North Shore University Hospital The Joint Commission

Advanced Certification for Palliative Care

January 31, 2012

Mission & VisionTo be a national health care leader, committed to excellence, compassion and

improving the health of the community.

NSUH is an 812-bed quaternary teaching hospital. The campus is home to the Katz Women’s Hospital, Feinstein Institute for Medical Research, Stern Family Center for Extended Care and Rehabilitation and the Schwartz Ambulatory Surgery Center. NSUH also operates the 103 bed Syosset Hospital.

North Shore University Hospital - Profile

• 6,645 employees• 3,240 physicians• 1,558 nurses• 600 allied health• 55,124 discharges/year• 5.3 day mean LOS• 4.25 % operating margin• 80,000 annual ED visits

Cardiology; 6,058Cardiovascular

and Thoracic Surgery; 1,670

Medicine; 18,726

Neurology; 1,398Neurosurgery; 1,579

Obstetrics & Gynecology;

7,511

Ophthalmology; 2

Orthopaedic Surgery; 1,416

Pediatrics; 7,140

Psychiatry; 707

Surgery; 5,802Urology; 1,249

2010 Hospital Discharges

• Designated Renal Transplant Center• Bariatric Surgery Centers of

Excellence• Stroke Center• Foundation for the Accreditation of

Cellular Therapy (FACT) Accreditation – Adult Bone Marrow

• HealthGrades Awards 2012: Awards in 14 specialties

• One of the Top 50 Hospitals in the Country - AARP

• Thomson Reuters Top 100 Hospitals® for Cardiovascular Care

• Consumer’s Choice Award for last 10 years as most preferred hospital on quality and image

• CMS award for participation in Health Quality Incentive Demonstration Project (HQID) – 2010

• International study site for excellence

of treatment for chest pain in the Emergency Department (Early Heart Attack Care)

• Ranked #1 for Emergency Angioplasty by the State Department of Health report

• US News & World Report 2012 Best-In Geriatrics and Gastroenterology

• 2010 “Top Performers on Key Quality Measures”

• New York State Hospital Report Card 2011, one of “America’s Safest Hospital”

• Nassau and Suffolk Counties, Honorable Mention

Hospital Recognition

Key Initiatives

• Patient Experience

• Collaborative Care Councils

• Team Stepps

• Patient Safety Rounds

• Administrative Rounds

• Employee Wellness

• Create Palliative Care Institute• Conference with national leaders• CAPC Leadership Center• Clinical service begins

• Philanthropy• Palliative Care Unit Opens• HPM Fellowship

• ACGME accreditation for HPM Fellowship• Inpatient hospice capacity• HANYS Recognition• NSLIJHS “President’s Teamwork Award” • Palliative Care Information Act• Growth of HPM Fellowship

•Harvard Faculty Development Grant•NSLIJ Health System Senior

Leadership Retreat on Palliative Care

• Dana Lustbader MD, Section Head• Michael Frankenthaler MD• Sindee Weiss MD• Kathy Trombley RN, Nurse Manager• Elizabeth Gorowski NP• Adriana Calosso NP• Trish Klare LCSW• Lynda Cooper LCSW, Administrator• Rev. Jon Overvold MDiv.,BCC, Chaplain

The Palliative Care Team

• Pastoral Care– Spiritual support– Interfaith memorial service– Community clergy relationship

• Child Life– Prepare children for death of

loved one– Center for Hope - bereavement– Hand prints, bedside grief

• Nutrition– Accommodate dietary requests

during end of life– Mini bar – scotch, beer– Nutritional strategies for

patients with terminal disease

Other Team Members

• Pharmacy– Policy development: ketamine,

subcut infusions– Antibiotic stewardship

• Respiratory Therapy– Weaning protocols– Non invasive ventilation

• Volunteers– Quilt to cover gurney to

morgue for dignity– Junior volunteer fundraising– Holiday food– Pet therapy – dogs– High school work study

