Emergency department discharges directly to hospice: Longitudinal assessment of a streamlined referral program

• Published in: The American journal of emergency medicine Vol. 86; pp. 56 - 61
• Main Authors: Markwalter, Daniel W., Lowe, Jared, Ding, Ming, Lyman, Michelle, Lavin, Kyle
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2024; Elsevier Limited
• Subjects: Aged; Aged, 80 and over; Beneficiaries; Education; Electronic Health Records; Electronic medical records; Emergency; Emergency medical care; Emergency medical services; Emergency Service, Hospital - organization & administration; End-of-life care; Ethnicity; Female; Generalized linear models; Goal-concordant care; Hospice; Hospice care; Hospice Care - organization & administration; Hospice Care - standards; Hospices - organization & administration; Hospitals; Human subjects; Humans; Length of Stay - statistics & numerical data; Longitudinal Studies; Male; Medical referrals; Medicare; Middle Aged; Palliative care; Patient Discharge; Patient Transfer - standards; Patients; Physicians; Quality control; Quality improvement; Quality Improvement - organization & administration; Referral and Consultation; Regression analysis; Workflow; United States > US; Palliative care; Quality improvement; End-of-life care; Hospice; Goal-concordant care
• ISSN: 0735-6757; 1532-8171; 1532-8171
• DOI: 10.1016/j.ajem.2024.09.049

80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice. We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS). 202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21). In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there. •Direct transfers to hospice from the emergency department are feasible.•Efforts to increase direct discharges to hospice need not prolong length of stay.•Workflows, education, and documentation changes are necessary but insufficient.•Obstacles to direct hospice transfer remain that require targeted intervention.