Description:
The University of Kansas Hospital is a 500 bed tertiary care academic
medical center with a level one trauma center and a regional burn
unit with a large Medicare/Medicaid population in addition to private
pay/insured patients.
The University of Kansas Palliative Care inpatient consult service is a fellowship training site for 4 rotations. The service sees a broad range of patients, from all of the ICU settings (medical, cardiac, surgical, neurosurgical, trauma, burn), medicine and oncology. The team sees an average of 45 new patients per month. Approximately 40% of patients on the service are discharged from the hospital alive. Diagnoses include cancer and non-cancer patients and represent a case mix index for disease severity of approximately 2.8. (Local community hospitals average a CMI of 1, KU inpatient population in general averages 2).
The fellow has significant interaction in the ICUs and gains experience in facilitating emotional and often complicated intra-professional discussions and family meetings. Consults range from patient and family support and education through aggressive trials of intervention, to management of the natural dying process on a purely comfort directed approach. Decision-making process, logistics, and management of patients in removal from artificial life support are also experienced. The core team consists of an attending physician, an advance practice nurse, and a dedicated social worker. A chaplain also supports the team. Learners present on the service may include 4th year medical students, senior residents and fellows, with no more than two learners present at any given time.During rotation with the Palliative Care service at KU, the fellow participates in the daily operations of the interdisciplinary team, seeing new consults as well as follow up patients in conjunction with the Palliative Care Attending, the rounding clinical nurse specialist, and the dedicated social worker. The fellow is integrally involved in whole patient assessments, symptom management, patient and family meetings, formulation of "goals of care" based treatment plans, and negotiating the medical system to facilitate safe and timely disposition from the acute care environment when appropriate. The fellow maintains continuity of patient care throughout the hospital stay and is available to be the patient's home hospice physician. The fellow takes a lead role for his/her patients in communication with other members of the Palliative Care rounding team as well as the primary team attending, house staff, and other consulting physicians regarding patient care recommendations and plan of care. Interdisciplinary rounds with the pertinent floor nursing, social work, and care coordination staff as well as ancillary services are performed daily as needed for each patient. The fellow serves in a supervisory role with residents and medical students rotating on the service as well. Finally, the fellow participates in the 90 minute Wednesday interdisciplinary care team conference where patient care plans are discussed and where the team debriefs on difficult or meaningful events of the week.
There are a few additional conferences that the fellow will be expected to participate in while on service at KU. The Palliative Care program actively participates in peer review forums to assess and review the quality and safety of patient care. First, the fellow will participate in the Burnett Burn Center’s monthly peer review. The Palliative Care program and the burn specialists have partnered to create clinical triggers for team involvement, hence our presence in the burn unit is regular. Peer review provides an opportunity to look objectively at elements of each case, debrief with all of the professionals involved, and optimize strategies for intra-professional communication and seamless patient and family management through very stressful clinical scenarios.
Second, every death in the hospital undergoes a multi-disciplinary peer review by the physicians involved, physician leadership, nursing leadership, risk management, and medical records. This forum is an excellent opportunity for care providers to evaluate the processes of care for safety, quality, and optimization of the patient care experience. It has also become a way for the Palliative Care program and the hospital administration to review the “quality of death”—90% of deaths reviewed in the past year were classified as “disease following expected course” (Mortality index is .71). While on rotation at KU, the fellow will be included in the mortality reviews for his or her patients from the Palliative Care consult service, to gain experience in identifying system errors/inadequacies which could adversely impact the quality of the patient and family dying experience, and to learn about systematic peer review in general.
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The University of Kansas Medical Center