Prepared by: The Center for Health Services and Outcomes Research

Transcription

1 . WEST VIRGINIA PALLIATIVE CARE TEAM REPORT Prepared by: The Center for Health Services and Outcomes Research January December 2012 Mary Emmett, Ph.D. Director Suzanne E. Kemper, MPH Research Associate Scott Dean, Ph.D. Senior Biostatistician MacCorkle Avenue, SE Charleston, WV / Fax 304/

2 2012 West Virginia Palliative Care Team Report Table of Contents Executive Summary Palliative Care Consultation All Sites Report Cabell-Huntington Hospital Charleston Area Medical Center Davis Memorial Hospital Fairmont General Hospital Ruby Memorial Hospital Ruby Memorial Hospital Pediatric St Joseph s Hospital St Mary s Hospital Thomas Memorial Hospital United Hospital Center Page 1 Page 4 Page 21 Page 30 Page 39 Page 48 Page 57 Page 66 Page 75 Page 84 Page 93 Page 102 CAMC Health Education & Research Institute i Center for Health Services & Outcomes Research

3 The following report is based on data submitted by the Palliative Care Teams for completed consults during the period of January 1 through December 31, Executive Summary A total of 2536 individuals received Palliative Care Services during Site % Cabell-Huntington Hospital Camden-Clark Hospital Charleston Area Medical Center Davis Memorial Hospital Fairmont General Hospital Monongalia General Hospital Ohio Valley Medical Center Preston Memorial Hospital Princeton Community Hospital Raleigh General Hospital Raleigh Regional Cancer Center Reynolds Memorial Hospital Ruby Memorial Hospital St. Francis Hospital St. Joseph s Hospital St. Mary s Hospital Thomas Memorial Hospital United Hospital Center Total Characteristics of the individuals followed by the Palliative Care Services include: 96.0% were White or Caucasian 52.9% of the patients were female 41.0% were married 28.7% were widowed Patients from 53 of 55 counties had a Palliative Care consult 1

4 Referral: Primary Diagnosis: Resuscitation: Advance Directives: There was a 15% increase in the total number of consults from 2011 to The main reasons for consults were goal clarification (77.7%), psychological/spiritual support of patient/family (13.7%), pain and symptom management (5.5%), and disposition (3.2%). Cancer represented the largest primary diagnosis (34.5%) followed by Neurological (14.6%), and Pulmonary (14.0%) consults (91.9%) had multiple chronic illnesses and of those 98.1% had more than 2 illnesses. At the completion of the palliative care consultation, 77.3% of the patients had Do Not Resuscitate (DNR) orders. After consultation, 61.6% of the patients had a medical power of attorney (MPOA) appointed. Of the 1507 (59.5%) patients without decision-making capacity, 777 (52.8%) had an MPOA, 602 (40.8%) had a health care surrogate (HCS), 552 (37.7%) had a living will, 439 (17.8%) had a POST Form and 97 (6.7%) had a legal guardian. Of the 1507 without decision-making capacity: 1298 (89.0%) had either an MPOA or HCS 47 (3.2%) had neither an MPOA, HCS nor POST 16 (1.1%) had both an MPOA and HCS A total of 1462 (97.0%) consults without decision-making capacity had some form of advance directives and 47 (3.0%) had no form. Of the 898 (35.5%) patients with decision-making capacity, 679 (76.8%) had an MPOA, 473 (53.6%) had a living will, 244 (9.9%) had a POST Form and 26 (3.0%) had a HCS. Of the 898 with decision-making capacity: 688 (78.7%) had either MPOA or HCS 172 (19.7%) had neither an MPOA, HCS nor POST 12 (1.4%) had a legal guardian 2 (0.2%) had both an MPOA and HCS A total of 723 (80.5%) patients with decision-making capacity had some form of advance directives and 175(19.5%) had no form. A total of 126 (5.0%) patients had a status of undetermined decision making capacity and of those 22 (17.5%) had no form of advance directives. 2

