Improving Care Systems
10.1377/hlthaff.2014.0790 HEALTH AFFAIRS 34, NO. 5 (2015): 788–795 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Corita Grudzen (corita [email protected]) is an associate professor of emergency medicine and population health at NYU Langone Medical Center and Bellevue Hospital, both in New York City. Lynne D. Richardson is a professor of emergency medicine and of population health science and policy at the Icahn School of Medicine at Mount Sinai, in New York City. Kevin M. Baumlin is a professor of emergency medicine at the Icahn School of Medicine at Mount Sinai. Gary Winkel is a research professor of oncology at the Icahn School of Medicine at Mount Sinai. Carine Davila is a medical student at the Icahn School of Medicine at Mount Sinai. Kristen Ng is a medical student at the Icahn School of Medicine at Mount Sinai. Ula Hwang is an associate professor of emergency medicine and geriatrics at the Icahn School of Medicine at Mount Sinai. The GEDI WISE investigators are identified at the end of the article.
788
By Corita Grudzen, Lynne D. Richardson, Kevin M. Baumlin, Gary Winkel, Carine Davila, Kristen Ng, Ula Hwang, and the GEDI WISE investigators
AG I NG
&
H E A LT H
Redesigned Geriatric Emergency Care May Have Helped Reduce Admissions Of Older Adults To Intensive Care Units Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City’s Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. ABSTRACT
H
alf of Americans ages sixty-five and older are seen in the emergency department (ED) in the last month of life, and threequarters visit the ED in the six months before their death.1 Despite these numbers, the intensity of medical care has not been realigned to better reflect the needs or goals of older adults with serious, life-limiting illnesses. Preliminary data suggest that early palliative
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care inpatient consultation can improve care, decrease hospital lengths-of-stay and costs, and even extend life.2–6 Palliative care teams are now present in over two-thirds of US hospitals and in 98 percent of National Cancer Institute–designated cancer centers.7 However, consultation by palliative care teams is available only Monday through Friday during regular business hours, and palliative care teams are not routinely available to
come to the ED when a patient is in crisis. Meanwhile, the available literature indicates that the number and rate of admissions to the intensive care unit (ICU) by emergency providers have been increasing, especially among older adults.8 The ED presents a key decision point at which providers set the subsequent care trajectory, including whether an older adult is hospitalized and in which setting. Emergency physicians can thus play an integral role in transforming care for older adults.9 A recent study of older adults with serious illnesses found that more than 75 percent of them had thought about end-of-life care and that only 12 percent wanted lifeprolonging care.10 Real-time identification of ED patients who would benefit from palliative care interventions, such as matching goals of care to treatments, may both improve the quality of care and reduce costs. This could result in better concordance of older adults’ goals of care with the environment 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. Programs to better integrate palliative care into emergency medicine exist.11 However, little research has been conducted to study their impact. In addition, until recently there has not been a validated ED screening tool for the rapid identification of older adults with a high likelihood of ED revisit and readmission, who therefore might be appropriate candidates for palliative care. Older adults presenting to the ED have substantial palliative care needs.12 At the same time, there are many barriers to integrating palliative care into emergency medicine, including knowledge deficits among emergency providers, time constraints, and infrequent advance care planning in older adults.13 In response, physician leaders from the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai in New York City created a multidisciplinary process improvement team to improve the care of frail older adults through the integration of fundamental palliative care principles into the emergency care provided to those with serious illnesses. The objective of the palliative care innovation was to identify older adults presenting to the ED with a serious life-limiting illness who would benefit from further clarification of their goals of care, as well as early referral to palliative and hospice care. This article describes the evolution of palliative care interventions in the Mount Sinai Medical Center ED, from the creation of the process improvement team in July 2011 through the
launch of a new model of care for older adults in October 2012. The overarching objective of this model is to transform emergency care for older adults to improve quality of care, improve health, and decrease costs. The model is named GEDI WISE, for Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements. Palliative care interventions are an important component of the model. However, more broadly, GEDI WISE uses ED-based care coordination, transitional care management, evidence-based geriatric clinical protocols, informatics support for patient monitoring and clinical decision making, and changes to the physical environment to improve patient safety and satisfaction for older adults. GEDI WISE is modeled after the geriatric ED paradigm.14 This article focuses on the palliative care innovations in the Mount Sinai Medical Center ED that were implemented in the course of the GEDI WISE model’s development and launch. It describes the innovations’ impact on associated changes to the ICU admission rate for older adults presenting to the ED. The GEDI WISE model was developed specifically for use in the ED. However, its innovative features were integrated with features of existing inpatient and outpatient programs.
