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Baugh CW, Ouchi K, Bowman JK, Aizer AA, Zirulnik AW, Wadleigh M, Wise A, Remón Baranda P, Leiter RE, Molyneaux BJ, McCabe A, Hansrivijit P, Lally K, Littlefield M, Wagner AM, Walker KH, Salmasian H, Ravvaz K, Devlin JA, Brownell KL, Vitale MP, Firmin FC, Jain N, Thomas JD, Tulsky JA, Ray S, O’Mara LM, Rickerson EM, Mendu ML. A Hospice Transitions Program for Patients in the Emergency Department. JAMA Netw Open 2024; 7:e2420695. [PMID: 38976266 PMCID: PMC11231795 DOI: 10.1001/jamanetworkopen.2024.20695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/02/2024] [Indexed: 07/09/2024] Open
Abstract
Importance Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. Objective To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. Design, Setting, and Participants This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. Main Outcome and Measures The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. Results This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). Conclusions and Relevance In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.
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Affiliation(s)
- Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jason K. Bowman
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Ayal A. Aizer
- Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander W. Zirulnik
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Martha Wadleigh
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Angela Wise
- Massachusetts Department of Public Health, Boston, Massachusetts
| | | | - Richard E. Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Andrea McCabe
- Mass General Brigham Home Hospital, Boston, Massachusetts
| | - Panupong Hansrivijit
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kate Lally
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Melissa Littlefield
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexei M. Wagner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Hojjat Salmasian
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kourosh Ravvaz
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jada A. Devlin
- Mass General Brigham Home Hospital, Boston, Massachusetts
| | - Karen Lewis Brownell
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Matthew P. Vitale
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frantzie C. Firmin
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jane deLima Thomas
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Soumi Ray
- Department of Analytics, Planning, Strategy and Improvement, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lynne M. O’Mara
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elizabeth M. Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Office of the Chief Operating Officer, Brigham and Women’s Hospital, Boston, Massachusetts
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Bourmorck D, Pétré B, de Saint-Hubert M, De Brauwer I. Is palliative care a utopia for older patients with organ failure, dementia or frailty? A qualitative study through the prism of emergency department admission. BMC Health Serv Res 2024; 24:773. [PMID: 38956595 PMCID: PMC11218079 DOI: 10.1186/s12913-024-11242-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population. METHODS We designed a qualitative study based on 1) interviews - conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers - and 2) focus groups - conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis. RESULTS Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile. CONCLUSIONS Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier.
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Affiliation(s)
- Delphine Bourmorck
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium.
| | - Benoit Pétré
- Department of Public Health Sciences, Faculty of Medecine, University of Liège, Liège, Belgium
| | - Marie de Saint-Hubert
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- CHU-UCL Namur, Yvoir, Belgium
| | - Isabelle De Brauwer
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Department of Geriatric Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Testa L, Richardson L, Cheek C, Hensel T, Austin E, Safi M, Ransolin N, Carrigan A, Long J, Hutchinson K, Goirand M, Bierbaum M, Bleckly F, Hibbert P, Churruca K, Clay-Williams R. Strategies to improve care for older adults who present to the emergency department: a systematic review. BMC Health Serv Res 2024; 24:178. [PMID: 38331778 PMCID: PMC10851482 DOI: 10.1186/s12913-024-10576-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance. METHODS A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach. RESULTS Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience. CONCLUSION It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Lieke Richardson
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Colleen Cheek
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia.
