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 2013 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 2013 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 - Adult Ruby Memorial Hospital Pediatric St Francis Hospital St Joseph s Hospital St Mary s Hospital Thomas Memorial Hospital United Hospital Center Page 1 Page 5 Page 22 Page 31 Page 40 Page 49 Page 58 Page 67 Page 76 Page 85 Page 94 Page 103 Page 112 CAMC Health Education & Research Institute i Center for Health Services & Outcomes Research

3 Site 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 3373 individuals received Palliative Care Services during Total n 2005 Total n 2006 Total n 2007 Total n 2008 Total n 2009 Total n 2010 Total n 2011 Total n 2012 Total n 2013 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 (Adult and Pediatric) St. Francis Hospital St. Joseph s Hospital St. Mary s Hospital Thomas Memorial Hospital United Hospital Center Total % 1

4 Characteristics of the individuals followed by the Palliative Care Services include: Referral: Primary Diagnosis: Resuscitation: Advance Directives: 96.7% were White or Caucasian 54.0% of the patients were female 40.8% were married 27.5% were widowed Palliative care services provided care to patients in all 55 counties There was a 33% increase in the total number of consults from 2012 to The main reasons for consults were goal clarification (75.4%), psychological/spiritual support of patient/family (13.1%), pain and symptom management (9.2%), and disposition (2.3%). During goal clarification, 62% of the consults included a conversation about pain management. Cancer represented the largest primary diagnosis (32.2%) followed by Pulmonary (16.8%) and Neurological (12.1%) consults (90.2%) had multiple chronic illnesses and of those 96.8% had more than 2 illnesses. At the completion of the palliative care consultation, 70.5% of the patients had Do Not Resuscitate (DNR) orders. 53% of the DNR orders were initiated by Palliative Care. 58.2% of the patients had a medical power of attorney (MPOA) appointed. Of the 1867 (55.5%) patients without decision-making capacity, 893 (48.8%) had an MPOA, 727 (39.8%) had a health care surrogate (HCS), 606 (33.0%) had a living will, 546 (30.2%) had a POST Form and 189 (10.5%) had a legal guardian. The majority of the patients with a legal guardian were on the Pediatric Service. Of the 1867 without decision-making capacity: 1520 (84.2%) had either an MPOA or HCS 70 (3.9%) had neither an MPOA, HCS nor POST 26 (1.4%) had both an MPOA and HCS 2

5 Pain Assessment: A total of 1789 (95.8%) patients without decision-making capacity had some form of advance directives and 78 (4.2%) had no advance directive. Of the 1370 (40.7%) patients with decision-making capacity, 975 (71.7%) had an MPOA, 616 (46.3%) had a living will, 366 (27.8%) had a POST Form and 64 (4.9%) had a HCS. Of the 1370 with decision-making capacity: 946 (73.2%) had either MPOA or HCS 300 (23.2%) had neither an MPOA, HCS nor POST 28 (2.2%) had a legal guardian 19 (1.5%) had both an MPOA and HCS A total of 1042 (76.1%) patients with decision-making capacity had some form of advance directives and 328(23.9%) had no advance directive. A total of 126 (3.8%) patients had a status of undetermined decision making capacity and of those 33 (26.2%) had no form of advance directives. The PAINAD Scale was used for 1487 (51.8%) patients and 1371 (47.7%) used the Numerical Rating Pain Scale. Numeric Rating Scale Of the 1370 patients with decision making capacity at time of first visit 379 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 195 (51.2%) 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 21 (5.5%) patients. The average increase between initial and 48-hour assessment was 3. Mean score for initial assessment was 2 and the mean score for 48-hour pain assessment was 5. PAINAD Rating Scale Of the 1867 patients without decision making capacity at time of first visit 611 had PAINAD 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 163 (26.7%) patients. 3

6 Treatments: Disposition: The average decrease between initial and 48-hour assessment was 4. Mean score for initial assessment was 4 and the mean score for 48-hour pain assessment was 0. An increase in pain from initial to 48-hour pain assessment was reported for 12 (2.0%) patients. The average increase between initial and 48-hour assessment was 3. Mean score for initial assessment was 1 and the mean score for 48-hour pain assessment was 4. See attached information and method for understanding the data on page 9. Of the 773 people that died, 396 (51.8%) died in an acute care bed, 248 (32.5%) died in the ICU, 40 (5.2%) died in Hospice and 1 (0.1%) died in SNU. At the time of discharge from the hospital or nursing home 773 (23.5%) patients died, 516 (15.7%) went home with Hospice, 454 (13.8%) went to a Hospice House, 444 (13.5%) were discharged home and 289 (8.8%) went to a Nursing Home/Skilled Nursing Facility. Process Measures: For the 2894 patients admitted to the hospital, the following mean number of days was reported: Admission to Referral = 6 days, Referral to Discharge = 7 days, Referral to Death = 7 days. For those 4 patients admitted to nursing homes, the following mean number of days was reported: Admission to Referral = 3 days, Referral to Discharge = 6 days. A total of 1152 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 390 patients were admitted to the ICU. The following mean days were reported: Admission to Referral = 7 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. 4