Transforming Care For Older Adults Getting Started In May 2011 the Mount Sinai Medical Center adopted an integrated electronic medical record (EMR) system to be used across ambulatory, ED, and inpatient units. This was a change external to the project of transforming emergency care for older adults. Nonetheless, it allowed the creation of EMR-enabled geriatric screens that providers throughout the health care system could view. As explained above, physician leaders from the Department of Emergency Medicine created a process improvement team in 2011 to improve the care of frail older adults in the ED. The team included leaders from the nursing, social work, volunteer services, and information technology groups. Its first act was to create a volunteer program designed to assist and engage older adults throughout the ED.15 While the process improvement team was developing new ED staff procedures, including the screening and follow-up processes that are the focus of this article, enhancements to the physical environment transformed a portion of the adult ED into a geriatric ED space that would maximize safety for older adults.14,16 Because the geriatric ED is not large enough to accommodate all patients ages sixty-five and older, only May 2 015
34:5
Health Affa irs
789
Improving Care Systems older adults who are well enough to ambulate on their own and who know their own names are triaged to that area. These and other early changes in geriatric ED care spearheaded by the process improvement team, in concert with the opening of Mount Sinai Medical Center’s inpatient palliative care unit in June 2011, helped fuel staff enthusiasm for the geriatric ED innovations yet to come. Innovation Grant Meanwhile, health services researchers in the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai who focused on geriatrics and palliative care had identified the initial round of awards from the Center for Medicare and Medicaid Innovation as an opportunity to fund a rapid expansion of the existing geriatric ED programs and evaluate their impact on improving the health of patients with high health care needs, improving their care, and reducing its cost. As Mount Sinai Medical Center researchers worked on a grant application, they decided to invite leaders at two other medical centers to join them. The two centers—St. Joseph’s Regional Medical Center, in Patterson, New Jersey, and Northwestern Memorial Hospital, in Chicago, Illinois—were at different stages in the development of their geriatric ED programs. With Mount Sinai Medical Center serving as the coordinating center and primary applicant, physician leaders from the Departments of Emergency Medicine at the three medical centers applied for and received a Health Care Innovation Award to implement GEDI WISE. During the implementation process there would be commonalities across the three sites, including screening during triage to identify patients at risk for high use of health care. However, each of the three medical centers would implement protocols tailored to local needs. Geriatric Screening Tool Starting in October 2012, the existing ED workforce at the Mount Sinai Medical Center was retooled to administer a validated geriatric screening tool, the Identification of Seniors at Risk (ISAR).17–19 Training in the use of this tool is now required for all triage nurses at Mount Sinai. ISAR scores range from 0 to 6, with a higher score indicating an increased risk of future hospital use. When a cutoff score of 2 or more is used, the overall sensitivity and specificity of the tool to predict future hospital use are 73 percent and 51 percent, respectively.20 Patients who are critically ill or unable to answer questions when they present to the ED are not screened. Also in October 2012, two GEDI WISE nurse practitioners were hired to perform more detailed assessments of older adults who had a score of 2 or higher on the Identification of Se79 0
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niors at Risk tool. Patients who may benefit from advance care planning or referral to palliative or hospice care are identified based on diseasespecific criteria that indicate a life expectancy of six months or less (for example, the presence of a metastatic solid tumor). The GEDI WISE nurse practitioners review notes and action plans and refer patients to ED social workers, who can arrange more intensive home or other outpatient care and support as needed. The ED team may also consult with patients’ primary care providers to determine which older adults meet hospice criteria and are sufficiently stable to go home. The team can make referrals for outpatient hospice care. Workforce Enhancements A set of workforce enhancements was also introduced, including new protocols for emergency physicians, physician assistants, registered nurses, pharmacists, and social workers. In addition, there were regular mandatory training sessions on new clinical roles, newly available resources (for example, hospice referral), screening tools (such as ISAR), and newly developed work algorithms and clinical protocols. To educate staff members, educational programs that focused on palliative care and were discipline appropriate were made available free of charge to emergency physicians, physician assistants, advance practice nurses, social workers, and pharmacists. The programs included a modified curriculum from the Education in Palliative and End-of-Life Care for Emergency Medicine program for physicians, nurse practitioners, and physician assistants;21 a two-day communication skills training program for select faculty members called Geritalk;22 an advance care planning facilitator course called Respecting Choices that was required for the GEDI WISE nurse practitioners and ED social workers; and geriatric pharmacy certification for the pharmacists. Exhibit 1 locates the innovations described above on a timeline.
