CREST: The Case Review Escalation Support Team

From the 2019 HVPAA National Conference

Dr. Kevin Hauck (NYU), Dr. Nicole Adler (NYU Langone Health), Dr. Frank Volpicelli (NYU Langone Health), Mr. William Winfree (NYU Langone Health), Dr. Paresh Shah (NYU Langone Health), Dr. Brian Bosworth (NYU Langone Health)

Background

The care for end-of-life (EOL) patients is challenging for many physicians. Variability in expectations can lead to conflict among providers and between providers and families. This can lead to variability in care despite clear institutional guidelines. To address these issues, we launched a system-wide program that targeted improvements to the quality and cost of end-of-life care.

Objective

With the support of senior hospital leadership and the medical board, we created the Case Review Escalation Support Team (CREST) to allow any team member (physician, nurse, care manager, etc.), to escalate in real time any concerns about (1) provider-provider or provider-patient/family conflict and (2) non-value added care in EOL patients.

Methods

The CREST team consists of the Chiefs of Medicine and Surgery and a rotating third “on call” senior Medicine or Surgery attending. Subject matter experts (SME) are available as needed in areas including Ethics, Palliative Care, Nephrology and Oncology.

Consults to the CREST team can be made by any member of a patient’s care team. After placement of a consult, the “on call” attending will discuss the case both with the provider placing the consult, as well as the attending physician. The CREST team then huddles, along with any SMEs. Making use of established institutional protocols and SMEs, the CREST team makes a binding decision regarding the question at hand appealable only to the Chief Medical Officer. To complete the process, the relevant service chief documents the decision and communicates with the service attending.

Results

Since its launch in early 2018, CREST has been consulted on 50 cases. CREST consult patients are an ill population with an average age of 78 and with 52% of patients having died since their initial consult. The most common questions are the appropriateness of a surgical or interventional radiology procedure (31%), triage to the appropriate level of care (31%), initiation of dialysis (19%) and placement of percutaneous endoscopic gastrostomy tubes (19%). Most (92%) of consults originated from the Medicine service, with the remainder split between Critical Care and Surgery. In post-consult surveys, providers that have used the consult service all indicated a positive experience and that they would likely use the service again in the future.

Conclusions

The creation of a structured model for escalation of complex end of life cases has created a consistent means for any team member to escalate difficult issues to institutional leadership in a standardized way. CREST has been utilized across numerous disciplines and service lines, and for various clinical scenarios. Providers have found CREST to be clinically useful.

Clinical Implications

The formation of CREST is one arm of a larger supportive care initiative aimed at reducing conflict and improving the value of care delivered to patients at the end of life. By creating a clear line of escalation for any team member, conflict in EOL can be reduced, and ultimately higher value care can be provided.

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