| | - Theresa Hensel
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Cologne, Germany
| | - Elizabeth Austin
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Mariam Safi
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Internal Medicine Research Unit, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Natália Ransolin
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Universidade Federal Do Rio Grande Do Sul, Porto Alegre, RS, Brasil
| | - Ann Carrigan
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Janet Long
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Magali Goirand
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, 5001, Australia
| | - Felicity Bleckly
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
- Allied Health and Human Performance, IIMPACT in Health, University of South Australia, Adelaide, 5001, Australia
| | - Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, 2109, Australia
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Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:633-643. [PMID: 37163667 DOI: 10.1093/ehjacc/zuad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Neville House 2nd Floor, Boston, MA 02115, USA
| | - Yonathan Freund
- Emergency Department Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Philippe Gabriel Steg
- Department of Cardiology, Université Paris-Cité, Institut Universitaire de France, FACT, French Alliance for Cardiovascular Trials, INSERM-1148, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Mullins MA, Ruterbusch J, Cote ML, Uppal S, Wallner LP. Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities. Int J Gynecol Cancer 2023; 33:1099-1105. [PMID: 37208020 PMCID: PMC10577799 DOI: 10.1136/ijgc-2023-004405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer. METHODS This retrospective claims analysis included 4258 Medicare beneficiaries over age 66 diagnosed with ovarian cancer who survived at least 6 months after diagnosis, died between 2007 and 2016, and enrolled in a hospice. We examined trends in timing and clinical location (outpatient, inpatient hospital, nursing/long-term care, other) of hospice referrals and associations with patient race and ethnicity using multivariable multinomial logistic regression. RESULTS In this sample, 56% of hospice enrollees were referred to a hospice within a month of death, and referral timing did not vary by patient race. Referrals were most commonly inpatient hospital (1731 (41%) inpatient, 703 (17%) outpatient, 299 (7%) nursing/long-term care, 1525 (36%) other), with a median of 6 inpatient days prior to hospice enrollment. Only 17% of hospice referrals were made in an outpatient clinic, but participants had a median of 1.7 outpatient visits per month in the 6 months prior to hospice referral. Referral location varied by patient race, with non-Hispanic black people experiencing the most inpatient referrals (60%). Hospice referral timing and location trends did not change between 2007 and 2016. Compared with individuals referred to a hospice in an outpatient setting, individuals referred from an inpatient hospital setting had more than six times the odds of a referral in the last 3 days of life (OR=6.5, 95% CI 4.4 to 9.8) versus a referral more than 90 days before death. CONCLUSION Timeliness of hospice referral is not improving over time despite opportunities for earlier referral across multiple clinical settings. Future work delineating how to capitalize on these opportunities is essential for improving the timeliness of hospice care.
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Affiliation(s)
- Megan A Mullins
- Peter O'Donnell Jr. School of Public Health, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Julie Ruterbusch
- Karmanos Cancer Insitute, Wayne State University, Detroit, Michigan, USA
| | - Michele L Cote
- Simon Comprehensive Cancer Center, Indiana University, Indianapolis, Indiana, USA
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, Indiana, USA
| | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Bayuo J, Agbeko AE, Acheampong EK, Abu-Odah H, Davids J. Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes. Acad Emerg Med 2022; 29:1357-1378. [PMID: 35435306 DOI: 10.1111/acem.14508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/22/2022] [Accepted: 04/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Existing evidence suggest the emergence of palliative care (PC) services in the emergency department (ED). To gain insight into the nature of these services and provide direction to future actions, there is a need for a comprehensive review that ascertains the components of these services, integration models, and outcomes. METHODS A scoping review design was employed and reported according to the PRISMA extension guidelines for scoping reviews. Extensive searches in peer-reviewed databases (CINAHL, EMBASE, PubMed, Cochrane Library, and Medline) and gray literature sources (Trove, MedNar, OpenGrey, and the Agency for Healthcare Research and Quality) were undertaken and supplemented with hand searching. Titles, abstracts, and full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on a PC intervention implemented in the ED for adults. Codes were formulated across the included studies, which facilitated the conduct of a narrative synthesis. RESULTS Twenty-three studies were retained with the majority (n = 15) emerging from the United States. The components of PC interventions in the ED were categorized as: (1) screening, (2) goals of care discussion and communication, (3) managing pain and other distressing symptoms in the ED, (4) transitions across care settings, (5) end-of-life (EoL) care, (6) family/caregiver support, and (7) ED staff education. Traditional PC consultations and integrated ED-PC services were the main modes of delivery. PC in the ED can potentially improve patient symptoms, facilitate access to relevant services, reduce length of stay, improve care at the EoL, facilitate bereavement and postbereavement support for family members, and improve ED staff confidence in delivering PC. CONCLUSIONS PC implementation in the ED may potentially improve patient and family outcomes. More studies are needed, however, to standardize trigger or screening tools. More prospective studies are also needed to test PC interventions in the ED.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | | | | | - Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | - Jephtah Davids
- College of Health Science, University of Ghana, Legon, Greater Accra, Ghana
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Kim JS, Lee SY, Lee MS, Yoo SH, Shin J, Choi W, Kim Y, Han HS, Hong J, Keam B, Heo DS. Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea. Palliat Care 2022; 21:105. [PMID: 35668487 PMCID: PMC9170493 DOI: 10.1186/s12904-022-00988-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED. Methods We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status. Results Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%). Conclusions Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00988-3.