5 Pain Assessment: The PAINAD Scale was used for 1148 (60.8%) of the consults and 741 (39.2%) used the Numerical Rating Pain Scale. Of the 898 patients with decision making capacity at time of first visit 233 had Numerical Rating Pain Scale scores for both the initial assessment and 48-hour assessment. A decrease in pain from initial to 48-hour pain assessment was reported for 105 (45.06%) patients. The average decrease between initial and 48-hour assessment was 4. Mean score for initial assessment was 6 and the mean score for 48-hour pain assessment was 2. An increase in pain from initial to 48-hour pain assessment was reported for 13 (5.6%) patients. The average increase between initial and 48-hour assessment was 3. Mean score for initial assessment was 4 and the mean score for 48-hour pain assessment was 7. Treatments: Disposition: Process Measures: See attached information and method for understanding the data on page 6. Of the 643 people that died, 390 (63.8%) died in an acute care bed, 171 (28.0%) died in the ICU, 11 (1.8%) died in Hospice and 21 (3.4%) died in SNU. At the time of discharge from the hospital or nursing home 643 (25.9%) patients died, 401 (16.1%) went home with Hospice, 310 (12.5%) were discharged home, 232(9.3%) went to a Nursing Home/Skilled Nursing Facility and 415 (16.7%) went to a Hospice House. For the 2244 patients admitted to the hospital, the following mean number of days was reported: Admission to Referral = 7 days, Referral to Discharge = 6 days, Referral to Death = 4 days. For those 7 patients admitted to nursing homes, the following mean number of days was reported: Admission to Referral = 11 days, Referral to Discharge = 7 days. A total of 899 patients were discharged to a Hospice care setting. The following mean days were reported: Admission to Referral = 6 days, Referral to Discharge = 4 days. A total of 256 patients were admitted to the ICU. The following mean days were reported: Admission to Referral = 6 days, Referral to Discharge = 4 days and Referral to Death = 4 days. NOTE: Throughout the report you will notice that the totals do not always match the total number of patients. The reason is because data are missing. Missing data were checked. 3

6 All Sites PCT Data Collection - Tool Total number of patients discharged during January through December 2012: 2536 The data throughout this report that are noted as missing data were checked. Gender: n % Marital Status: n % Male Single Female Married Total Divorced Separated Widowed Total Pediatric: n % Yes No Total County of Residence: In State: n % n % Barbour Mineral Berkeley Mingo Boone Monongalia Braxton Monroe Brooke Morgan Cabell Nicholas Calhoun Ohio Clay Pendleton Doddridge Pleasants Fayette Pocahontas Gilmer Preston Grant Putnam Greenbrier Raleigh Hampshire Randolph Hancock Ritchie Hardy Roane Harrison Summers Jackson Taylor Jefferson Tucker Kanawha Tyler Lewis Upshur Lincoln Wayne Logan Webster Marion Wetzel Marshall Wirt Mason Wood McDowell Wyoming Mercer Total Out of State: n % Boyd, KY Lawrence, OH Carter, KY Racine, OH Elliott, KY Scioto, OH Floyd, KY Other OH Greenup, KY Other States Johnson, KY Carter, KY Magoffin, KY Martin, KY Other KY Total Ethnicity: n % n % Black or African American American Indian/Alaskan Native White or Caucasian Hispanic or Spanish Asian or Pacific Islander Other Total CAMC Health Education & Research Institute 4 Center for Health Services & Outcomes Research

7 All Sites Reason for Consult: n % Reason for Consult: Was pain and symptom management discussed? Only one answer could be marked. No Yes Total Goal clarification Goal clarification Psych/spiritual support of pt/family % Pain and symptom management Psych/spiritual support of pt/family Disposition % Total Pain and symptom management % Disposition % Total % Patient was admitted to: n % Consult Location: n % Hospital Hospital floor bed Nursing Home/SNF ED ICU ICU/Stepdown SNU Nursing Home/SNF ED SNU Other Total Total Primary Diagnosis: n % Did patient have multiple chronic illnesses: Cancer n % Cardiac Yes AIDS No Renal Total Pulmonary Liver Neurological Of the 2300 that had multiple illnesses, note the following: Noncardiac Vascular n % Dementia <= General disability > Sepsis Total Multi-organ failure Total PPS at first contact: (n=2530) PPS Range n % Average 28.0 < = Minimum 0 > = Maximum 100 Total Symptoms at initial assessment: Those who reported 'yes' they had these symptoms. Percentages are out of the total number of patients (2536). n % n % Pain Nausea/Vomiting Anorexia Insomnia Dysphasia Weakness/malaise Sore Mouth Edema Dyspnea Restlessness Cough Confusion/delirium Constipation Anxiety Diarrhea Depression No symptoms Total 3848 Would you be surprised if the patient died in the next year? n % Yes No Total Do Not Resuscitate: n % DNR initiated by PCT: n % Yes Yes No No Total Total DNR Card: n % DNR Card initiated by PCT: n % Yes Yes No No Total Total CAMC Health Education & Research Institute 5 Center for Health Services & Outcomes Research

