and desiring palliative and hospice care, and how to expedite referrals

Screening of ED patients with the Identification of Seniors at Risk tool was instituted in October 2012. Researchers found that 59 percent of the 8,519 visitors to Mount Sinai's ED ages sixty-five and older who were screened with the tool had a score that indicated an increased risk for revisit and readmission. The five most common presenting diagnoses among this cohort were chest pain, shortness of breath, malaise and fatigue, abdominal pain, and dizziness.

Specifically, Dr. Grudzen's analysis found that using the GEDI WISE model brought about a 1.4 percent--in the ICU admission rate for ED for patients ages 65 and older at the Mount Sinai Hospital. This decrease remained significant even after changes in comorbidity and other key characteristics of ED patients in this age group were accounted for.

The absolute reduction of 1.4 percent in ICU admissions from the ED during the study period, in which there were 38,240 unique ED encounters, corresponded to a decrease of 535 ICU admissions. Assuming that these patients were admitted to the hospital, this drop in admissions would produce an estimated savings of more than $3.14 million to Medicare.

"This study shows that identifying emergency patients who would benefit from palliative care interventions may both improve the quality of care and reduce costs," said Dr. Richardson. "This could result in a better match of older adults' goals of care with the environments to which they are discharged from the ED, including decreased admissions to the ICU, and increased referrals to hospice and palliative care provided at home."