Study Data And Methods Hospital administrative data were used to track monthly palliative care consultations initiated by emergency providers and referrals to inpatient or outpatient hospice care during the study period. Time trend analyses were used to test changes in the ICU admission rate. Univariate analyses were performed to test changes over time, and multivariate analyses were used to control for other factors. Setting Mount Sinai Medical Center has more than 1,100 beds and annually treats approximately 59,000 inpatients and 557,000 out-
patients. Each year the forty-eight-bed ED has over 100,000 visits and cares for 14,000 patients ages sixty-five and older (about thirty-eight per day), 10,000 of whom are ages seventy-five and older. The Icahn School of Medicine at Mount Sinai is home to the Brookdale Department of Geriatrics and Palliative Medicine. In turn, the department is home to the Center to Advance Palliative Care and the National Palliative Care Research Center, both of which are nationally recognized programs. In addition, the palliative care service, within the Lilian and Benjamin Hertzberg Palliative Care Institute at Mount Sinai Hospital, sees over 1,000 patients a year. Participants All visits by people ages sixtyfive and older to the Mount Sinai ED between January 1, 2011, and May 31, 2013, were included in the analyses. January 1, 2011, was chosen as the starting date for the study period because it preceded the formation of the process improvement team by six months. Outcomes The primary outcome was the ICU admission rate from the ED for patients ages sixty-five and older during the study period. ED-initiated palliative care consultations and hospice referrals for this population were also measured. Potential Confounders Categorical variables for sex (male or female), race/ethnicity (white, black, Hispanic, and other or unknown), and insurance status (Medicare and Medicaid, Medicare only, or other private or self-pay) were assigned. Charlson-Manitoba comorbidity scores were calculated for each ED encounter.23 Age was considered as a continuous variable. A patient’s score on the Emergency Severity Index (ESI), an instrument administered to ED patients in triage, was included as a potential confounding variable.24 A score of 1 (out of a possible 5) indicates that a patient requires immediate resuscitation. A score of 5 suggests a nonurgent complaint. Data Sources And Measurement Encounterlevel administrative data compiled from various electronic sources of health record and billing data were obtained from the Data Warehouse. Patient demographic characteristics; ESI score; primary and secondary International Classification of Diseases, Ninth Revision (ICD-9), diagnosis codes; and inpatient data (for admitted patients) were merged into a single data set for the 38,240 unique encounters that occurred during the twenty-nine-month study period. Statistical Methods All analyses employed SAS statistical software, version 9.3, and considered p values of < 0.05 as significant. Given the small numbers of ICU admissions, the distributions for these outcomes were skewed toward the
Exhibit 1 Timeline Of Changes Related To The Implementation Of Geriatric Emergency Department Innovations In Care Through Workforce, Informatics, And Structural Enhancements (GEDI WISE)
SOURCE Authors’ analysis. NOTES “Internal changes” refer to events set in motion by the Mount Sinai Medical Center emergency department (ED) or the process improvement team created by leaders from the Department of Emergency Medicine at Mount Sinai. “External changes” refer to events that were not within the purview of the ED staff or process improvement team but that might have affected the outcomes examined in the article. EMR is electronic medical record. PCU is inpatient palliative care unit. ED is emergency department. ISAR is Identification of Seniors at Risk (explained in the text).