8 All Sites Advanced Directives Living Will: n % Living will initiated by PCT: n % Yes Yes No No Total Total Medical Power Of Attorney: n % MPOA initiated by PCT: n % Yes Yes No No Total Total Health Care Surrogate: n % HCS initiated by PCT: n % Yes Yes No No Total Total Legal Guardian: n % Legal Guardian initiated by PCT: n % Yes Yes No No Parent of Minor Total Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes No No Total Total Did patient have decision making capacity at time of first visit? n % Yes No Unable to determine Total Of the 1507 patients WITHOUT decision making capacity the following advanced directives were noted: Living Will: n % Living will initiated by PCT: n % Yes Yes No No Total Total Medical Power Of Attorney: n % MPOA initiated by PCT: n % Yes Yes No No Total Total Health Care Surrogate: n % HCS initiated by PCT: n % Yes Yes No No Total Total Legal Guardian: n % Legal Guardian initiated by PCT: n % Yes Yes No No Parent of Minor Total Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes No No Total Total MPOA and Health Care Surrogate appointment: Advance Directives of any kind appointed: n % n % Yes Both MPOA and HCS appointed No MPOA or HCS appointed Total Legal Guardian appointed Neither MPOA or HCS appointed Total CAMC Health Education & Research Institute 6 Center for Health Services & Outcomes Research

9 All Sites Of the 898 patients WITH decision making capacity the following advanced directives were noted: Living Will: n % Living will initiated by PCT: n % Yes Yes No No Total Total Medical Power Of Attorney: n % MPOA initiated by PCT: n % Yes Yes No No Total Total Health Care Surrogate: n % HCS initiated by PCT: n % Yes Yes No No Total Total Legal Guardian: n % Legal Guardian initiated by PCT: n % Yes Yes No No Parent of Minor Total Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes No No Total Total MPOA and Health Care Surrogate appointment: Advance Directives of any kind appointed: n % n % Yes Both MPOA and HCS appointed No MPOA or HCS appointed Total Legal Guardian appointed Neither MPOA or HCS appointed Total Of the 126 patients WITH an undetermined decision making capacity the following advanced directives were noted: MPOA and Health Care Surrogate appointment: n % Advance Directives of any kind appointed: n % Both MPOA and HCS appointed Yes MPOA or HCS appointed No Legal Guardian appointed Total Neither MPOA or HCS appointed Total CAMC Health Education & Research Institute 7 Center for Health Services & Outcomes Research

10 All Sites Pain Scale used Pain Scale used n % Numeric PAINAD Total Numerical Rating Scale With decision making capacity PAINAD Scale % Total Without decision making capacity % Total % Overall - Regardless of Pain Scale Used Of the 2536 patients, 949 had pain scale scores for both the initial pain assessment and the 48 hour assessment. The difference in pain scores between the two assessments. The difference in pain scores between the two assessments, n % with 0's for both initial and 48 hour removed. n % Higher Higher Lower Lower No Change No Change Total Total Of those 319 patients with decrease in pain score from initial Of the 34 patients that experienced a increase in pain score from initial assessment to 48 hours, the following pain scores were reported: assessment to 48 hours, the following changes were noted: Time1 /Time 2 n % Time1 /Time 2 n % Severe to Moderate None to Mild Severe to Mild None to Moderate Severe to None None to Severe Moderate to Mild Mild to Moderate Moderate to None Mild to Severe Mild to None Moderate to Severe Numerical Rating Scale Used Of those 898 patients WITH decision making capacity at time of first visit & Numerical Rating Scale scores, 233 had Numerical Rating scale scores for both the initial pain assessment and the 48 hour assessment. The difference in pain scores between the two assessments. The difference in pain scores between the two assessments, n % with 0's for both initial and 48 hour removed. n % Higher Higher Lower Lower No Change No Change Total Total Of those 105 patients with decrease in pain score from initial Of the 13 patients that experienced a increase in pain score from initial assessment to 48 hours, the following pain scores were reported: assessment to 48 hours, the following changes were noted: Time1 /Time 2 n % Time1 /Time 2 n % Severe to Moderate None to Mild Severe to Mild None to Moderate Severe to None None to Severe Moderate to Mild Mild to Moderate Moderate to None Mild to Severe Mild to None Moderate to Severe PAIN AD SCALE Of those 1507 patients WITHOUT decision making capacity at time of first visit & PAIN AD scale scores, 479 had PAIN AD scale scores for both the initial pain assessment and the 48 hour assessment. The difference in pain scores between the two assessments. The difference in pain scores between the two assessments, n % with 0's for both initial and 48 hour removed. n % Higher Higher Lower Lower No Change No Change Total Total Of those 106 patients with decrease in pain score from initial assessment to 48 hours, the following pain scores were reported: Of the 10 patients that experienced a increase in pain score from initial assessment to 48 hours, the following changes were noted: Time1 /Time 2 n % Time1 /Time 2 n % Severe to Moderate None to Mild Severe to Mild None to Moderate Severe to None None to Severe Moderate to Mild Mild to Moderate Moderate to None Mild to Severe Mild to None Moderate to Severe CAMC Health Education & Research Institute 8 Center for Health Services & Outcomes Research