7 All Sites PCT Data Collection - Tool Total number of patients discharged during January through December 2013: 3373 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 Lawrence, 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 5 Center for Health Services & Outcomes Research

8 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 OB/L&D Total NICU PICU Peds Floor Total Primary Diagnosis: n % Did patient have multiple chronic illnesses: Cancer n % Cardiac Yes AIDS No Kidney Total Pulmonary Liver Neurological Of the 3000 that had multiple illnesses, note the following: Noncardiac Vascular n % Dementia <= General disability > Sepsis Total Multi-organ failure Premature Birth Heart Defects Genetic Anomalies Neural Tube Defects Drug Addiction Inter-Uterine Fetal Demise Trauma Pre-term Labor Total PPS at first contact: (n=3360) PPS Range n % Average 30.1 < = 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 (3373). n % n % Anorexia Fever Confusion related to dementia Nausea Constipation Pain Delirium Seizures Depression Weakness/fatigue Dysphagia No symptoms Dyspnea No symptoms due to decreased LOC Total 5770 Would you be surprised if the patient died in the next year? n % Yes No Total CAMC Health Education & Research Institute 6 Center for Health Services & Outcomes Research

9 All Sites 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 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 1867 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 7 Center for Health Services & Outcomes Research

10 All Sites Of the 1370 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 8 Center for Health Services & Outcomes Research

11 All Sites Pain Scale used Pain Scale used n % Numeric PAINAD Total Numerical Rating Scale With decision making capacity PAINAD Scale % PIPS (Premature Infants) Without decision making capacity NIPS (0-2 years) % FLACC Scale (2 months - 7 years) Total CPOT (Intubated patients Only) % Total Overall - Regardless of Pain Scale Used Of the 3373 patients, 1304 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 439 patients with decrease in pain score from initial Of the 37 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 1370 patients WITH decision making capacity at time of first visit & Numerical Rating Scale scores, 379 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 195 patients with decrease in pain score from initial Of the 21 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 1867 patients WITHOUT decision making capacity at time of first visit & PAIN AD scale scores, 611 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 163 patients with decrease in pain score from initial assessment to 48 hours, the following pain scores were reported: Of the 12 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 9 Center for Health Services & Outcomes Research

12 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: 1650 patients (86.39%) were receiving intravenous fluids, 260 (13.61%) were not using the intravenous fluids. Of the 1650 patients using IV fluids, 1227 (74.36%) discontinued use. Of the 260 patients not receiving IV fluids, 121 (46.54%) 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 10 Center for Health Services & Outcomes Research

13 All Sites Discharge Summary: Even after discharge the palliative care teams continue to track and follow-up with their patients. A total of 773 (23.5%) 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 (Acute) Home Home Home Health Home Health Hospice Hospice Hospice House Hospice House Hospice inpatient Hospice Inpatient Hospital (Transfer) Hospital (ICU) LTAC Acute Rehabilitation NH/SNF NH/SNF NH/SNF with Hospice NH/SNF with Hospice Acute Rehabilitation Personal Care Home PCU PCU Personal care home SNU (Hospital) SNU (Hospital) Other Outpatient Palliative Care Team Total Team services no longer needed Other Total Of those 773 patients who died the following were designated: Primary Diagnosis: n % Cancer Cardiac AIDS Kidney Pulmonary Liver Neurological Noncardiac Vascular Dementia General disability Sepsis Multi-organ failure Premature Birth Heart Defects Genetic Anomalies Neural Tube Defects Drug Addiction Inter-Uterine Fetal Demise Trauma Pre-term Labor Total Interventions by PCT: (More than one option can be checked. Percentages are out of the total number of patients (3373).) 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 (3373). n % Patient and family participated in family care conference Pastoral Care referral Involvement of own clergy for spiritual support Total 4275 CAMC Health Education & Research Institute 11 Center for Health Services & Outcomes Research

14 PCT Data Collection - Tool Total number of Palliative Care consults completed during 2013: 3373 Palliative Care Team All Sites Reason for Consult (n=3,332) 13.12% 9.18% 2.28% 75.42% Goal clarification Psych/spiritual support of pt/family Pain and symptom management Disposition Primary Diagnosis (n=3,349) Cancer Pulmonary Neurological 1000 Cardiac 800 Dementia General disability Premature Birth Kidney Multi-organ failure Sepsis Liver 0 Noncardiac Vascular 1200 Symptoms at Initial Assessment (n=5,770) Weakness/fatigue Anorexia Seizures Dyspnea No symptoms due to decreased LOC Pain Depression 200 Confusion related to dementia Nausea 0 Symptoms No symptoms Constipation CAMC Health Education & Research Institute 12 Center for Health Services & Outcomes Research