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Affiliation(s)
- Jung Sun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sun Young Lee
- Public Healthcare Center, Seoul National University Hospital, Seoul, Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Jeongmi Shin
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Wonho Choi
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Yejin Kim
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Hyung Sook Han
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jinui Hong
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Dae Seog Heo
- Patient-Centered Clinical Research Coordinating Center, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
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Rege RM, Peyton K, Pajka SE, Grudzen CR, Conroy MJ, Southerland LT. Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study. J Pain Symptom Manage 2022; 63:e281-e286. [PMID: 34411660 PMCID: PMC9069289 DOI: 10.1016/j.jpainsymman.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice. METHODS Setting: Academic ED with 82,000 annual visits. POPULATION ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition. RESULTS Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27). CONCLUSION Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.
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Affiliation(s)
- Rahul M Rege
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH.
| | - Kelee Peyton
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
| | - Sarah E Pajka
- The Ohio State University College of Medicine, (S.E.P.) Columbus OH
| | - Corita R Grudzen
- Department of Population Health, (C.R.G.) NYU Grossman School of Medicine, New York, NY
| | - Mark J Conroy
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
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9
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Zeng H, Kamath B, Sekhon S. Why do patients revoke hospice in the emergency department? Am J Emerg Med 2021; 56:344-346. [PMID: 34593299 DOI: 10.1016/j.ajem.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Henry Zeng
- Hospice and Palliative Medicine, Stanford University, Stanford, CA, United States of America; VITAS Healthcare, Miami, FL, United States of America.
| | - Bhoomika Kamath
- Hospice and Palliative Medicine, Stanford University, Stanford, CA, United States of America
| | - Simranjit Sekhon
- Hospice and Palliative Medicine, Stanford University, Stanford, CA, United States of America; VITAS Healthcare, Miami, FL, United States of America
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10
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Ouchi K, Liu S, Tonellato D, Keschner YG, Kennedy M, Levine DM. Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities. J Am Coll Emerg Physicians Open 2021; 2:e12517. [PMID: 34322684 PMCID: PMC8295243 DOI: 10.1002/emp2.12517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/27/2021] [Accepted: 07/01/2021] [Indexed: 12/03/2022] Open
Abstract
The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Shan Liu
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Daniel Tonellato
- Department of Emergency MedicineMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
- Department of Emergency MedicineGeorgetown University School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Yonatan G. Keschner
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Maura Kennedy
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - David M. Levine
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal Medicine and Primary CareBrigham and Women's HospitalBostonMassachusettsUSA
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11
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Ding CQ, Jin JF, Lan MJ, Zhang YP, Wang YW, Yang MF, Wang S. Do-not-resuscitate decision making for terminally ill older patients in the emergency department: An explorative, descriptive inquiry of Chinese family members. Geriatr Nurs 2021; 42:843-849. [PMID: 34090229 DOI: 10.1016/j.gerinurse.2021.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Many terminally ill older adults depend on family members to make medical decisions in China. Many family members find it difficult to make do-not-resuscitate (DNR) decisions in emergency departments (ED). Currently, factors that affect DNR decision making by family members for older adults needing emergency care have not been well studied. This qualitative inquiry explores factors influencing DNR decision-making among family members of terminally ill older adults in ED. Semi-structured in-depth interviews were conducted for a 12-family member of terminally ill older adults at ED in China. Results of the conventional content analysis showed that family members made DNR decisions based on a wide of reasons: (a) subjective perception of family members, (b) conditions of the terminally ill older adults, (c) external environmental factors, and (d) internal family factors. The findings of this study expand our knowledge and understanding of factors influencing DNR decision-making by family members of terminally ill older adults in ED.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China; Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang Province, PR China
| | - Jing-Fen Jin
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China; Changxing Branch Hospital of SAHZU, Huzhou, Zhejiang Province, PR China.