lower end. To handle this issue, the GENMOD procedure was used to fit a negative binominal model to test whether the ICU admission rate changed over time after a set of baseline variables (sex, race/ethnicity, insurance status, ESI score, and comorbidity) was accounted for. Limitations Our study had several limitations. It was a single-site study in a large quaternary care center with a well-developed palliative care service. Moreover, GEDI WISE received a high level of support from ED staff at all levels and was set in motion by physician leaders in the Mount Sinai Medical Center’s Department of Emergency Medicine. These considerations may limit the generalizability of our findings to smaller hospitals, those without a palliative care consultation service, and those less open to redefining staff roles and goals. Nonetheless, the reduction in the ICU admission rate for older adults presenting to the ED is encouraging. This reduction was likely a result of increased concordance of care plans with patients’ goals of care. However, this was not measured explicitly by determining patients’ or surrogates’ goals of care and assessing congruence with the setting to which patients were admitted. Time trend analyses were used to track outcomes over time, but it was not possible to establish clear relationships between those outcomes and specific interventions implemented during the study period. However, this approach is still useful, particularly in cases of continuous quality improvement in which it is difficult to pinpoint the exact start time of an intervention. In this case, the analysis was further complicated May 2 015
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Health Affa irs
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Improving Care Systems by multiple interventions that were initiated in rapid succession, and at different rates.
Study Results From the time that screening with Identification of Seniors at Risk was instituted in October 2012 to the end of the study period, 59 percent of the 8,519 visitors to the ED who were ages sixty-five and older and who were screened with the tool had a score of 2 or greater, which indicated an increased risk for revisit and readmission (Exhibit 2). The five most common principal ICD-9 diagnoses for the 38,240 ED visits examined were chest pain (1,559 visits; 4.1 percent), shortness of breath (1,292 visits; 3.4 percent), malaise and fatigue (982 visits; 2.6 percent), abdominal pain (897 visits; 2.3 percent), and dizziness (830 visits; 2.2 percent). Identification of Seniors at Risk was used in
Exhibit 2 Characteristics Of Patients Ages 65 And Older For Unique Encounters In The Mount Sinai Medical Center Emergency Department, January 1, 2011–May 31, 2013 Encounters Characteristic Age (years)
Number
Percent
65–74 75–84 85 or older
22,465 8,371 7,404
58.7 21.9 19.4
Race/ethnicity White Black Hispanic Unknown or other
12,694 9,181 12,227 4,138
33.2 24.0 32.0 10.8
Medicare and Medicaid 14,778 Medicare only 18,357 Other private or self-pay 5,105 Charlson-Manitoba comorbidity score
38.6 48.0 13.3
0 1–5 6–9 10–15
26,398 10,902 857 83
69.0 28.5 2.2 0.2
Identification of Seniors at Risk scorea 0 822 1 2,653 2 1,867 3 1,263 4 1,143 5 564 6 207 Missing values 2,118
9.6 31.1 21.9 14.8 13.4 6.6 2.4 —b
Insurance type
SOURCE Authors’ analysis of administrative data from Mount Sinai Medical Center. NOTES There were 38,240 unique encounters (one patient may have had more than one encounter). The only missing values were for Identification of Seniors at Risk (ISAR) scores. Percentages and other numbers may not sum to totals because of rounding. aThe ISAR screening was performed on 8,519 of the 10,637 eligible patients. bNot applicable.
79 2
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ED triage in 80 percent of the 10,637 visits by people ages sixty-five and older that occurred after global geriatric screening began in October 2012. Of the 2,118 visits without screening, 1,589 (75 percent; data not shown) occurred during the first two months of the global screening initiative, when some nurses were still being trained in the procedure. From December 2012 onward, when all nurses had been fully trained in the protocol, there were only 529 missing ISAR scores, representing just 6 percent of ED visits during this later time period. The missing scores were associated with ED visits for a range of conditions, some of which were emergencies and therefore exempt from the screening. On a scale of 0 to 6, the median ISAR score was 2 (mean: 2.21; standard deviation: 1.52). During the study period, sixty-one adults ages sixty-five and older received ED-initiated palliative care consults. An additional thirty-five EDinitiated palliative care consults occurred as part of a separate research protocol and were excluded for this reason. Six patients in this age group were discharged with home hospice care, and two were discharged to inpatient hospice care. Over the twenty-nine-month study period, the unadjusted ICU admission rate declined from 2.3 percent to 0.9 percent (beta: −0.0095; 95 percent confidence interval: −0.0127, −0.0064; p
10.1377/hlthaff.2014.0790 HEALTH AFFAIRS 34, NO. 5 (2015): 788–795 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Corita Grudzen (corita [email protected]) is an associate professor of emergency medicine and population health at NYU Langone Medical Center and Bellevue Hospital, both in New York City. Lynne D. Richardson is a professor of emergency medicine and of population health science and policy at the Icahn School of Medicine at Mount Sinai, in New York City. Kevin M. Baumlin is a professor of emergency medicine at the Icahn School of Medicine at Mount Sinai. Gary Winkel is a research professor of oncology at the Icahn School of Medicine at Mount Sinai. Carine Davila is a medical student at the Icahn School of Medicine at Mount Sinai. Kristen Ng is a medical student at the Icahn School of Medicine at Mount Sinai. Ula Hwang is an associate professor of emergency medicine and geriatrics at the Icahn School of Medicine at Mount Sinai. The GEDI WISE investigators are identified at the end of the article.
