A Quality Improvement Assessment of Emergency Department Visits by Hospice Home Care Patients

Abstract

Estimates suggest that greater than 25% of Medicare resources are used in the last 6 months of life. One significant source of cost is related to emergency care delivered to hospice patients for symptom management near the end of life. As the first phase of a quality improvement initiative, the purpose of this project was to determine reasons for and prevalence of hospice home care patients who access emergency departments for symptom management near the end of life and to explore factors that may influence patients' decisions to do so. A review of 1 hospice agency's annual report data for 2011 indicated that 147 hospice patients sought emergency care many for symptoms that occur near the end of life, whereas a significant number of visits were attributed to falls and sequelae. Results of an investigator-developed survey distributed to home care nurses indicated that although written information was provided to patients and caregivers regarding what to do when changes in condition occurred, family/ caregivers became anxious and sought emergency care. Revision of educational materials and development of strategies to address the needs of this population should inform future projects. KEY WORDSemergency care, hospice, symptom management A ccording to the National Hospice and Palliative Care Organization (NHPCO), hospice is a model of care that provides quality compassionate care for patients and their family and is expressly tailored to the individual's needs and wishes of those facing a lifelimiting illness. 1 The purpose of the hospice program is to provide patients in the terminal stages of disease with an improved quality of life for their remaining time and that strategies to control symptoms be instituted in their environment of choice. According to the literature, given a choice, terminally ill patients prefer to die at home. 1 The NHPCO reports that 66.7% of hospice patients are cared for in the place that the patient calls home: private residence, residential facility, or nursing home. 2 As death approaches, symptoms may escalate, causing increased suffering. When patients experience an increase in symptoms, they often seek care at the emergency department (ED), which can be disruptive and exhausting. 3 This can also be distressing to the caregiver and the health care professionals responsible for their care. 3 Seeking treatment in an acute care facility while enrolled in a hospice program can also have philosophical and financial repercussions for all involved. The hospice philosophy focuses on comfort care and allows the disease to take its natural course, whereas care in an ED is usually focused on more aggressive treatment. Although findings indicate that hospice patients access the ED for symptom management, the prevalence of ED visits among patients enrolled in this hospice program and the possible factors that may contribute to ED visits in this population is not known. Objective of the ProjectThe initiation of this quality improvement (QI) project was based on this author's observations of hospice ...