15 PCT Data Collection Tool - Outcomes Palliative Care Team All Sites Disposition (n=3,289) Death Hospice Hospice House Home NH/SNF Home Health Team services no longer needed Hospice inpatient Personal care home NH/SNF with Hospice Hospital (Transfer) LTAC Acute Rehabilitation Outpatient Palliative Care Team Other SNU (Hospital) Place of death (n=764) CAMC Health Education & Research Institute 13 Center for Health Services & Outcomes Research

16 Patients Served by West Virginia Palliative Care Teams To otal Number Years Center for Health Services & Outcomes Research 14 CAMC Health Education & Research Institute

17 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% 70.5% 30% 20% 10% 0% Years Center for Health Services & Outcomes Research 15 CAMC Health Education & Research Institute

18 Percentage of Patients with Advance Directives % 90% Percentages 80% 70.3% 70% 59.9% 66.7% 64.8% 61.7% 61.6% 63.4% 60% 56.3% 52.1% 52.0% 56.6% 50.3% 58.7% 52.4% 58.2% 50% 35.3% 37.5% 52.7% 52.6% 48.7% 43.5% 45.5% 39.5% 42.9% 39.0% 40% 38.4% 37.2% 36.2% 27.5% 29.9% 27.1% 29.2% 30.4% 28.3% 30% 29.4% 25.5% 22.2% 24.1% 24.9% 27.9% 28.4% 25.3% 28.1% 26.8% 25.3% 20% 14.3% 15.2% 15.0% 14.7% 10% 2.1% 1.3% 1.0% 6.9% 1.8% 0.9% 4.6% 0% 0.9% 0.8% 1.2% 1.6% 1.7% 0.9% Years MPOA Living Will HCS Legal Guardian POST Center for Health Services & Outcomes Research 16 CAMC Health Education & Research Institute

19 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% 5.8% 5.7% 5.1% 5.8% 5.9% 4.6% 3.0% 4.2% Years NOTE: Data includes those patients without MPOA, Living Will, Health Care Surrogate or Legal Guardian. Center for Health Services & Outcomes Research 17 CAMC Health Education & Research Institute

20 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% 37.4% 35.0% 35.7% 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 18 CAMC Health Education & Research Institute

21 Patients Discharged with Hospice by Location Total Number Years Hospice Hospice Inpatient NH/SNF Hospice Hospice House Center for Health Services & Outcomes Research 19 CAMC Health Education & Research Institute

22 Percentage of Patients with a Disposition of Death % 90% 80% 70% Percentages 60% 50% 40% 30% 52.5% 47.5% 49.7% 43.3% 29.6% 29.4% 27.4% 29.2% 27.7% 25.9% 20% 10% 25.7% 26.7% 23.5% 0% Years NOTE: Data includes those patients that died at Disposition. Center for Health Services & Outcomes Research 20 CAMC Health Education & Research Institute

23 Patients Dying in Hospital Setting Total Number Years ICU Acute SNU Center for Health Services & Outcomes Research 21 CAMC Health Education & Research Institute

24 Cabell- Huntington Hospital PCT Data Collection - Tool Total number of patients discharged during January through December 2013: 328 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 Lawrence, 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 22 Center for Health Services & Outcomes Research

25 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 OB/L&D Total NICU PICU Peds Floor Total Primary Diagnosis: n % Did patient have multiple chronic illnesses: Cancer n % Cardiac Yes AIDS No Kidney Total Pulmonary Liver Neurological Of the 302 that had multiple illnesses, note the following: Noncardiac Vascular n % Dementia <= General disability > Sepsis Total Multi-organ failure Premature Birth Heart Defects Genetic Anomalies Neural Tube Defects Drug Addiction Inter-Uterine Fetal Demise Trauma Pre-term Labor Total PPS at first contact: (n=328) PPS Range n % Average 24.2 < = Minimum 0 > = Maximum 80 Total Symptoms at initial assessment: Those who reported 'yes' they had these symptoms. Percentages are out of the total number of patients (328). n % n % Anorexia Fever Confusion related to dementia Nausea Constipation Pain Delirium Seizures Depression Weakness/fatigue Dysphagia No symptoms Dyspnea No symptoms due to decreased LOC Total 710 Would you be surprised if the patient died in the next year? n % Yes No Total CAMC Health Education & Research Institute 23 Center for Health Services & Outcomes Research

