Wednesday, July 24, 2013 Audio Conference 1:30 – 2:30 PM EST

1. ICU Screening for Unmet Palliative Care Needs Wednesday, July 24, 2013 Audio Conference 1:30 – 2:30 PM EST David E. Weissman, MD Consultant, Center to Advance Palliative Care (CAPC), New York, NY; Professor Emeritus, Medical College of Wisconsin, Milwaukee, WI dweissma@mcw.edu Judith Nelson, MD, JD Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY judith.nelson@mssm.edu

2. Learning Objectives • In this audio conference, you will learn: • Three categories of screening criteria appropriate to the ICU setting. • Four process steps in a collaborative ICU-Palliative Care process to develop criteria that meet the need of ICU patients and families. • Four process steps to develop a system whereby the screening criteria become part of daily ICU practice. • BONUS Material: Preview of 2013 CAPC National Seminar

3. IPAL-ICU Advisory Board Colleen Mulkerin, MSW, LCSW Kathleen A. Puntillo, RN, DNSc, FAAN Daniel E. Ray, MD, MS, FCCP Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN Renee D. Boss, MD Karen J. Brasel, MD, MPH David E. Weissman, MD, FACP • Judith E. Nelson, MD, JD, • Margaret L. Campbell, PhD, RN,FAAN • J. Randall Curtis, MD, MPH • Jennifer A. Frontera, MD • Michelle Gabriel, RN, MS • Dana R. Lustbader, MD, FCCM, FCCP • Anne C. Mosenthal, MD, FACS

4. The “Critical Care Express”A Non-Stop Train ED Ward ICU “ We’re doing everything”

5. “There is nothing more we can do.” Trach /Feeding Tube Dialysis / Infections Cognitive Impairment

6. Key Principles • All patients need to be screened for unmet palliative care needs • Screening is a responsibility of all ICU team members • An organized screening system may or may not be appropriate in a given unit • Collecting data to document the problems is recommended: • Clinical, satisfaction, utilization, financial data

7. What is an unmet need? • Distressing physical or psychological symptoms? • Social or spiritual concerns affecting daily life for patient or family. • Patient/family/surrogate understanding of the illness, prognostic trajectory, and treatment options. • Clearly identified goals of care. • Are treatments matched to the patient-centered goals? • Key considerations for a safe and sustainable transition from one care setting to another.

8. Key Principles • The process steps in managing unmet needs will vary from ICU to ICU... • Screening and management can occur with or without a specialist palliative care team.

9. Key Principles • There are no Best screening criteria • There are no Validated screening criteria Screening criteria work best when they meet the needs of a particular ICU; its patients, staff, and the needs of the hospital/health system.

10. Role of the Palliative Care Specialist • Promote a relationship with ICU leadership that can lead to ... • Data collection documenting problems in care • A screening system for unmet needs • Implementation steps with or without consultation • Project evaluation and QI activities

11. Screening System Pathway

12. Workgroup Members • ICU staff and leadership • Palliative care staff • Hospital staff • ICU administrator • Quality • Decision support • Staff education • Others

13. Workgroup Tasks Define project goals: The Why Determine screening criteria: The What Determine process steps for implementation: The How/When Evaluate outcomes Maintain open communication with stakeholders

14. Sample Statement of Goals * • Following Implementation of an ICU-Palliative Care Screening Pathways We Expect: • Earlier identification of patient-centered care goals • Reduced symptom burden • Improved family satisfaction with ICU communication • Reduced readmissions to ICU during index hospitalization • These should be derived from identified and agreed upon gaps in care.

15. Selecting Criteria: 4 questions • What are the major needs of patients/families? • Support for decision making • Symptom control • What are the major needs of ICU staff? • Conflict resolution • Disposition planning

16. Selecting Criteria: 4 questions • What are the unique aspects of the ICU? • Frequent LTC admits: end-stage dementia • Frequent poor prognosis neuro-trauma • Frequent lack of patient social support • What are the important institutional priorities? • Readmission reduction • Patient satisfaction • Improving ICU thru-put

17. Criteria Categories Disease Criteria • Cancer • COPD/CHF • Dementia • ESRD • Neuro-trauma • Other Utilization Criteria • ICU LOS of (x) days • LTC admit • PEG placement • RRT • Ethics consult

18. Other Criteria Surprise question Family in crisis Conflicts re: goals, CPR Lack of social support Considering LTAC referral Complex care needs pre-admission

20. Pilot and Review • Select 4-8 criteria • Gather data: 1-2 weeks • Review/revise criteria based on ... • How many patients would be identified? • Are the “right” patients identified? • What % of issues can be managed by improved internal ICU care processes? • What % of issues are best managed by specialty palliative care consultation?