The Palliative Care Program

• Consultation team• ACGME accredited

Hospice and Palliative Medicine Fellowship

• Flagship program providing mentorship to 15 NSLIJHS hospitals

• Palliative Care Unit

• 1,700 new consults per year• 6,000 visits per year• Average daily census = 30 pts• Reduced hospital LOS for

MICU patients that die – (Lustbader et al. Pal Supp Care 2011)

• Diagnosis– Cancer 40%; Non cancer 60%

– 30% consults from ICUs• DNR at death = 96%• Consults ordered by anyone

Palliative Medicine Consultation Service

Discharge Disposition

Palliative Care Consultation Volume (2005-2011)

• Consultation growth of 300% over seven years

• Increased penetration into ICUs and Oncology

• Growth sustained with administrative support and backing by senior leadership

Timeliness of Palliative Care Consult

• More timely palliative care referral

• Anyone can order palliative care consult

• Mean days from admission to consultation reduced by 46% from 2006 to 2011 from 13 days to 7 days.

• ACGME accredited HPM Fellowship - 4 per year

• Fellows are part of pediatric palliative care team at Cohen Children’s Hospital and NICU

• Provide palliative care education to trainees

• The family meeting room– Located outside ICU– Training with actors

Palliative Medicine Fellowship and Education

• Provide mentorship to System hospitals– Site visits– Shared resources

• Standardized orders and policies• Brochures (What is Palliative Care, What is a

Trach?)

• IHI Palliative Care Strategic Partnership• Palliative care integration with home care and

hospice through Advanced Illness Coordinating Committee (AICC)

Palliative Care Team and The NSLIJ Health System

• Local– Complex Care Rounds - LOS > 45 days– Palliative Care Grand Rounds

• Regional– Harvard Faculty Development Grant– Empire Clinical Research Investigation Program– GNYHA - Palliative Care Leadership Network

• National– CAPC - The IPAL-ICU Project– ABIM – Palliative Care Test Writing Committee– AAHPM

Local, Regional and National Involvement

Palliative Care Unit

• Align treatments with patient preferences

• Terminally ill ICU patients requiring mechanical ventilation moved to more appropriate site for care

• Weaning protocols• DNR not required • Inpatient hospice care

Palliative Care Unit

Palliative Care Unit

• Patient centered care– Sleeper sofas– Open visiting– Family rounds– Family pets

• Follow up telephone call• Bereavement resources• RN death pronouncement• NP death certification

Donna’s Story

• Terminal Tissue Injuries• Skin changes near death• Unlike traditional pressure ulcers

Research: Terminal Tissue Injuries

Palliative Care Nursing

• Palliative Care RN Certification

• Halo effect in normalizing palliative care for other NSUH nurses

• Family centered care– Child Life– Special events

• Anatomic Gift Program

Palliative Care Education, Research and Grants

Venue or Grant Topic

Cardiovascular Grand RoundsPalliative Care in the Age of Health Care Reform

Nurse-Practitioner Conference Critical Conversations

Safety RoundsAdvance Directives and the Family Health Care Decisions Act

Molloy College Palliative Care Conference

Palliative Care and New York State Law

Long Island Caregiver ConferencePalliative Care and the Family Caregiver

Nursing Grand Rounds Terminal Tissue Injuries

Harvard Faculty Development GrantCommunication for use during Rapid Response when patient is dying

NY State Dept of Health Empire Clinical Research Investigator Award

Palliative Care Communication Training for Surgeons

Max’s Story

• Sam was a 39 year old man with metastatic pancreatic cancer receiving chemotherapy

• He was followed by his oncologist and home health care program.

• Outpatient palliative care for pain management

Max

• Progressive debility • Inpatient hospice in PCU for paracentesis for massive

ascites, pain and treatment of DVT• Klezmer band in PCU• Sam died with wife and children at bedside after

making memorial handprints with his daughter

Max