11 All Sites Treatments in use and changes while PCT involved in care: How to interpret the data: (Information reported reflects only those variables that were marked, no assumptions can be made.) The patient(s) can be using or not using a treatment at the time palliative care gets involved. If the treatment is marked "in use" it can be stopped. If the treatment is marked "not in use" it can be avoided. Example: Intravenous fluids: 1415 patients (87.51%) were receiving intravenous fluids, 202 (12.49%) were not using the intravenous fluids. Of the 1415 patients using IV fluids, 1111 (78.52%) discontinued use. Of the 202 patients not receiving IV fluids, 68 (33.66%) treatments were avoided. Intravenous fluids n % Mechanical ventilation n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Intravenous antibiotics n % BIPAP or CPAP n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Intravenous Vasopressors n % Transfusions n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided TPN/PPN n % Chemotherapy n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Gastric feedings n % Radiation Therapy n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Dialysis n % Surgery n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Diagnostic labs n % ICU Admission to the floor n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Diagnostic x-rays n % In use Not in use In use and stopped Not in use and avoided CAMC Health Education & Research Institute 9 Center for Health Services & Outcomes Research

12 All Sites Discharge Summary: Even after discharge the palliative care teams continue to track and follow-up with their patients. A total of 643 (25.86%) patients died while being followed by the palliative care teams during Disposition: n % Place of Death: n % Data reported for the following is strictly based on what happened Data reported for the following is based on the patient to the patient on their exact discharge date. dying on the date of discharge. Death Hospital (ICU) SNU (Hospital) Hospital (Acute) PCU Personal Care Home NH/SNF Home Home SNU (Hospital) Hospice NH/SNF Home Health Hospice Inpatient Hospital (Transfer) Hospice House Hospice inpatient PCU NH/SNF with Hospice Home Health Personal care home Hospice Acute Rehabilitation NH/SNF with Hospice Hospice House Acute Rehablitation LTAC Other Team services no longer needed Total Other Total Of those 643 patients who died the following were designated: Primary Diagnosis: n % Cancer Cardiac AIDS Renal Pulmonary Liver Neurological Noncardiac Vascular Dementia General Disability Sepsis Mulit-organ failure Total Interventions by PCT: (More than one option can be checked. Percentages are out of the total number of patients (2536).) n % Education about the process of their disease, prognosis and options for care Conduct a patient and family care conference with appropriate members of the interdisciplinary team Education about the benefits and burdens of specific treatments or potential interventions Provide information about spiritual care services or counseling services available Provide individual education and support to families and unlicensed caregivers to assure safe and appropriate care after discharge Provide pain and symptom management recommendations Education about the signs and symptoms of imminent death or dying process in a timely, culturally appropriate manner Hospice option for care was presented at this admission Total Outcomes or decisions followed by family: (More than one option can be checked. Percentages are out of the total number of patients (2536). n % Patient and family participated in family care conference Pastoral Care referral Involvement of own clergy for spiritual support Total 3487 CAMC Health Education & Research Institute 10 Center for Health Services & Outcomes Research

13 PCT Data Collection - Tool Total number of Palliative Care consults completed during 2012: 2536 Palliative Care Team All Sites Reason for Consult (n=2,528) 9.45% 9.73% 3.16% 77.65% Goal clarification Psych/spiritual support of pt/family Pain and symptom management Disposition Primary Diagnosis (n=2,473) Cancer Neurological Pulmonary General disability Cardiac Dementia 500 Sepsis Liver Renal Multi-organ failure Noncardiac Vascular AIDS 1200 Symptoms at Initial Assessment (n=2,536) Weakness/malaise Pain No symptoms Dyspnea Cough Anorexia 400 Nausea/Vomiting Dysphasia Confusion/delirium 0 Symptoms Depression Constipation CAMC Health Education & Research Institute 11 Center for Health Services & Outcomes Research

14 PCT Data Collection Tool - Outcomes Palliative Care Team All Sites Disposition (n=2,508) Death Hospice House Hospice Home NH/SNF Home Health Team services no longer needed NH/SNF with Hospice Hospital (Transfer) LTAC Acute Rehabilitation Hospice inpatient Other SNU (Hospital) Personal care home PCU Place of death (n=611) CAMC Health Education & Research Institute 12 Center for Health Services & Outcomes Research

15 Patients Served by West Virginia Palliative Care Teams To otal Number Years Center for Health Services & Outcomes Research 13 CAMC Health Education & Research Institute

16 Percentage of Patients with Do Not Resuscitate Orders Percentages 100% 90% 80% 70% 60% 50% 40% 65.6% 87.3% 75.3% 85.5% 77.7% 77.1% 86.0% 85.0% 78.8% 80.1% 75.2% 77.3% 30% 20% 10% 0% Years Center for Health Services & Outcomes Research 14 CAMC Health Education & Research Institute