21. Implementation Process Steps • Who will responsible for completing a screening assessment? • Process must be simple, fast and acceptable to screeners • What happens when criteria are met? • Discussed on rounds? Automatic consultation? • Internal ICU process steps? • Palliative care consultation? • What happens if nothing is done? • Daily evaluation? • Who is responsible?

22. Internal ICU Process Steps Examples ... • Detailed nursing symptom assessment • Early family meeting for goal setting • Family education materials (e.g. PEG, CPR) • Non-pharmacological pain treatments • Chaplain support for spiritual concerns

23. Palliative Care Consultation • If Palliative Care Consultation ... • What is the desired response time? • Who will make contact with palliative care team? • What is the expected role: one time or on-going follow-up? Order writing? Lead communication discussions? • Who should the consultant contact to discuss findings? • Review with Palliative Care Team • Assess capability to manage expected number of new consultations

24. Diagram and Walk the Process

25. What else is needed? • New documentation forms? • Screening assessment tool • Goals of care documentation form • Staff education? • Screening assessment • New internal processes (non-pharmacologic pain management techniques) • The function of the palliative care consultant

26. Before you implement ... • Think about the data needed to evaluate ... • Impact and acceptance by: ICU and Palliative Care staff • Clinical data • Satisfaction data • Utilization/Financial data • Who will collect, manage, review and report the data?

27. Time to Implement

28. Evaluation

29. The Best Performers ... • Develop screening criteria through local consensus among key stakeholders • Pay strict attention to details of pathway implementation that mesh with ICU structure and current workflow • Build in evaluation stopping points to assess and revise screening criteria and the implementation process • Recognize and attend to the common barriers of program implementation: attitudes, time, lack of trust and accountability

30. IPAL-ICU Resources Implementing ICU Screening Criteria for Unmet Palliative Care Needs: A Technical Assistance Monograph from the IPAL-ICU Project http://www.capc.org/ipal/ipal-icu/monographs-and-publications Choosing and Using Screening Criteria for Palliative Care Consultation in the ICU. Critical Care Medicine, Oct 2013 (in press)

31. CAPC 2013 National Seminar Dallas, Texas; November 7-9, 2013 Registration: Open Poster Presentations: Closes August 2 • Over 60 peer presentations • Adult and Pediatrics Program Operations/Outcomes • Health Reform: ACO, PCMH Models of Palliative Care • Clinics and Home-Based Palliative Care • Palliative Care Work within Health Systems • ED/ICU Integration • More!!

32. Plenary Presentations Palliative Care in the Mainstream: Stepping Up to the Plate (Meier) Current and Emerging Models for Delivering Palliative Care in Nursing Homes (Ersek) How Can a “Care Planning System” Improve Care? (Hammes) Integrating Pediatric Palliative Care into a Patient-Centered Medical Home (Friebert) Is Excellence in Palliative Care Mission-Critical or Nice-To-Have? (Milstein) @HOMe Support™:  The Missing Piece in Health Care Reform (Doremo)

33. 8 Intensives (1:45) • Creating Value: Measuring Non-Financial Outcomes of Palliative Care • Working Smarter, Not Harder: Improving the Process of Care Delivery • Choosing/Using Quality Metrics for Your Palliative Care Program • Promoting Generalist Palliative Care in Hospitals • ACO-Palliative Care Outpatient Models • Boot Camps • Clinic Start-Up • ED-Palliative Care Integration • Program Start Up

34. Concurrent Sessions (1:15) • Starting an ICU screening system • Leading a family meeting • Reaching out to payers • Pediatric reimbursement issues • Billing update 2013 • Nurse led palliative care programs • Teaching palliative care • Ethics and palliative care teams • Quality improvement • Strategies when your program can’t get more financial resources • Implementing a team wellness strategy • AHACircle of Life awardees • Advance care planning/POLST • Joint Commission certification • Peds community relationships • Home-based palliative care • Long term care

35. Additional CAPC Resources • CAPC National Seminar • http://www.capc.org/capc-resources/capc-seminars/dallas-2013/seminar-overview • IPAL Project: Includes IPAL-ICU, IPAL-EM, & IPAL-OP • http://www.capc.org/ipal/ • CAPC E-Learning Courses: Program Operations • https://campus.capc.org

36. 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 Icahn School of Medicine at Mount Sinai in New York City, CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious, complex illness.

37. 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 the ICU” discussion topic!