26 Cabell- Huntington Hospital 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 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 0 N/A No No 0 N/A 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 194 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 0 N/A No No 0 N/A 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 24 Center for Health Services & Outcomes Research

27 Cabell- Huntington Hospital Of the 89 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 Total POST Form completed: n % POST Form initiated by PCT: n % Yes Yes 0 N/A No No 0 N/A 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 45 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 25 Center for Health Services & Outcomes Research

28 Cabell- Huntington Hospital Pain Scale used Pain Scale used n % Numeric PAINAD Total Numerical Rating Scale With decision making capacity PAINAD Scale % PIPS (Premature Infants) Without decision making capacity NIPS (0-2 years) % FLACC Scale (2 months - 7 years) Total CPOT (Intubated patients Only) % Total Overall - Regardless of Pain Scale Used Of the 328 patients, 328 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 163 patients with decrease in pain score from initial Of the 1 patients that experienced a increase in pain score from initial 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 89 patients WITH decision making capacity at time of first visit & Numerical Rating Scale scores, 77 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 62 patients with decrease in pain score from initial Of the 0 patients that experienced a increase in pain score from initial 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 PAIN AD SCALE Of those 194 patients WITHOUT decision making capacity at time of first visit & PAIN AD scale scores, 175 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 53 patients with decrease in pain score from initial Of the 1 patients that experienced a increase in pain score from initial 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 26 Center for Health Services & Outcomes Research

29 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: 162 patients (98.18%) were receiving intravenous fluids, 3 (1.82%) were not using the intravenous fluids. Of the 162 patients using IV fluids, 162 (100%) discontinued use. Of the 3 patients not receiving IV fluids, 2 (66.67%) 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 0 N/A 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 0 N/A 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 27 Center for Health Services & Outcomes Research

30 Cabell- Huntington Hospital Discharge Summary: Even after discharge the palliative care teams continue to track and follow-up with their patients. A total of 99 (30.18%) 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 (Acute) Home Home Home Health Home Health Hospice Hospice Hospice House Hospice House Hospice inpatient Hospice Inpatient Hospital (Transfer) Hospital (ICU) LTAC Acute Rehabilitation NH/SNF NH/SNF NH/SNF with Hospice NH/SNF with Hospice Acute Rehabilitation Personal Care Home PCU PCU Personal care home SNU (Hospital) SNU (Hospital) Other Outpatient Palliative Care Team Total Team services no longer needed Other Total Of those 99 patients who died the following were designated: Primary Diagnosis: n % Cancer Cardiac AIDS Kidney Pulmonary Liver Neurological Noncardiac Vascular Dementia General disability Sepsis Multi-organ failure Premature Birth Heart Defects Genetic Anomalies Neural Tube Defects Drug Addiction Inter-Uterine Fetal Demise Trauma Pre-term Labor Total Interventions by PCT: (More than one option can be checked. Percentages are out of the total number of patients (328).) 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 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 Provide pain and symptom management recommendations Education about the signs and symptoms of imminent death or dying process in a timely, Hospice option for care was presented at this admission Total 1574 Outcomes or decisions followed by family: (More than one option can be checked. Percentages are out of the total number of patients (328). n % Patient and family participated in family care conference Pastoral Care referral Involvement of own clergy for spiritual support Total 622 CAMC Health Education & Research Institute 28 Center for Health Services & Outcomes Research

31 PCT Data Collection - Tool Total number of Palliative Care consults completed during 2013: 328 Palliative Care Team Cabell-Huntington Hospital 25.30% Reason for Consult (n=328) 2.13% 60.98% 11.59% Goal clarification Psych/spiritual support of pt/family Pain and symptom management Disposition Primary Diagnosis (n=328) Cancer 160 Pulmonary 140 Trauma 120 Cardiac 100 Sepsis 80 Dementia Noncardiac Vascular Kidney Neurological Liver General disability Symptoms at Initial Assessment (n=710) Weakness/fatigue Pain Dyspnea No symptoms due to decreased LOC Symptoms Anorexia Nausea Constipation Confusion related to dementia Seizures Depression Delirium Dysphagia Fever No symptoms CAMC Health Education & Research Institute 29 Center for Health Services & Outcomes Research

32 Cabell-Huntington Hospital 120 Disposition (n=328) Death Hospice House Hospice Home Home Health NH/SNF LTAC NH/SNF with Hospice Acute Rehabilitation Team services no longer needed Hospital (Transfer) Hospice inpatient 0 SNU (Hospital) Place of death (n=99) CAMC Health Education & Research Institute 30 Center for Health Services & Outcomes Research

33 Charleston Area Medical Center PCT Data Collection - Tool Total number of patients discharged during January through December 2013: 793 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 Lawrence, 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 31 Center for Health Services & Outcomes Research