526274 research-article2014
PMJ0010.1177/0269216314526274Palliative MedicineCarroll et al.
Research Letter Palliative Medicine 2014, Vol. 28(6) 536–537 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216314526274 pmj.sagepub.com
Appropriateness of consults to an inpatient Palliative Care service To the Editor,
Introduction As a newly minted specialty, the field of Palliative Care has naturally focused on how to establish programs, grow referral bases, and optimize clinical output. There has, however, been little consideration given to what may happen if, or indeed when, these efforts to grow the field prove successful.1–3 Inpatient Palliative Care clinicians in our institution increasingly express that the service often feels overwhelmingly busy and that some consult requests are for questions that do not require consultation by specialist Palliative Care or might be best addressed by another services (e.g. consult requests for “refer to Hospice” after the decision has been made by the patient). Prospective identification of “inappropriate” consults may, therefore, allow for timely redirection of services and promote more efficient patient care. We designed a Quality Improvement (QI) project to describe the prevalence and distribution of “inappropriate” consults and to assess whether clinicians’ perceived “busyness” was associated with the frequency of “inappropriate” consults.
new consult. We defined “concordance” as agreement between the initial impression and consensus opinion and “discordance” as any disagreement between the two. Chisquare analyses were used to examine potential relationships of the selected categorical variables.
Results Among the 515 consults that occurred between January and June 2013, we obtained at least one “appropriateness” rating for 449 (87%). Among these, 390 (87%) included both pre-/post-“appropriateness” measures and 381 (85%) included “busyness” ratings. The average number of consults received each day was 5.0 (standard deviation (SD) = 2.5) and ranged from 1 to 11. Table 1 shows the frequency of ratings for “Busyness,” “Immediate Impression,” and “Consensus Opinion.” Of those consults with both the “Immediate Impression” and “Consensus Opinion” recorded, 302 (85%) were concordant, while 55 (15%) were discordant. Figure 1 displays the proportions of concordant and discordant ratings as well as the direction of disagreement of the latter. “Busyness,” reason for consult, service requesting consultation, time of day, or day of the week were not associated with consult appropriateness. There was, however, a Table 1. Frequency and percentage of busyness and consult ratings.
Methods This is an analysis of data collected during the course of a QI project performed for the Palliative Care division that serves an 800-bed, tertiary hospital in Rochester, NY, USA. Inpatient Palliative Care consultative services are provided by two teams consisting of about three to five people each, including: an attending, a nurse practitioner, and a fellow, plus one resident and/or one fourth-year medical student. Each time a consult request was received, the person receiving the request rated his or her initial impression of the consult’s “appropriateness” and their subjective degree of “busyness.” Neither “appropriateness” nor “busyness” was given any definition, leaving each rater to make his or her own determination free from systematic influence. During each week’s interdisciplinary meeting, the full team reached a “consensus opinion” about the appropriateness of each
Busyness Immediate Impression Consensus Opinion
Rating
Number of consults
Slow Somewhat Very Missing Appropriate Questionable Inappropriate Declined Missing Appropriate Questionable Inappropriate Missing
72 122 187 68 342 44 3 4 56 332 29 10 70
Downloaded from pmj.sagepub.com at Bobst Library, New York University on July 13, 2015
Percent of Total 16% 27% 42% 15% 76% 10% 0.7% 0.9% 12% 74% 6.5% 2.2% 16%
537
Carroll et al.
Figure 1. Measure of concordance and direction of discordance of “Consensus Opinion” as a function of “Initial Impression.” Data labs are absolute number of consults. App: Appropriate; Ques: Questionable; Inapp: Inappropriate.
statistically significant association between the rating of busyness and the number of consults received on the same day (p < 0.0001). These findings validate the impressions of the teams regarding their cognizance of the magnitude of their workload and also underscore that workload is unrelated to perceptions of appropriateness of consult, even when the teams are very busy.
project. We would like to especially thank Dr Robert Horowitz and Dr Timothy Quill for their input and support. The deidentified data set can be accessed by contacting the corresponding author.
Declaration of conflicting interests The authors declare that there is no conflict of interest.
Funding
Conclusion We undertook a QI project to quantify both the feeling of busyness and the appropriateness of consults as well as to look for factors that may be influencing determination of the latter. Our data lead us to conclude that inappropriate consults are both rare, accounting for fewer than one out of 30 consults, and unpredictable, being reliably identified only in retrospect. This is, to our knowledge, the first attempt to define the prevalence of inappropriate consults referred to an inpatient Palliative Care service. We hope that these data will inform the discussion about what the future may, and should ideally, hold for the field of Palliative Care and prompt further investigation into how the skill set of Palliative Care clinicians can be utilized most efficiently. Acknowledgements We would like to thank all faculty and staff of the Palliative Care division for their willing participation in, and support for, this
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1.
Matlock D. Do we really want to grow the field of palliative medicine? J Palliat Med 2013; 16: 998–999. 2. Von Gunten CF. Secondary and tertiary palliative care in US hospitals. JAMA 2002; 287: 875–881. 3 . Quill TE and Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013; 368: 1173–1175. Thomas M Carroll, Susan Ladwig, Robert Gramling, Laura Hogan, Darlene Harmor and Marcia Buckley University of Rochester Medical Center, Rochester, NY, USA Corresponding author: Thomas M Carroll, University of Rochester Medical Center, Box GMD, 601 Elmwood Ave., Rochester, NY 14642, USA. Email: [email protected]
Downloaded from pmj.sagepub.com at Bobst Library, New York University on July 13, 2015
PMJ0010.1177/0269216314526274Palliative MedicineCarroll et al.
