Objectives I want to go home: Developing a pediatric palliative care transport model Vivian Broussard, RN, BSN, CPN, CHPPN Christy Dressler, RRT-NPS, C-NPT Jenni Linebarger, MD, MPH, FAAP 1. Understand the role a transport team can have in providing palliative care 2. Identify barriers to palliative care transport 3. Apply strategies to overcome barriers of palliative care transports Patient story #1 Published case reports 1994 3 neonates (from NICU) In the U.K.; involved senior registrar and nurse 2006 infant (from PICU) In California; hospice very involved 2009 infant (from PICU) In Oregon; PICU attending and respiratory therapist 1973 1984 1986 1991 History of EMS Emergency Medical Services Systems Act Emergency Medical Services for Children (EMS-C) program Emergency Medical Treatment and Active Labor Act (EMTALA) cornerstone of transport law Commission on Accreditation of Medical Transport Systems 4 types of transport systems 1. Hospital-based Owned and operated by sponsoring institutions Designed to serve hospital needs Usually operate at a net loss but generate indirect revenue streams providing an overall profit 2. Community-based Owned and operated by private companies Depend on a mix of adult transports, high volume, and low expenses 3. EMS-based Owned and subsidized by local, regional, and state government funding (inc. tax payer revenue) 4. Hybrid 1
Children s Mercy Transport Team What is a critical care transport team? Interdisciplinary team Provide advanced therapies High frequency ventilation, whole-body cooling, surfactant, pain management Receive specialty training and accreditation Available 24/7 Goal of meeting the patient s care goals, often aimed at survival and most appropriate level of care What is a palliative care team? Interdisciplinary team Provide advanced care Communication, care planning, and symptom management Receive specialty training and accreditation Available 24/7 Sounds like they have the same goals, so what are the barriers? Goal of meeting the patient s care goals, often aimed at comfort and most appropriate level of care Barriers to preferred location of death Urgent need for transport due to patient s rapidly changing condition Limited time to organize transfers Management of specialist equipment Continuity and comfort level of providers Need to clarify the resuscitation status of patients Legal barriers State EMS licensing requirements Specifically about who must be on board Resuscitation orders Hospital vs. Community Who receives the patient? EMTALA requires acceptance by a receiving physician Ingleton et al. Barriers to achieving care at home at the end of life: transferring patients between care settings using patient transport services. Pall Med, 2009 Hands et al. The implication of end-of-life transfers on a transport service. Infant, 2013 Zwerdling et al. Home pediatric compassionate extubation: bridging intensive and palliative care. Am J Hosp Pall Care, 2006 2
Staff availability Patient stability Timing barriers Getting there emotionally Mode and mileage of transport Practice barriers Going into a residence, access to the house Attitudes (general) of transport staff Medication Equipment needed in the home Safety training Funding barriers Trying to do the right thing Insurance reimbursement Support from institution Sept 2010 Nov 2010 Dolce dies Meet to discuss how to do the right thing Aug 2011 Policy written Dec 2011 Policy approved March 2012 First official palliative care transport Patient Story #2 How our policy addresses the barriers 3
Legal barriers Timing barriers EMS licensing requirements Attendants on transport Resuscitation orders Printed copy of hospital DNR Community DNR Who receives the patient? Hospice referral made Hospice RN meeting on arrival Staff availability Nonemergent, prescheduled for weekdays only Patient stability Accept that death en-route is possible Family readiness Mode and mileage of transport Ground only, with some exceptions Within 175 miles, with some exceptions Practice barriers Going into a residence Home assessment form Attitudes (general) Medication All prescribed medications en-route Anticipate comfort care medication needs Safety training Funding barriers Patient story #3 Insurance reimbursement Consent to Transport Ambulance Billing Authorization form Physician Certification Statement for Non- Emergency Ambulance Services Support from institution 4
Lessons learned More information to do this It can be done! Policy helps, but flexibility matters a lot! http://www2.aap.org/sections/transmed/tran sportteamsdatabase.pdf Our contacts: Vivian Broussard vrbroussard@cmh.edu Christy Dressler cdressler@cmh.edu Jenni Linebarger jslinebarger@cmh.edu References Hands S, Crabtree L, Wolfenden, Harrison C. The implication of end-of-life transfers on a transport service. Infant, 2013; 9(1):30-33 Hawdon JM, Williams S, Weindling AM. Withdrawal of neonatal intensive care in the home. Arch Dis Child, 1994; 71;F142-F144 Ingleton C, Payne S, Sargeant A, Seymour J. Barriers to achieving care at home at the end of life: transferring patients between care settings using patient transport services. Pall Med, 2009; 23(8):723-730 Needle JS. Home extubation by a pediatric critical care team: providing a compassionate death outsode the pediatric intensive care unit. Pediatr Crit Care Med, 2010; 11(3):401-403 Stroud MH et al. Pediatric and neonatal interfacility transport: results from a national consensus conference. Pediatrics, 2013; 132(2):359-366 Zwerdling T, Hamann KC, Kon AA. Home pediatric compassionate extubation: bridging intensive and palliative care. Am J Hosp Pall Care, 2006; 23(3):224-228 5