North Shore University Hospital The Joint Commission Advanced Certification for Palliative Care January January 31, 2012

Mission & Vision To 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 Womens 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 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 Consumers 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 Americas 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 Presidents 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 ( ) 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 Childrens 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

Patient centered care –Sleeper sofas –Open visiting –Family rounds –Family pets Follow up telephone call Bereavement resources RN death pronouncement NP death certification

Donnas 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 GrantTopic Cardiovascular Grand Rounds Palliative Care in the Age of Health Care Reform Nurse-Practitioner ConferenceCritical Conversations Safety Rounds Advance Directives and the Family Health Care Decisions Act Molloy College Palliative Care Conference Palliative Care and New York State Law Long Island Caregiver Conference Palliative Care and the Family Caregiver Nursing Grand RoundsTerminal Tissue Injuries Harvard Faculty Development Grant Communication 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

Maxs 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