17 Percentage of Patients with Advance Directives % 90% Percentages 80% 70% 60% 50% 40% 37.2% 30% 24.1% 20% 10% 0% 52.1% 52.0% 50.3% 59.9% 35.3% 37.5% 45.5% 2.1% 1.3% 1.0% 63.4% 52.7% 70.3% 56.6% 66.7% 64.8% 52.6% 39.5% 52.4% 58.7% 42.9% 36.2% 27.5% 27.1% 29.2% 61.7% 48.7% 29.9% 29.4% 25.5% 22.2% 24.9% 27.9% 25.3% 28.1% 14.3% 15.2% 15.0% 61.6% 56.3% 43.5% 39.0% 28.3% 30.4% 26.8% 14.7% 1.8% 0.9% 0.9% 0.8% 1.2% 1.6% 1.7% 0.9% 4.6% Years MPOA Living Will HCS Legal Guardian POST Center for Health Services & Outcomes Research 15 CAMC Health Education & Research Institute

18 Patients without Decision Making Capacity and without Advance Directives % 90% 80% Percentages 70% 60% 50% 40% 30% 20% 10% 0% 9.4% 7.5% 6.3% 3.5% 3.9% 5.9% 4.6% 5.8% 5.7% 5.1% 3.0% 5.8% Years NOTE: Data includes those patients without MPOA, Living Will, Health Care Surrogate or Legal Guardian. Center for Health Services & Outcomes Research 16 CAMC Health Education & Research Institute

19 Percentage of Patients Discharged with Hospice % 90% 80% 70% Percentages 60% 50% 40% 30% 20% 10% 8.6% 16.9% 27.7% 26.5% 29.3% 38.7% 29.1% 42.2% 35.7% 37.4% 35.0% 35.5% 0% Years NOTE: Data includes those patients with the following dispositions: Hospice, Hospice Inpatient, NH/SNF with Hospice or Hospice House. Hospice House was added as an option in Center for Health Services & Outcomes Research 17 CAMC Health Education & Research Institute

20 Patients Discharged with Hospice by Location Total Number Years Hospice Hospice Inpatient NH/SNF Hospice Hospice House Center for Health Services & Outcomes Research 18 CAMC Health Education & Research Institute

21 Percentage of Patients with a Disposition of Death % 90% 80% 70% Percentages 60% 50% 40% 30% 20% 52.5% 47.5% 49.7% 43.3% 29.6% 29.4% 27.4% 29.2% 27.7% 25.7% 26.7% 25.9% 10% 0% Years NOTE: Data includes those patients that died at Disposition. Center for Health Services & Outcomes Research 19 CAMC Health Education & Research Institute

22 Patients Dying in Hospital Setting Total Number Years ICU Acute SNU Center for Health Services & Outcomes Research 20 CAMC Health Education & Research Institute

23 Cabell- Huntington Hospital PCT Data Collection - Tool Total number of patients discharged during January through December 2012: 218 The data throughout this report that are noted as missing data were checked. Gender: n % Marital Status: n % Male Single Female Married Total Divorced Separated Widowed Total Pediatric: n % Yes No Total County of Residence: In State: n % n % Barbour Mineral Berkeley Mingo Boone Monongalia Braxton Monroe Brooke Morgan Cabell Nicholas Calhoun Ohio Clay Pendleton Doddridge Pleasants Fayette Pocahontas Gilmer Preston Grant Putnam Greenbrier Raleigh Hampshire Randolph Hancock Ritchie Hardy Roane Harrison Summers Jackson Taylor Jefferson Tucker Kanawha Tyler Lewis Upshur Lincoln Wayne Logan Webster Marion Wetzel Marshall Wirt Mason Wood McDowell Wyoming Mercer Total Out of State: n % Boyd, KY Lawrence, OH Carter, KY Racine, OH Elliott, KY Scioto, OH Floyd, KY Other OH Greenup, KY Other States Johnson, KY Carter, KY Magoffin, KY Martin, KY Other KY Total Ethnicity: n % n % Black or African American American Indian/Alaskan Native White or Caucasian Hispanic or Spanish Asian or Pacific Islander Other Total CAMC Health Education & Research Institute 21 Center for Health Services & Outcomes Research