788
By Corita Grudzen, Lynne D. Richardson, Kevin M. Baumlin, Gary Winkel, Carine Davila, Kristen Ng, Ula Hwang, and the GEDI WISE investigators
AG I NG
&
H E A LT H
Redesigned Geriatric Emergency Care May Have Helped Reduce Admissions Of Older Adults To Intensive Care Units Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City’s Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. ABSTRACT
H
alf of Americans ages sixty-five and older are seen in the emergency department (ED) in the last month of life, and threequarters visit the ED in the six months before their death.1 Despite these numbers, the intensity of medical care has not been realigned to better reflect the needs or goals of older adults with serious, life-limiting illnesses. Preliminary data suggest that early palliative
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care inpatient consultation can improve care, decrease hospital lengths-of-stay and costs, and even extend life.2–6 Palliative care teams are now present in over two-thirds of US hospitals and in 98 percent of National Cancer Institute–designated cancer centers.7 However, consultation by palliative care teams is available only Monday through Friday during regular business hours, and palliative care teams are not routinely available to
come to the ED when a patient is in crisis. Meanwhile, the available literature indicates that the number and rate of admissions to the intensive care unit (ICU) by emergency providers have been increasing, especially among older adults.8 The ED presents a key decision point at which providers set the subsequent care trajectory, including whether an older adult is hospitalized and in which setting. Emergency physicians can thus play an integral role in transforming care for older adults.9 A recent study of older adults with serious illnesses found that more than 75 percent of them had thought about end-of-life care and that only 12 percent wanted lifeprolonging care.10 Real-time identification of ED patients who would benefit from palliative care interventions, such as matching goals of care to treatments, may both improve the quality of care and reduce costs. This could result in better concordance of older adults’ goals of care with the environment 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. Programs to better integrate palliative care into emergency medicine exist.11 However, little research has been conducted to study their impact. In addition, until recently there has not been a validated ED screening tool for the rapid identification of older adults with a high likelihood of ED revisit and readmission, who therefore might be appropriate candidates for palliative care. Older adults presenting to the ED have substantial palliative care needs.12 At the same time, there are many barriers to integrating palliative care into emergency medicine, including knowledge deficits among emergency providers, time constraints, and infrequent advance care planning in older adults.13 In response, physician leaders from the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai in New York City created a multidisciplinary process improvement team to improve the care of frail older adults through the integration of fundamental palliative care principles into the emergency care provided to those with serious illnesses. The objective of the palliative care innovation was to identify older adults presenting to the ED with a serious life-limiting illness who would benefit from further clarification of their goals of care, as well as early referral to palliative and hospice care. This article describes the evolution of palliative care interventions in the Mount Sinai Medical Center ED, from the creation of the process improvement team in July 2011 through the
launch of a new model of care for older adults in October 2012. The overarching objective of this model is to transform emergency care for older adults to improve quality of care, improve health, and decrease costs. The model is named GEDI WISE, for Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements. Palliative care interventions are an important component of the model. However, more broadly, GEDI WISE uses ED-based care coordination, transitional care management, evidence-based geriatric clinical protocols, informatics support for patient monitoring and clinical decision making, and changes to the physical environment to improve patient safety and satisfaction for older adults. GEDI WISE is modeled after the geriatric ED paradigm.14 This article focuses on the palliative care innovations in the Mount Sinai Medical Center ED that were implemented in the course of the GEDI WISE model’s development and launch. It describes the innovations’ impact on associated changes to the ICU admission rate for older adults presenting to the ED. The GEDI WISE model was developed specifically for use in the ED. However, its innovative features were integrated with features of existing inpatient and outpatient programs.
