St. Luke's Episcopal Health System - St. Luke's Episcopal Hospital Institution and Program Description

St. Luke's Episcopal Hospital, home of the Texas Heart Institute, is a 912 bed tertiary facility in the Texas Medical Center, the world's largest medical center consisting of 46 not-for-profit institutions. Approximately 800 patients die in this institution annually. The palliative Care Service started in 1999 with one nurse. The service has grown and includes 1 Advanced Practice Nurse, 1 Palliative Care RN, 1 chaplain, 2 Social Workers, an Advanced Practice Nurse who splits between the pain management team and Palliative Care team, and another Advanced Practice Nurse on the pain management team who cross covers for Palliative Care as needed. The challenge of providing palliative care in an acute care setting has been a resounding success, as evidenced by the number of consults and referrals. St. Luke's is committed to improving the outcome for all patients, even if that outcome is death.

Topic Description

The Palliative Care Program physician coverage has been intermittent with no MD coverage from April, 2004 to May, 2005 and from July, 2006 to August, 2008. Meanwhile, the Nurse/Social Worker led team continued to provide effective symptom management and end-of-life care by accommodating and empowering other health care professionals (especially MDs and RNs) as an extension of the team.

Impact on Program

As Evidenced By

Measures:

• Customer satisfaction survey: Overall satisfaction rating averaged 4.5 on a 1-5 point likert rating scale
• Annual percent increase in number of referrals
• Monthly palliative Care educational series: Demonstrated a high need for further education on Cultural Diversity at the End of Life, Medical Futility, and a general understanding of PC.
• Palliative Care memorial service: Anticipated attendance goal was 20%; actual was 63%.
• Bereavement program: In the last 2yrs, 1500 phone calls have been made, 1277 sympathy cards sent, and since 2005, 529 prayer shawls have been donated to dying patients.
• Cost saving: "41% cost reduction in variable direct cost for expired patients with a length of stay greater than 8 days followed by palliative care"

Changes:

• Improved symptom management at the end of life
  • Implementing standards of care from leading PC organizations. (i.e. Center to Advance Palliative Care; End of Life/Palliative Education Resource Center)
  • Participation in the Harvard Medical School Center for Palliative Care's Program in Palliative Care Education and Practice
• Improved patient and family psychosocial support
  • Participation in the City of Hope- Advocating for Clinical Excellence(ACE) project
  • Implementing standards of care from leading PC organizations. (i.e. Center to Advance Palliative Care; End of Life/Palliative Education Resource Center)
  • Participation in the Harvard Medical School Center for Palliative Care's Program in Palliative Care Education and Practice
  • Bereavement program
• Improved symptom management and end of life care by continued education for patient/family/staff/community
  • PC conference-"Integrating Palliative Care into Clinical Practice" (2007)
  • PC committee started in 2006, was meeting monthly, changed to every other month Jan 2008.
  • Monthly educational series (2008)
  • Orientation classes for new employees
  • Registered Nurse orientation
  • Graduate Nurse residency program orientation
  • Patient Care Associate II classes
  • Individual one on one education with healthcare providers
  • Unit based in-services
  • Oncology collaborative practice team (CPT)
  • Heart Failure CPT
  • Ongoing lectures at local Nursing School
  • Chaplain orientation
  • Research (in progress): Family Experience With Death
  • Ongoing membership with the Center to Advance Palliative Care
• Piloting ICU rounds to identify appropriate patients
  • Developed ICU audit tool to promote timely referrals
• Improved symptom management during withdrawal of life prolonging measures
  • Implementing standards of care from leading PC organizations and institutions (i.e. Center to Advance Palliative Care; End of Life/Palliative Education Resource Center)
  • Participation in the Harvard Medical School Center for Palliative Care's Program in Palliative Care Education and Practice
  • Developing ventilator withdrawal protocol
• Added Internal & External Palliative Care Website with bereavement information
  www.sleh.com >About Us > Departments > Palliative Care
• Expanded Bereavement Service
  • Sympathy Cards
  • Prayer Shawls
  • Monthly Phone Calls (1500 in past 2 yrs)
  • Family Care Bereavement Volunteers
  • Annual Memorial Service (2007 & Nov 1, 2008)
  • Staff Support Group (2008)
  • Newsletter - (Coming Oct or Nov 2008)
• Performed time & motion study based on National Consensus Project guidelines for Quality Palliative Care to ensure variety of optimal care is provided (most time was spent on Domain 1-structure and process of care)???
• Developing automated referral protocol
• Developing Computerized history and physical/progress note
• Added Palliative Care Pager with computer generated referrals automatically sent to the pager.
• Added Palliative Care phone number with messages left automatically transferred to pager

Lessons Learned

Consults to the Nurse/SW led palliative care service continues to increase with high overall customer satisfaction despite limited to no physician representation.

• Do not underestimate the power of a Nurse/SW led palliative care consult service. Empowering staff nurses and attending physicians as extension of the team helps with education and buy-in into appropriate end-of-life care.
• Do not be afraid of initial physician and staff nurse's resistance to a Nurse/SW led palliative care team. Emphasize the role of supporting and supplementing physicians and staff nurse's desire to provide best practice care at the EOL. Once the benefit of the team is realized, such as early identification of goals of care and decreased length of stay, referrals to the service steadily increases.
• Be creative in getting the word out. Implement diverse method of promoting the service (such as ICU rounds and increased participation in different committees). Be visible as much as possible in patient care units; allowing for more teaching opportunities.
• Gain a strong commitment from senior leadership. Involve any champions of the program in senior leadership and extend invitations to others whenever possible to participate in planned activities (i.e. participation in conferences, educational series, and annual memorial service). Provide evidence of benefits to organization
• Do not be disappointed or discouraged if the attending physician does not agree with a consult requested by nurses and/or other healthcare team members. The nurse can still be supported in her efforts towards best practice by discussing nursing interventions and suggestions that can be discussed with the physician that can lead to improved patient comfort.
• Do not be discouraged about all the misconceptions about palliative care and its services. View these instances as an opportunity to educate and promote palliative care best practice standards.
• Assure a collegial atmosphere among other disciplines; to help foster and promote collaboration among other healthcare providers.
• Do not be afraid of failure. You'll learn how to do it better the next time.