Research Letter Palliative Medicine 2014, Vol. 28(6) 536–537 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216314526274 pmj.sagepub.com
Appropriateness of consults to an inpatient Palliative Care service To the Editor,
Introduction As a newly minted specialty, the field of Palliative Care has naturally focused on how to establish programs, grow referral bases, and optimize clinical output. There has, however, been little consideration given to what may happen if, or indeed when, these efforts to grow the field prove successful.1–3 Inpatient Palliative Care clinicians in our institution increasingly express that the service often feels overwhelmingly busy and that some consult requests are for questions that do not require consultation by specialist Palliative Care or might be best addressed by another services (e.g. consult requests for “refer to Hospice” after the decision has been made by the patient). Prospective identification of “inappropriate” consults may, therefore, allow for timely redirection of services and promote more efficient patient care. We designed a Quality Improvement (QI) project to describe the prevalence and distribution of “inappropriate” consults and to assess whether clinicians’ perceived “busyness” was associated with the frequency of “inappropriate” consults.
new consult. We defined “concordance” as agreement between the initial impression and consensus opinion and “discordance” as any disagreement between the two. Chisquare analyses were used to examine potential relationships of the selected categorical variables.
Results Among the 515 consults that occurred between January and June 2013, we obtained at least one “appropriateness” rating for 449 (87%). Among these, 390 (87%) included both pre-/post-“appropriateness” measures and 381 (85%) included “busyness” ratings. The average number of consults received each day was 5.0 (standard deviation (SD) = 2.5) and ranged from 1 to 11. Table 1 shows the frequency of ratings for “Busyness,” “Immediate Impression,” and “Consensus Opinion.” Of those consults with both the “Immediate Impression” and “Consensus Opinion” recorded, 302 (85%) were concordant, while 55 (15%) were discordant. Figure 1 displays the proportions of concordant and discordant ratings as well as the direction of disagreement of the latter. “Busyness,” reason for consult, service requesting consultation, time of day, or day of the week were not associated with consult appropriateness. There was, however, a Table 1. Frequency and percentage of busyness and consult ratings.
Methods This is an analysis of data collected during the course of a QI project performed for the Palliative Care division that serves an 800-bed, tertiary hospital in Rochester, NY, USA. Inpatient Palliative Care consultative services are provided by two teams consisting of about three to five people each, including: an attending, a nurse practitioner, and a fellow, plus one resident and/or one fourth-year medical student. Each time a consult request was received, the person receiving the request rated his or her initial impression of the consult’s “appropriateness” and their subjective degree of “busyness.” Neither “appropriateness” nor “busyness” was given any definition, leaving each rater to make his or her own determination free from systematic influence. During each week’s interdisciplinary meeting, the full team reached a “consensus opinion” about the appropriateness of each
Busyness Immediate Impression Consensus Opinion
Rating
Number of consults
Slow Somewhat Very Missing Appropriate Questionable Inappropriate Declined Missing Appropriate Questionable Inappropriate Missing
72 122 187 68 342 44 3 4 56 332 29 10 70
Downloaded from pmj.sagepub.com at Bobst Library, New York University on July 13, 2015
Percent of Total 16% 27% 42% 15% 76% 10% 0.7% 0.9% 12% 74% 6.5% 2.2% 16%
537
Carroll et al.
Figure 1. Measure of concordance and direction of discordance of “Consensus Opinion” as a function of “Initial Impression.” Data labs are absolute number of consults. App: Appropriate; Ques: Questionable; Inapp: Inappropriate.
statistically significant association between the rating of busyness and the number of consults received on the same day (p < 0.0001). These findings validate the impressions of the teams regarding their cognizance of the magnitude of their workload and also underscore that workload is unrelated to perceptions of appropriateness of consult, even when the teams are very busy.
project. We would like to especially thank Dr Robert Horowitz and Dr Timothy Quill for their input and support. The deidentified data set can be accessed by contacting the corresponding author.
Declaration of conflicting interests The authors declare that there is no conflict of interest.
Funding
Conclusion We undertook a QI project to quantify both the feeling of busyness and the appropriateness of consults as well as to look for factors that may be influencing determination of the latter. Our data lead us to conclude that inappropriate consults are both rare, accounting for fewer than one out of 30 consults, and unpredictable, being reliably identified only in retrospect. This is, to our knowledge, the first attempt to define the prevalence of inappropriate consults referred to an inpatient Palliative Care service. We hope that these data will inform the discussion about what the future may, and should ideally, hold for the field of Palliative Care and prompt further investigation into how the skill set of Palliative Care clinicians can be utilized most efficiently. Acknowledgements We would like to thank all faculty and staff of the Palliative Care division for their willing participation in, and support for, this
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1.
Matlock D. Do we really want to grow the field of palliative medicine? J Palliat Med 2013; 16: 998–999. 2. Von Gunten CF. Secondary and tertiary palliative care in US hospitals. JAMA 2002; 287: 875–881. 3 . Quill TE and Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013; 368: 1173–1175. Thomas M Carroll, Susan Ladwig, Robert Gramling, Laura Hogan, Darlene Harmor and Marcia Buckley University of Rochester Medical Center, Rochester, NY, USA Corresponding author: Thomas M Carroll, University of Rochester Medical Center, Box GMD, 601 Elmwood Ave., Rochester, NY 14642, USA. Email: [email protected]
Downloaded from pmj.sagepub.com at Bobst Library, New York University on July 13, 2015