Transforming Care For Older Adults Getting Started In May 2011 the Mount Sinai Medical Center adopted an integrated electronic medical record (EMR) system to be used across ambulatory, ED, and inpatient units. This was a change external to the project of transforming emergency care for older adults. Nonetheless, it allowed the creation of EMR-enabled geriatric screens that providers throughout the health care system could view. As explained above, physician leaders from the Department of Emergency Medicine created a process improvement team in 2011 to improve the care of frail older adults in the ED. The team included leaders from the nursing, social work, volunteer services, and information technology groups. Its first act was to create a volunteer program designed to assist and engage older adults throughout the ED.15 While the process improvement team was developing new ED staff procedures, including the screening and follow-up processes that are the focus of this article, enhancements to the physical environment transformed a portion of the adult ED into a geriatric ED space that would maximize safety for older adults.14,16 Because the geriatric ED is not large enough to accommodate all patients ages sixty-five and older, only May 2 015
34:5
Health Affa irs
789
Improving Care Systems older adults who are well enough to ambulate on their own and who know their own names are triaged to that area. These and other early changes in geriatric ED care spearheaded by the process improvement team, in concert with the opening of Mount Sinai Medical Center’s inpatient palliative care unit in June 2011, helped fuel staff enthusiasm for the geriatric ED innovations yet to come. Innovation Grant Meanwhile, health services researchers in the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai who focused on geriatrics and palliative care had identified the initial round of awards from the Center for Medicare and Medicaid Innovation as an opportunity to fund a rapid expansion of the existing geriatric ED programs and evaluate their impact on improving the health of patients with high health care needs, improving their care, and reducing its cost. As Mount Sinai Medical Center researchers worked on a grant application, they decided to invite leaders at two other medical centers to join them. The two centers—St. Joseph’s Regional Medical Center, in Patterson, New Jersey, and Northwestern Memorial Hospital, in Chicago, Illinois—were at different stages in the development of their geriatric ED programs. With Mount Sinai Medical Center serving as the coordinating center and primary applicant, physician leaders from the Departments of Emergency Medicine at the three medical centers applied for and received a Health Care Innovation Award to implement GEDI WISE. During the implementation process there would be commonalities across the three sites, including screening during triage to identify patients at risk for high use of health care. However, each of the three medical centers would implement protocols tailored to local needs. Geriatric Screening Tool Starting in October 2012, the existing ED workforce at the Mount Sinai Medical Center was retooled to administer a validated geriatric screening tool, the Identification of Seniors at Risk (ISAR).17–19 Training in the use of this tool is now required for all triage nurses at Mount Sinai. ISAR scores range from 0 to 6, with a higher score indicating an increased risk of future hospital use. When a cutoff score of 2 or more is used, the overall sensitivity and specificity of the tool to predict future hospital use are 73 percent and 51 percent, respectively.20 Patients who are critically ill or unable to answer questions when they present to the ED are not screened. Also in October 2012, two GEDI WISE nurse practitioners were hired to perform more detailed assessments of older adults who had a score of 2 or higher on the Identification of Se79 0
H e a lt h A f fai r s
May 2 015
34:5
niors at Risk tool. Patients who may benefit from advance care planning or referral to palliative or hospice care are identified based on diseasespecific criteria that indicate a life expectancy of six months or less (for example, the presence of a metastatic solid tumor). The GEDI WISE nurse practitioners review notes and action plans and refer patients to ED social workers, who can arrange more intensive home or other outpatient care and support as needed. The ED team may also consult with patients’ primary care providers to determine which older adults meet hospice criteria and are sufficiently stable to go home. The team can make referrals for outpatient hospice care. Workforce Enhancements A set of workforce enhancements was also introduced, including new protocols for emergency physicians, physician assistants, registered nurses, pharmacists, and social workers. In addition, there were regular mandatory training sessions on new clinical roles, newly available resources (for example, hospice referral), screening tools (such as ISAR), and newly developed work algorithms and clinical protocols. To educate staff members, educational programs that focused on palliative care and were discipline appropriate were made available free of charge to emergency physicians, physician assistants, advance practice nurses, social workers, and pharmacists. The programs included a modified curriculum from the Education in Palliative and End-of-Life Care for Emergency Medicine program for physicians, nurse practitioners, and physician assistants;21 a two-day communication skills training program for select faculty members called Geritalk;22 an advance care planning facilitator course called Respecting Choices that was required for the GEDI WISE nurse practitioners and ED social workers; and geriatric pharmacy certification for the pharmacists. Exhibit 1 locates the innovations described above on a timeline.
