Context. The coronavirus disease 2019 (COVID-19) pandemic is stressing health care systems throughout the world. Significant numbers of patients are being admitted to the hospital with severe illness, often in the setting of advanced age and underlying comorbidities. Therefore, palliative care is an important part of the response to this pandemic. The Seattle area and UW Medicine have been on the forefront of the pandemic in the U.S. Methods. UW Medicine developed a strategy to implement a palliative care response for a multihospital health care system that incorporates conventional capacity, contingency capacity, and crisis capacity. The strategy was developed by our palliative care programs with input from the health care system leadership. Results. In this publication, we share our multifaceted strategy to implement high-quality palliative care in the context of the COVID-19 pandemic that incorporates conventional, contingency, and crisis capacity and focuses on the areas of the hospital caring for the most patients: the emergency department, intensive care units, and acute care services. The strategy focuses on key content areas, including identifying and addressing goals of care, addressing moderate and severe symptoms, and supporting family members. Conclusion. Strategy planning for delivery of high-quality palliative care in the context of the COVID-19 pandemic represents an important area of need for our health care systems. We share our experiences of developing such a strategy to help other institutions conduct and adapt such strategies more quickly.

Rationale: Palliative care in the intensive care unit (ICU) is an important focus for quality improvement. Objectives: To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU. Methods: We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre-(n 5 253) and postintervention (n 5 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results. Measurements and Main Results: There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P 5 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P , 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P , 0.01). Conclusions: We found no significant improvement in familyassessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Palliative care providers and administrators should explore opportunities to expand outpatient palliative care clinics with an emphasis on primary care and continuity of care. NPs by experience and education are ideally suited to manage both primary and palliative care needs for people at the end of life.

Background: Cost savings associated with palliative care (PC) consultation have been demonstrated for total hospital costs and daily costs after PC involvement. This analysis adds another approach by examining costs stratified by hospital length of stay (LOS). Objective: To examine cost savings for patients who receive PC consultations during short, medium, and long hospitalizations. Methods: Data were analyzed for 1815 PC patients and 1790 comparison patients from two academic medical centers between 2005 and 2008, matched on discharge disposition, LOS category, and propensity for a PC consultation. We used generalized linear models and regression analysis to compare cost differences for LOS of 1 to 7 days (38% of consults), 8 to 30 days (48%), and > 30 days (14%). Comparisons were done for all patients in both hospitals (n = 3605) and by discharge disposition: survivors (n = 2226) and decedents (n = 1379); analyses were repeated for each hospital. Results: Significant savings per admission were associated with shorter LOS: For stays of 1 to 7 days, costs were lower for all PC patients by 13% ($2141), and for survivors by 19.1% ($2946). For stays of 8 to 30 days, costs were lower for all PC patients by 4.9% ($2870), and for survivors by 6% ($2487). Extrapolating the per admission cost across the PC patient groups with lower costs, these programs saved about $1.46 million for LOS under a week and about $2.5 million for LOS of 8 to 30 days. Patients with stays > 30 days showed no differences in costs, perhaps due to preferences for more aggressive care for those who stay in the hospital more than a month. Conclusion: Cost savings due to PC are realized for short and medium LOS but not stays > 30 days. These findings suggest savings can be achieved by earlier involvement of palliative care, and support screening efforts to identify patients who can benefit from PC services early in an admission.

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