24 Cabell- Huntington Hospital Reason for Consult: n % Reason for Consult: Was pain and symptom management discussed? Only one answer could be marked. No Yes Total Goal clarification Goal clarification Psych/spiritual support of pt/family % Pain and symptom management Psych/spiritual support of pt/family Disposition % Total Pain and symptom management % Disposition % Total % Patient was admitted to: n % Consult Location: n % Hospital Hospital floor bed Nursing Home/SNF ED ICU ICU/Stepdown SNU Nursing Home/SNF ED SNU Other Total Total Primary Diagnosis: n % Did patient have multiple chronic illnesses: Cancer n % Cardiac Yes AIDS No Renal Total Pulmonary Liver Neurological Of the 211 that had multiple illnesses, note the following: Noncardiac Vascular n % Dementia <= General disability > Sepsis Total Multi-organ failure Total PPS at first contact: (n=218) PPS Range n % Average 21.9 < = Minimum 10 > = Maximum 70 Total Symptoms at initial assessment: Those who reported 'yes' they had these symptoms. Percentages are out of the total number of patients (218). n % n % Pain Nausea/Vomiting Anorexia Insomnia Dysphasia Weakness/malaise Sore Mouth Edema Dyspnea Restlessness Cough Confusion/delirium Constipation Anxiety Diarrhea Depression No symptoms Total 347 Would you be surprised if the patient died in the next year? n % Yes No Total Do Not Resuscitate: n % DNR initiated by PCT: n % Yes Yes No No Total Total DNR Card: n % DNR Card initiated by PCT: n % Yes Yes No No Total Total CAMC Health Education & Research Institute 22 Center for Health Services & Outcomes Research

25 Cabell- Huntington Hospital Advanced Directives Living Will: n % Living will initiated by PCT: n % Yes Yes No No Total Total Medical Power Of Attorney: n % MPOA initiated by PCT: n % Yes Yes No No Total Total Health Care Surrogate: n % HCS initiated by PCT: n % Yes Yes No No Total Total Legal Guardian: n % Legal Guardian initiated by PCT: n % Yes Yes No No Parent of Minor Total Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes No No Total Total Did patient have decision making capacity at time of first visit? n % Yes No Unable to determine Total Of the 157 patients WITHOUT decision making capacity the following advanced directives were noted: Living Will: n % Living will initiated by PCT: n % Yes Yes No No Total Total Medical Power Of Attorney: n % MPOA initiated by PCT: n % Yes Yes No No Total Total Health Care Surrogate: n % HCS initiated by PCT: n % Yes Yes No No Total Total Legal Guardian: n % Legal Guardian initiated by PCT: n % Yes Yes No No Parent of Minor Total Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes No No Total Total MPOA and Health Care Surrogate appointment: Advance Directives of any kind appointed: n % n % Yes Both MPOA and HCS appointed No MPOA or HCS appointed Total Legal Guardian appointed Neither MPOA or HCS appointed Total CAMC Health Education & Research Institute 23 Center for Health Services & Outcomes Research

26 Cabell- Huntington Hospital Of the 36 patients WITH decision making capacity the following advanced directives were noted: Living Will: n % Living will initiated by PCT: n % Yes Yes No No Total Total Medical Power Of Attorney: n % MPOA initiated by PCT: n % Yes Yes No No Total Total Health Care Surrogate: n % HCS initiated by PCT: n % Yes Yes No No Total Total Legal Guardian: n % Legal Guardian initiated by PCT: n % Yes Yes 0 N/A No No 0 N/A Parent of Minor Total 0 N/A Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes 0 N/A No No 0 N/A Total Total 0 N/A MPOA and Health Care Surrogate appointment: Advance Directives of any kind appointed: n % n % Yes Both MPOA and HCS appointed No MPOA or HCS appointed Total Legal Guardian appointed Neither MPOA or HCS appointed Total Of the 25 patients WITH an undetermined decision making capacity the following advanced directives were noted: MPOA and Health Care Surrogate appointment: n % Advance Directives of any kind appointed: n % Both MPOA and HCS appointed Yes MPOA or HCS appointed No Legal Guardian appointed Total Neither MPOA or HCS appointed Total CAMC Health Education & Research Institute 24 Center for Health Services & Outcomes Research