Study Data And Methods Hospital administrative data were used to track monthly palliative care consultations initiated by emergency providers and referrals to inpatient or outpatient hospice care during the study period. Time trend analyses were used to test changes in the ICU admission rate. Univariate analyses were performed to test changes over time, and multivariate analyses were used to control for other factors. Setting Mount Sinai Medical Center has more than 1,100 beds and annually treats approximately 59,000 inpatients and 557,000 out-
patients. Each year the forty-eight-bed ED has over 100,000 visits and cares for 14,000 patients ages sixty-five and older (about thirty-eight per day), 10,000 of whom are ages seventy-five and older. The Icahn School of Medicine at Mount Sinai is home to the Brookdale Department of Geriatrics and Palliative Medicine. In turn, the department is home to the Center to Advance Palliative Care and the National Palliative Care Research Center, both of which are nationally recognized programs. In addition, the palliative care service, within the Lilian and Benjamin Hertzberg Palliative Care Institute at Mount Sinai Hospital, sees over 1,000 patients a year. Participants All visits by people ages sixtyfive and older to the Mount Sinai ED between January 1, 2011, and May 31, 2013, were included in the analyses. January 1, 2011, was chosen as the starting date for the study period because it preceded the formation of the process improvement team by six months. Outcomes The primary outcome was the ICU admission rate from the ED for patients ages sixty-five and older during the study period. ED-initiated palliative care consultations and hospice referrals for this population were also measured. Potential Confounders Categorical variables for sex (male or female), race/ethnicity (white, black, Hispanic, and other or unknown), and insurance status (Medicare and Medicaid, Medicare only, or other private or self-pay) were assigned. Charlson-Manitoba comorbidity scores were calculated for each ED encounter.23 Age was considered as a continuous variable. A patient’s score on the Emergency Severity Index (ESI), an instrument administered to ED patients in triage, was included as a potential confounding variable.24 A score of 1 (out of a possible 5) indicates that a patient requires immediate resuscitation. A score of 5 suggests a nonurgent complaint. Data Sources And Measurement Encounterlevel administrative data compiled from various electronic sources of health record and billing data were obtained from the Data Warehouse. Patient demographic characteristics; ESI score; primary and secondary International Classification of Diseases, Ninth Revision (ICD-9), diagnosis codes; and inpatient data (for admitted patients) were merged into a single data set for the 38,240 unique encounters that occurred during the twenty-nine-month study period. Statistical Methods All analyses employed SAS statistical software, version 9.3, and considered p values of < 0.05 as significant. Given the small numbers of ICU admissions, the distributions for these outcomes were skewed toward the
Exhibit 1 Timeline Of Changes Related To The Implementation Of Geriatric Emergency Department Innovations In Care Through Workforce, Informatics, And Structural Enhancements (GEDI WISE)
SOURCE Authors’ analysis. NOTES “Internal changes” refer to events set in motion by the Mount Sinai Medical Center emergency department (ED) or the process improvement team created by leaders from the Department of Emergency Medicine at Mount Sinai. “External changes” refer to events that were not within the purview of the ED staff or process improvement team but that might have affected the outcomes examined in the article. EMR is electronic medical record. PCU is inpatient palliative care unit. ED is emergency department. ISAR is Identification of Seniors at Risk (explained in the text).
