Palliative Pulse - March 2023

Clinical Pearl

Vignette: One of the patients that you just received in signout is an 86-year-old female with a history of prior strokes, Type II DM, advanced dementia (A&O*0 at baseline) who had been brought in for increasing agitation. Just prior to you coming on, she had gotten out of bed and fell. Verbal attempts at redirecting her and getting her back in bed for an assessment were unsuccessful. She was administered Haldol 2mg IV and this facilitated her trauma imaging. Normal Head CT but Pelvis XR showed femoral neck fracture. You assess the patient after you got signout and notice that she is unable to answer your questions about her pain. So, you wonder, "How does one assess pain in a cognitively impaired patient"?

Assessing Pain on a Non-Verbal Patient:

• Non-verbal clinical signs that raise concern for pain include¹:
  • Facial grimace
  • Tachycardia
  • Agitation
  • Hypertension
  • Diaphoresis
  • Tachypnea
  • Decreased Appetite
• Pain rating scales that have been developed for similar clinical scenarios*:
  • Abbey Pain Scale
  • Doloplus-2 Scale
  • Pain Assessment in Advanced Dementia

* There remains limited evidence with pain scales

Education/Training Resources:

• Education in Palliative & End-of-Life Care Program (EPEC):
  • Likely Fall 2023 In-person Conference
  • Online Curricula
• Integrating Palliative Care Practices in the Emergency Department (IPAL-EM)
• Palliative Care Network of Wisconsin:
  • Fast Facts & Free Curricula
• Vital Talk
  • Best-practice communication methodologies and tools
• Prodigy EMS:
  • offering a free 2-hour palliative skills course to all EMS clinicians (also CAPCE credit eligible)
  • covers EMS management of patients during end-of-life scenarios and communication with patients and families
  • Prodigy EMS

ED Palliative Program Highlight

Site/Institutions: Rutgers New Jersey Medical School, Newark, NJ, 90K ED visits/year, Palliative care team: 2 ANPs 1 SW 1 Counselor palliative clinicians.

Initiative Model: 0.2 FTE Palliative care clinician consults 1 day/ week

Funding: 100% funded by the Department of Emergency Medicine.

Billing: Direct billing using codes Z51.5 as primary dx, and the consult set 99251-99255. For advanced care planning to optimize RVU with ACP services 99497 First 30 minutes (minimum of 16 minutes) and 99498 add-on an additional 30 minutes.

Results: Wrote hospice policy, inpatient/comfort hospice order set, ED comfort set, hospice committee

Next Steps: Increased FTE 0.5 for ED-PC physician and funding to be done by the hospital.

Contact: Rebecca Goett, MD

Research Article of the Month

Wang DH, Heidt R. Emergency Department Embedded Palliative Care Service Creates Value for Health Systems. J Palliat Med. 2022 Nov 11. doi: 10.1089/jpm.2022.0245. Epub ahead of print. PMID: 36367980.

What the authors did²:

• From August 2020 to August 2021, an ED-embedded Palliative Care provider was stationed in the ED workstation area 11a - 7p daily.
• Matched analysis compared consults from ED vs from the floor & ICU.
• ED became the hospital's primary source of PC consults w/ clinically meaningful outcomes - eg. 49% changed code status, 11% admitted to lower level of care. Compared with Floor & ICU consults, ED consults were associated w/ decreased hospital LOS and median direct costs compared with patients.

Why it matters^2: 

• There's increasing awareness of the benefits of early PC involvement, but the results of this single-center quasi-experimental pragmatic study makes an argument for a collaborative model in which a PC provider is embedded in the ED.

Announcements

Meet the New Section leadership team:

• Chair/Councilor: Dr. Rebecca Goett
• Vice Chair/Chair Elect: Dr. Justin Brooten
• Secretary/Newsletter Editor: Dr. Temitope Gafaar
• EMRA Representative: Scott Gay

Out & About:
Pictures from Palliative Care Section at ACEP 2022 Scientific Assembly:

Upcoming Events

AAHPM

• Lecture:
  • Upstreaming Palliative Care: Emergency Department Opportunities (TH120A).
  • Thursday, March 23, 2023, 2:30 PM – 3:00 PM
• Poster:
  • Embedding Palliative Care Clinicians into the ED: A Case Study
• Emergency Medicine Special Interest Group (SIG) meeting:
  • March 24, from 5pm-6pm EST.
  • Following the meeting the group will have drinks/snacks/fellowship at a nearby location (TBA)
  • Contact: Paul L. DeSandre, DO, FAAHPM

SAEM:

• Lecture:
  • Pearls and Pitfalls of Rapid Goals of Care Discussions in the Emergency Department (Palliative Medicine Interest Group Sponsored)
    • Friday May 19, 2023, 10:30 AM-10:50 AM (All times are CDT)
    • Lone Star Ballroom H: Level Three (Room assignments subject to change)
• Palliative Care Interest Group Meeting:
  • • Wednesday, May 17, 2023, 1:00 PM - 1:50 PM.
    • Meeting room location (TBA) and can be found on the onsite meeting app.

Upcoming Emergency Medicine-Palliative Care Events 2023: Are you presenting too? Please let us know!

Leaders in Transition

Hospice & Palliative Medicine Fellowship bound EM residents:

Erica Lash MD, Assistant Professor of Emergency Medicine, and Emergency Medicine Physician

• Residency: Emergency Medicine, Alpert School of Medicine of Brown University
• Fellowship 2023-2024: Hospice and Palliative Care at the University of Vermont Medical Center

Jessica Tu MD

• Residency: Rutgers New Jersey Medical School, Newark, NJ
• Fellowship 2023-2024: Hospice and Palliative Care at the Montefiore Medical Center, NY, NY

James Liebow MD

• Residency: Rutgers New Jersey Medical School, Newark, NJ
• Fellowship 2023-2024: Hospice and Palliative Care at the University of Rochester School of Medicine and Dentistry, Rochester, NY

Congratulations! Are you a current/new/graduated HPM fellow? Please let us know!

References

1. Fast Fact #126. Originally edited by David E Weissman MD, published in November 2004. Palliative Care Network of Wisconsin; revised July 2015.
2. Wang DH, Heidt R. Emergency Department Embedded Palliative Care Service Creates Value for Health Systems. J Palliat Med. 2022 Nov 11. doi: 10.1089/jpm.2022.0245. Epub ahead of print. PMID: 36367980.