Background: Multiple studies show that patients with serious illness often do not discuss their goals and preferences with their clinicians leading to low patient and family satisfaction, and costly care that is often unwanted and unnecessary. Even though there is increased awareness on the part of clinicians to have these difficult conversations, the busy schedules underline the need to quickly identify high risk patients for most impact. UMass Memorial Medical Center has recently acquired Epic as its electronic medical record and the system is set to automatically calculate LACE+ score for all patients on admission to the hospital. High LACE+ score has been shown in the studies to be associated with high risk of readmission or death (LACE + score of more than 70 indicates 20% or greater risk of 30-day readmission or death). In addition to that, the palliative care literature suggests some role of surprise question (“would you be surprised if this patient died in next 12 months?”) as a screening tool for identifying patients in need of GOC discussions.
Purpose: The aim of this pilot study was to assess feasibility and ease of using LACE+ score and surprise question to identify high risk patients on inpatient medical wards who would benefit from a goals of care (GOC) discussion in an effort to increase GOC discussions in this population.
Description: For this pilot study, high risk patients were defined as ones with LACE+ score of more than 70 and answer “no” on the surprise question. The baseline data was collected on the select inpatient teams for one week and medicine residents on inpatient wards were then provided education on LACE+ score and surprise question, and posters were hung in work areas describing this process of identification. The primary team was encouraged to engage in GOC discussions with their high-risk patients or consult palliative care where they felt specialized services were indicated. The data was thereafter collected for one-week post-intervention on the same inpatient teams. 46 patients were identified during pre-implementation with LACE+ >70, and out of them 23 (50%) met criteria for a positive screen with surprise question. 7/23 (30%) patients were documented to have GOC discussions or palliative care consultation. 39 patients were identified during post intervention phase with LACE+>70, out of which 25 (74%) met criteria for a positive screen with the surprise question. 9/25 (36%) were documented to have had GOC discussion in the post implementation group.
Conclusions: We demonstrated that combination of LACE+ score and surprise question can be an feasible screen to quickly identify patients in need of GOC discussions in general medicine inpatient teams. Even though our numbers were small, we exhibited a trend towards increased conversations (30 to 36%) with at-risk patients with easily accessible screening tools and education initiative.