Night and Day: A 24 hour coverage solution for a PCU

Topic: Staffing Models

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Objectives: Outline the challenges of covering a primary service with 24 hour demands, but only 12 hour coverage and describe a staffing solution that builds on partnerships with hospitalist colleagues.

Background: Our Palliative Care Unit (PCU) is a 14-bed geographically distinct unit in the Department of Geriatrics and Palliative Medicine which opened in June 2011. We accept patients with complex symptom management needs, who require support for establishing goals of care, or who have chosen comfort-oriented care. The PCU is staffed during the day by specialty trained palliative care (PC) physicians, nurse practitioners (NP), social workers, bedside nurses, patient care associates, and a clinical nurse manager. Caring for patients with 24-hour needs when the unit has no nighttime staffing presented a significant challenge.

To illustrate this problem, consider the case of TA, a 70 year old woman with gastric cancer metastatic to lung, presenting from the Emergency Department with dyspnea. She was evaluated by our team and her goal was to be comfortable and return home with hospice. The PC consult team ordered morphine which relieved her dyspnea after two doses, and began a scheduled morphine regimen. She was transferred to our PCU and evaluated as comfortable by the PC physician and NP at 4pm. At midnight, however, she became acutely dyspneic, hypotensive, hypoxic, and tachycardic.

Staffing Solution: Our team collaborated with the Division of Hospital Medicine within the Department of Medicine to provide seamless, continuous coverage overnight for our acutely ill and often symptomatic patients. Given their unit’s proximity to our floor, two physician assistants (PA) were selected to cover the PCU, guaranteeing a timely response to patients’ and families’ needs. To ensure quality coverage, the PAs rotated with the PC service for 3 days, observed family meetings, and received intensive education on pain and symptom management. In addition, we established back up by pager from both a palliative provider, as well as an in-house hospitalist. The PCU team sends a daily handoff email to the PA listing code status, contact for family or decision makers, cause of death, clinicians to notify at time of death, and a brief clinical summary for each patient. This email can be quickly referenced when the PA responds to patients’ changing clinical status, needs to update families, or has to fill out a death certificate.

With this staffing solution in place, TA was immediately evaluated by the covering PA, who ordered additional morphine and updated her husband. The PA also paged the PC fellow on call after the dose of morphine did not alleviate the patient’s dyspnea. Together, they developed a new regimen that relieved TA’s symptoms. TA died comfortably a few hours later, and was pronounced by the PA.

Conclusion: Providing intensive palliative care 24 hours a day is challenge for rapidly growing programs. Partnerships within the hospital can help to ensure the timely delivery of high quality round the clock care to patients while also advancing primary palliative education.

Author

  • Bridget Tracy, MD
  • Assistant Professor
  • Icahn School of Medicine at Mount Sinai Hospital
  • 1 Gustave L. Levy Place, Box 1070
  • New York, NY 10029
  • 212-241-1446

Co-authors

  • Bridget Tracy, MD
  • Emily Chai, MD
  • Maria Reyna, MD

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