Milana Zaurova, MD, knows firsthand the misconceptions that surround a specialized type of care for people struggling with serious illness.
The NYC Health + Hospitals physician says it was her own experience advocating for her grandmother after a brain cancer diagnosis that inspired her to later study the medical specialty known as palliative care. Even as a fourth-year medical student armed with research about palliative care’s value at the time, Dr. Zaurova found it difficult to explain to loved ones that using this option didn’t signify “giving up.”
On the contrary, palliative care can provide relief from symptoms, pain, and the stress of serious illness by getting to know patients and their families and eliciting patient-centered goals for their care.
“People often think of it as end-of-life care...but there are so many benefits palliative care can bring to a patient and their family at any point in their illness,” said Dr. Zaurova, who is now senior director for emergency and palliative care quality at H + H’s Office of Quality & Safety.
It is in part this stigma that often prevents patients from accessing palliative care early in their illness, when it can make the most difference for the hospital, patient, and their family, Dr. Zaurova said. Palliative care has been shown to reduce symptom distress by 66 percent and increase patient satisfaction, as well as cut down on readmissions, emergency department visits, and length of stay in the hospital—all of which save costs. But the long list of priorities for primary team clinicians can mean that palliative care teams are called only in times of crisis, making it difficult to gain family trust and reap these benefits.
A fellow with United Hospital Fund and Greater New York Hospital Association’s Clinical Quality Fellowship Program, Dr. Zaurova decided to tackle the issue.
Taking it on as her fellowship capstone project, Dr. Zaurova came up with an innovative idea: add an automated alert in the electronic health system that would screen patients for these needs as soon as they are admitted to the hospital. Should a patient meet certain criteria—the presence of a serious illness, frequent recent hospital admissions, and a certain illness severity level—the trigger tool would automatically send an alert to the palliative care team’s inbox for follow-up.
“The thinking was, ‘Is there a way to automate and cognitively offload the burden of having to think about when to call palliative care for this patient?,’” Dr. Zaurova said. “We created this tool on the back end to incorporate evidence-based triggers for unmet palliative care needs.”
As Dr. Zaurova predicted, the tool helped palliative care teams see patients earlier in their hospital stay: the average time between hospital admission and a palliative care consult dropped by nearly 16 percent once the tool was in place at the six hospitals using the tool. That difference is particularly meaningful when considering the volume of patients who benefitted from an earlier consultation. Nearly 4,000 total patients were flagged for a palliative care consult just six months after implementation of the palliative care trigger tool.
Plus, those patients were, on average, able to leave the hospital earlier and spent less time in the intensive care unit. The average length of stay in the hospital and the average time spent in the ICU for palliative care patients both dropped by two days in the six months following the screening tool’s implementation. In addition to the benefits to the patient, these reductions will save an estimated $14 million per year across the six hospitals, Dr. Zaurova said.
The impact on length of stay and ICU time are common results of palliative care given that specialists are focused on finding safe and effective care options aligned with a patient's wishes, which often are to leave the hospital as soon as they can do so safely.
“[Palliative care specialists] are experts in communication and symptom management, and it is part of their job to get to know you as a person—what scares you, what makes you happy, what makes you tick—things that most other specialists who you see for a routine 15 minute office visit may not know about you ,” Dr. Zaurova said. “What palliative care does is carve out time to get to know you and align your treatment plan with who you are and what is most important to you.”
Another important benefit of Dr. Zaurova’s tool has been the ability to better track how many patients in the hospital system are in need of palliative care, and thus advocate for more resources. At one of the six hospitals using the automated tool, staff successfully used the data to request a new nurse practitioner whose job includes monitoring the patients identified by the tool.
More generally, Dr. Zaurova says the idea of using automated screening tools can likely be applied to other patient needs. At another of the six hospitals using the palliative care screening, staff are working on operationalizing a tool to help track patients who might have a sudden change or decline.
“This can potentially be used to trigger patients who are suddenly getting very sick and need to be upgraded to the ICU, or need an extra eye on them,” Dr. Zaurova said.
Dr. Zaurova noted that mentorship, technical skills, and feedback from the Clinical Quality Fellowship Program were instrumental in ensuring not only her project’s success, but also providing expertise she can use in future quality improvement efforts.
“The program was so, so amazing,” Dr. Zaurova said. “It’s super motivating to have all of the educational content under my belt and also very inspiring to have made connections and learned from like-minded change makers in my fellowship class.”
Started in 2009, the Clinical Quality Fellowship Program has trained more than 300 mid-career physicians, nurses, and physician assistants from over 50 health care facilities in the New York metropolitan area to become quality improvement and patient safety leaders in their organizations. The 15-month program graduates a new class of these change-makers on the front lines of health care each year.