Collaboration: Neurosurgery and the Palliative Care Unit

Topic: Collaboration Across Specialties

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Background:

“Integrating Palliative Care into the Care of Neurocritically Ill Patients: A Report from The IPAL-ICU” in 2016 states that the onset of neurocritical illness is usually abrupt and follows a trajectory that is distinct from that of other patients with life-threatening illness and increasing work need to be done to bridge the worlds of neurocritical and palliative care. North Shore University Hospital (NSUH) has a dedicated palliative care unit(PCU) and Neurosurgical care unit (NSCU). The PCU admitted over 500 patients in 2016 of which, 6%(77) were from the NSCU. We found in our analysis that the 77 patients transferred were seen within one week of hospitalization and when transferred to the PCU they died within 24 hours. As a result the geriatrics and palliative (GAP) team at NSUH decided to embark on a quality improvement project to work collaboratively with the NSCU to have earlier GAP consultations, educate staff about geriatrics and palliative care in this population and prioritize earlier transfers to the PCU for better symptom management at end of life.

Methods:

The director and nurse manager of the PCU initiated a meeting with the director and nurse manager of the NSCU to obtain buy-in. They subsequently agreed that a collaborative effort was necessary. We then assembled a work group of both unit directors and nurse managers and the GAP consult nurse practitioners(NP). The work group decided upon twice a week rounding with the interdisciplinary team(IDT) during a morning huddle attended by our GAP NP. The IDT included physicians, physician assistant nutrition and physical therapy. Consults were triggered by using an ICH(intracranial Hemorrhage) score > 4 and guidelines from Center to Advance Palliative Care recommendations about initiating a palliative consult. Our team educated the nurses and attended a workgroup session with the NSCU intensivist prior to beginning. Rounds started on June 5th 2017.

Results:

To date the GAP NP has attended 10 IDT morning huddles. As a result, the total number of consults triggered in June was 29 of which 3 were due to the ICH score > 4. Of those 30 patients, 17 were transferred to the PCU for end of life care. The average and median days to consult was 4.2 and 3.2 respectively. The average consult to transfer to the PCU was 2.3 days.

Conclusion:

Integrating a GAP team member into the morning huddle is a successful means of initiating consults. Prior to the huddle, the PCU accepted an average of 4 to 5 patients per month from the NSCU. Within the first moth of implementation, we were able to reduce days to consult by half, increased consult volume two-fold and prioritized over 100% more patients to the PCU. We observed the impact of earlier consultation allowed for improvement in patient and family centered care at end of life in neurosurgical conditions. As this collaboration matures we plan to expand the role to a daily huddle and work with the NSCU to promote the value of GAP consults earlier in the trajectory of these illnesses.

Author

  • Bridget I Earle MD
  • Palliative Medicine Attending
  • Lenox Hill Hospital
  • 100 East 77th street
  • New York, NY 10075
  • 212-434-4174

Co-authors

  • Adriana Calosso, NP
  • Tiffany Powell, RN BSN

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