27 Cabell- Huntington Hospital Pain Scale used Pain Scale used n % Numeric PAINAD Total Numerical Rating Scale With decision making capacity PAINAD Scale % Total Without decision making capacity % Total % Overall - Regardless of Pain Scale Used Of the 218 patients, 218 had pain scale scores for both the initial pain assessment and the 48 hour assessment. The difference in pain scores between the two assessments. The difference in pain scores between the two assessments, n % with 0's for both initial and 48 hour removed. n % Higher Higher Lower Lower No Change No Change Total Total Of those 106 patients with decrease in pain score from initial Of the 1 patients that experienced a increase in pain score from initial assessment to 48 hours, the following pain scores were reported: assessment to 48 hours, the following changes were noted: Time1 /Time 2 n % Time1 /Time 2 n % Severe to Moderate None to Mild Severe to Mild None to Moderate Severe to None None to Severe Moderate to Mild Mild to Moderate Moderate to None Mild to Severe Mild to None Moderate to Severe Numerical Rating Scale Used Of those 36 patients WITH decision making capacity at time of first visit & Numerical Rating Scale scores, 28 had Numerical Rating scale scores for both the initial pain assessment and the 48 hour assessment. The difference in pain scores between the two assessments. The difference in pain scores between the two assessments, n % with 0's for both initial and 48 hour removed. n % Higher Higher Lower Lower No Change No Change Total Total Of those 21 patients with decrease in pain score from initial Of the 1 patients that experienced a increase in pain score from initial assessment to 48 hours, the following pain scores were reported: assessment to 48 hours, the following changes were noted: Time1 /Time 2 n % Time1 /Time 2 n % Severe to Moderate None to Mild Severe to Mild None to Moderate Severe to None None to Severe Moderate to Mild Mild to Moderate Moderate to None Mild to Severe Mild to None Moderate to Severe PAIN AD SCALE Of those 157 patients WITHOUT decision making capacity at time of first visit & PAIN AD scale scores, 137 had PAIN AD scale scores for both the initial pain assessment and the 48 hour assessment. The difference in pain scores between the two assessments. The difference in pain scores between the two assessments, n % with 0's for both initial and 48 hour removed. n % Higher Higher Lower Lower No Change No Change Total Total Of those 49 patients with decrease in pain score from initial Of the 0 patients that experienced a increase in pain score from initial assessment to 48 hours, the following pain scores were reported: assessment to 48 hours, the following changes were noted: Time1 /Time 2 n % Time1 /Time 2 n % Severe to Moderate None to Mild 0 N/A Severe to Mild None to Moderate 0 N/A Severe to None None to Severe 0 N/A Moderate to Mild Mild to Moderate 0 N/A Moderate to None Mild to Severe 0 N/A Mild to None Moderate to Severe 0 N/A CAMC Health Education & Research Institute 25 Center for Health Services & Outcomes Research

28 Cabell- Huntington Hospital Treatments in use and changes while PCT involved in care: How to interpret the data: (Information reported reflects only those variables that were marked, no assumptions can be made.) The patient(s) can be using or not using a treatment at the time palliative care gets involved. If the treatment is marked "in use" it can be stopped. If the treatment is marked "not in use" it can be avoided. Example: Intravenous fluids: 134 patients (96.4%) were receiving intravenous fluids, 5 (3.6%) were not using the intravenous fluids. Of the 134 patients using IV fluids, 134 (100%) discontinued use. Of the 5 patients not receiving IV fluids, 5 (100%) treatments were avoided. Intravenous fluids n % Mechanical ventilation n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Intravenous antibiotics n % BIPAP or CPAP n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Intravenous Vasopressors n % Transfusions n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided 0 N/A Not in use and avoided TPN/PPN n % Chemotherapy n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Gastric feedings n % Radiation Therapy n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Dialysis n % Surgery n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Diagnostic labs n % ICU Admission to the floor n % In use In use Not in use Not in use In use and stopped In use and stopped Not in use and avoided Not in use and avoided Diagnostic x-rays n % In use Not in use In use and stopped Not in use and avoided CAMC Health Education & Research Institute 26 Center for Health Services & Outcomes Research

29 Cabell- Huntington Hospital Discharge Summary: Even after discharge the palliative care teams continue to track and follow-up with their patients. A total of 61 (27.98%) patients died while being followed by the palliative care teams during Disposition: n % Place of Death: n % Data reported for the following is strictly based on what happened Data reported for the following is based on the patient to the patient on their exact discharge date. dying on the date of discharge. Death Hospital (ICU) SNU (Hospital) Hospital (Acute) PCU Personal Care Home NH/SNF Home Home SNU (Hospital) Hospice NH/SNF Home Health Hospice Inpatient Hospital (Transfer) Hospice House Hospice inpatient PCU NH/SNF with Hospice Home Health Personal care home Hospice Acute Rehabilitation NH/SNF with Hospice Hospice House Acute Rehablitation LTAC Other Team services no longer needed Total Other Total Of those 61 patients who died the following were designated: Primary Diagnosis: n % Cancer Cardiac AIDS Renal Pulmonary Liver Neurological Noncardiac Vascular Dementia General Disability Sepsis Mulit-organ failure Total Interventions by PCT: (More than one option can be checked. Percentages are out of the total number of patients (218).) n % Education about the process of their disease, prognosis and options for care Conduct a patient and family care conference with appropriate members of the interdisciplinary team Education about the benefits and burdens of specific treatments or potential interventions Provide information about spiritual care services or counseling services available Provide individual education and support to families and unlicensed caregivers to assure safe and appropriate care after discharge Provide pain and symptom management recommendations Education about the signs and symptoms of imminent death or dying process in a timely, culturally appropriate manner Hospice option for care was presented at this admission Total 1073 Outcomes or decisions followed by family: (More than one option can be checked. Percentages are out of the total number of patients (218). n % Patient and family participated in family care conference Pastoral Care referral Involvement of own clergy for spiritual support Total 415 CAMC Health Education & Research Institute 27 Center for Health Services & Outcomes Research