lower end. To handle this issue, the GENMOD procedure was used to fit a negative binominal model to test whether the ICU admission rate changed over time after a set of baseline variables (sex, race/ethnicity, insurance status, ESI score, and comorbidity) was accounted for. Limitations Our study had several limitations. It was a single-site study in a large quaternary care center with a well-developed palliative care service. Moreover, GEDI WISE received a high level of support from ED staff at all levels and was set in motion by physician leaders in the Mount Sinai Medical Center’s Department of Emergency Medicine. These considerations may limit the generalizability of our findings to smaller hospitals, those without a palliative care consultation service, and those less open to redefining staff roles and goals. Nonetheless, the reduction in the ICU admission rate for older adults presenting to the ED is encouraging. This reduction was likely a result of increased concordance of care plans with patients’ goals of care. However, this was not measured explicitly by determining patients’ or surrogates’ goals of care and assessing congruence with the setting to which patients were admitted. Time trend analyses were used to track outcomes over time, but it was not possible to establish clear relationships between those outcomes and specific interventions implemented during the study period. However, this approach is still useful, particularly in cases of continuous quality improvement in which it is difficult to pinpoint the exact start time of an intervention. In this case, the analysis was further complicated May 2 015
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Improving Care Systems by multiple interventions that were initiated in rapid succession, and at different rates.
Study Results From the time that screening with Identification of Seniors at Risk was instituted in October 2012 to the end of the study period, 59 percent of the 8,519 visitors to the ED who were ages sixty-five and older and who were screened with the tool had a score of 2 or greater, which indicated an increased risk for revisit and readmission (Exhibit 2). The five most common principal ICD-9 diagnoses for the 38,240 ED visits examined were chest pain (1,559 visits; 4.1 percent), shortness of breath (1,292 visits; 3.4 percent), malaise and fatigue (982 visits; 2.6 percent), abdominal pain (897 visits; 2.3 percent), and dizziness (830 visits; 2.2 percent). Identification of Seniors at Risk was used in
Exhibit 2 Characteristics Of Patients Ages 65 And Older For Unique Encounters In The Mount Sinai Medical Center Emergency Department, January 1, 2011–May 31, 2013 Encounters Characteristic Age (years)
Number
Percent
65–74 75–84 85 or older
22,465 8,371 7,404
58.7 21.9 19.4
Race/ethnicity White Black Hispanic Unknown or other
12,694 9,181 12,227 4,138
33.2 24.0 32.0 10.8
Medicare and Medicaid 14,778 Medicare only 18,357 Other private or self-pay 5,105 Charlson-Manitoba comorbidity score
38.6 48.0 13.3
0 1–5 6–9 10–15
26,398 10,902 857 83
69.0 28.5 2.2 0.2
Identification of Seniors at Risk scorea 0 822 1 2,653 2 1,867 3 1,263 4 1,143 5 564 6 207 Missing values 2,118
9.6 31.1 21.9 14.8 13.4 6.6 2.4 —b
Insurance type
SOURCE Authors’ analysis of administrative data from Mount Sinai Medical Center. NOTES There were 38,240 unique encounters (one patient may have had more than one encounter). The only missing values were for Identification of Seniors at Risk (ISAR) scores. Percentages and other numbers may not sum to totals because of rounding. aThe ISAR screening was performed on 8,519 of the 10,637 eligible patients. bNot applicable.
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ED triage in 80 percent of the 10,637 visits by people ages sixty-five and older that occurred after global geriatric screening began in October 2012. Of the 2,118 visits without screening, 1,589 (75 percent; data not shown) occurred during the first two months of the global screening initiative, when some nurses were still being trained in the procedure. From December 2012 onward, when all nurses had been fully trained in the protocol, there were only 529 missing ISAR scores, representing just 6 percent of ED visits during this later time period. The missing scores were associated with ED visits for a range of conditions, some of which were emergencies and therefore exempt from the screening. On a scale of 0 to 6, the median ISAR score was 2 (mean: 2.21; standard deviation: 1.52). During the study period, sixty-one adults ages sixty-five and older received ED-initiated palliative care consults. An additional thirty-five EDinitiated palliative care consults occurred as part of a separate research protocol and were excluded for this reason. Six patients in this age group were discharged with home hospice care, and two were discharged to inpatient hospice care. Over the twenty-nine-month study period, the unadjusted ICU admission rate declined from 2.3 percent to 0.9 percent (beta: −0.0095; 95 percent confidence interval: −0.0127, −0.0064; p
