Background: Palliative care and geriatrics in hospital medicine have an established positive impact on patient experience and outcomes, however, these specialist care services remain underutilized. Recognizing an opportunity to improve the appropriateness of inpatient consultation on a large academic medical hospitalist service, we implemented a multi-disciplinary quality improvement intervention with the goal of increasing appropriate palliative care and geriatric consult rates, decreasing time to consult and educating hospitalists on geriatric and palliative care key concepts.
Methods: Patient care teams on a general medicine hospitalist service consisted of a hospitalist, RN case manager, and social worker. All patients admitted to eleven patient care teams were studied for the one-year intervention period and the immediate preceding year (a control year). Two of the eleven patient care teams participated in the intervention: scheduled, biweekly discharge planning rounds with the palliative care and geriatric teams. The nine control teams received usual care (weekday discharge rounds with specialist care available by consultation). Outcome measures included the palliative and geriatric consultation rates and time to consult. Chi-squared tests were used to analyze the proportion of admissions including a palliative or geriatric consult. Multivariable Cox-proportional hazards regression was used to analyze time from admission to consultation. In addition, participating patient care teams were surveyed with pre-post analysis about their impression of the integrated rounds.
Results: During the intervention time there were 1483 intervention team admissions and 12,458 control team admissions (either control teams and/or control time). Intervention patient admissions were more likely than controls to receive palliative care consultation (5.2% vs. 2.5% of patient admissions, p<.001) and geriatric consultation (3.4% vs. 2.1% of patient admissions, p<.002). Adjusting for age, gender, readmission, and cancer vs non-cancer diagnosis group (for palliative consult) and Elixhauser (for geriatric), the intervention was associated with improved time to consult for both palliative care (HR= 1.96, CI 1.52-2.51), and geriatric consults (HR 2.00, CI 1.43-2.82). Of the 25 hospitalists participating in the intervention, 15 completed the survey (53.6% response rate). 83% found the integrated rounds to be valuable for patient care, with the remaining 17% neutral. All of the respondents thought the intervention facilitated easier communication with consultants. 55% of hospitalists found the intervention to improve their own palliative care and geriatrics skills. Only one respondent (8%) found the integrated rounds to be too time consuming.
Conclusions: Integrated multidisciplinary hospitalist and specialist care rounds increased access to appropriate palliative care and geriatric services. Hospitalists found it valuable for patient care without being too time consuming.