30 PCT Data Collection - Tool Total number of Palliative Care consults completed during 2012: 218 Palliative Care Team Cabell-Huntington Hospital Reason for Consult (n=218) 9.63% 4.13% 16.51% 69.72% Goal clarification Psych/spiritual support of pt/family Pain and symptom management Disposition 140 Primary Diagnosis (n=218) Cancer Pulmonary Noncardiac Vascular Neurological Sepsis Cardiac Liver Dementia General disability Renal Multi-organ failure AIDS Symptoms at Initial Assessment (n=218) Pain Weakness/malaise Cough Dyspnea 50 Nausea/Vomiting 40 Anorexia Confusion/delirium Constipation 0 Symptoms Dysphasia Depression CAMC Health Education & Research Institute 28 Center for Health Services & Outcomes Research

31 Cabell-Huntington Hospital Disposition (n=218) Hospice House Death Hospice Home Health Hospice inpatient Home NH/SNF with Hospice NH/SNF LTAC Team services no longer needed Acute Rehabilitation SNU (Hospital) 0 Hospital (Transfer) Place of death (n=59) CAMC Health Education & Research Institute 29 Center for Health Services & Outcomes Research

32 Charleston Area Medical Center PCT Data Collection - Tool Total number of patients discharged during January through December 2012: 602 The data throughout this report that are noted as missing data were checked. Gender: n % Marital Status: n % Male Single Female Married Total Divorced Separated Widowed Total Pediatric: n % Yes No Total County of Residence: In State: n % n % Barbour Mineral Berkeley Mingo Boone Monongalia Braxton Monroe Brooke Morgan Cabell Nicholas Calhoun Ohio Clay Pendleton Doddridge Pleasants Fayette Pocahontas Gilmer Preston Grant Putnam Greenbrier Raleigh Hampshire Randolph Hancock Ritchie Hardy Roane Harrison Summers Jackson Taylor Jefferson Tucker Kanawha Tyler Lewis Upshur Lincoln Wayne Logan Webster Marion Wetzel Marshall Wirt Mason Wood McDowell Wyoming Mercer Total Out of State: n % Boyd, KY 0 N/A Lawrence, OH 0 N/A Carter, KY 0 N/A Racine, OH 0 N/A Elliott, KY 0 N/A Scioto, OH 0 N/A Floyd, KY 0 N/A Other OH 0 N/A Greenup, KY 0 N/A Other States 0 N/A Johnson, KY 0 N/A Carter, KY 0 N/A Magoffin, KY 0 N/A Martin, KY 0 N/A Other KY 0 N/A Total Ethnicity: n % n % Black or African American American Indian/Alaskan Native White or Caucasian Hispanic or Spanish Asian or Pacific Islander Other Total CAMC Health Education & Research Institute 30 Center for Health Services & Outcomes Research

33 Charleston Area Medical Center Reason for Consult: n % Reason for Consult: Was pain and symptom management discussed? Only one answer could be marked. No Yes Total Goal clarification Goal clarification Psych/spiritual support of pt/family % Pain and symptom management Psych/spiritual support of pt/family Disposition % Total Pain and symptom management % Disposition % Total % Patient was admitted to: n % Consult Location: n % Hospital Hospital floor bed Nursing Home/SNF ED ICU ICU/Stepdown SNU Nursing Home/SNF ED SNU Other Total Total Primary Diagnosis: n % Did patient have multiple chronic illnesses: Cancer n % Cardiac Yes AIDS No Renal Total Pulmonary Liver Neurological Of the 569 that had multiple illnesses, note the following: Noncardiac Vascular n % Dementia <= General disability > Sepsis Total Multi-organ failure Total PPS at first contact: (n=596) PPS Range n % Average 29.3 < = Minimum 10 > = Maximum 80 Total Symptoms at initial assessment: Those who reported 'yes' they had these symptoms. Percentages are out of the total number of patients (602). n % n % Pain Nausea/Vomiting Anorexia Insomnia Dysphasia Weakness/malaise Sore Mouth Edema Dyspnea Restlessness Cough Confusion/delirium Constipation Anxiety Diarrhea Depression No symptoms Total 1524 Would you be surprised if the patient died in the next year? n % Yes No Total Do Not Resuscitate: n % DNR initiated by PCT: n % Yes Yes No No Total Total DNR Card: n % DNR Card initiated by PCT: n % Yes Yes No No Total Total CAMC Health Education & Research Institute 31 Center for Health Services & Outcomes Research