| | - Mei-Juan Lan
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Yu-Ping Zhang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Yu-Wei Wang
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Min-Fei Yang
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
| | - Sa Wang
- Department of Emergency Medicine, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, PR China
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12
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Kirkland SW, Ghalab A, Kruhlak M, Ruske H, Campbell S, Yang EH, Villa-Roel C, Rowe BH. An Assessment of Emergency Department-Based Interventions for Patients with Advanced or End-Stage Illness: A Systematic Review. J Palliat Med 2021; 24:605-618. [PMID: 33555970 DOI: 10.1089/jpm.2020.0607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background and Objective: With the increase of visits among patients with end-of-life needs, palliative care (PC) interventions delivered in the emergency department (ED) have become increasingly important. The objective of this systematic review was to examine the effectiveness of ED-based PC interventions. Methods: A comprehensive search of the literature was conducted to identify any comparative studies assessing the effectiveness of ED-based PC interventions. Two independent reviewers completed study selection, quality assessment, and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: A total of 18 unique studies were included. Two studies reported no difference in return visits to the ED (RR = 1.31; 95% CI: 0.73-2.35; I2 = 47%). Two randomized trials reported no difference in mortality (RR = 0.89; 95% CI: 0.71-1.13; I2 = 0%), while one cohort study reported an increased mortality among patients referred to PC in the ED (RR = 1.89; 95% CI: 1.58-2.27). Overall, six out of eight studies reported a decrease in hospital length of stay (LOS) among patients undergoing an ED-based PC intervention compared with usual care. Conclusions: While there is compelling evidence to suggest that ED-based PC interventions can reduce hospital LOS, the evidence for the impact of these interventions on other outcomes is less robust. More high-quality comparative studies are needed to better understand the overall impact of ED-based PC interventions on improving patient outcomes as well as improving throughput and other quality of service-related outcomes.
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Affiliation(s)
- Scott W Kirkland
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ammar Ghalab
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Maureen Kruhlak
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hannah Ruske
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sandra Campbell
- J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H Yang
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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13
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Barash Y, Soffer S, Grossman E, Tau N, Sorin V, BenDavid E, Irony A, Konen E, Zimlichman E, Klang E. Alerting on mortality among patients discharged from the emergency department: a machine learning model. Postgrad Med J 2020; 98:166-171. [PMID: 33273105 DOI: 10.1136/postgradmedj-2020-138899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Physicians continuously make tough decisions when discharging patients. Alerting on poor outcomes may help in this decision. This study evaluates a machine learning model for predicting 30-day mortality in emergency department (ED) discharged patients. METHODS We retrospectively analysed visits of adult patients discharged from a single ED (1/2014-12/2018). Data included demographics, evaluation and treatment in the ED, and discharge diagnosis. The data comprised of both structured and free-text fields. A gradient boosting model was trained to predict mortality within 30 days of release from the ED. The model was trained on data from the years 2014-2017 and validated on data from the year 2018. In order to reduce potential end-of-life bias, a subgroup analysis was performed for non-oncological patients. RESULTS Overall, 363 635 ED visits of discharged patients were analysed. The 30-day mortality rate was 0.8%. A majority of the mortality cases (65.3%) had a known oncological disease. The model yielded an area under the curve (AUC) of 0.97 (95% CI 0.96 to 0.97) for predicting 30-day mortality. For a sensitivity of 84% (95% CI 0.81 to 0.86), this model had a false positive rate of 1:20. For patients without a known malignancy, the model yielded an AUC of 0.94 (95% CI 0.92 to 0.95). CONCLUSIONS Although not frequent, patients may die following ED discharge. Machine learning-based tools may help ED physicians identify patients at risk. An optimised decision for hospitalisation or palliative management may improve patient care and system resource allocation.
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Affiliation(s)
- Yiftach Barash
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,DeepVision lab, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Shelly Soffer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,DeepVision lab, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Ehud Grossman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Internal Medicine, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Noam Tau
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vera Sorin
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal BenDavid
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avinoah Irony
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Emergency Department, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eli Konen
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Zimlichman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hospital Management, The Chaim Sheba Medcical Center, Ramat Gan, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,DeepVision lab, The Chaim Sheba Medical Center, Ramat Gan, Israel
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14
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Baker EF, Marco CA. Advance directives in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:270-275. [PMID: 33000042 PMCID: PMC7493570 DOI: 10.1002/emp2.12021] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/16/2022] Open
Abstract
Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.
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Affiliation(s)
- Eileen F. Baker
- University of Toledo College of Medicine and Life SciencesToledoOhio
- Riverwood Emergency Services, Inc.PerrysburgOhio
| | - Catherine A. Marco
- Department of Emergency MedicineWright State University Boonshoft School of MedicineDaytonOhio
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15
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Wilson JG, English DP, Owyang CG, Chimelski EA, Grudzen CR, Wong HN, Aslakson RA. End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review. J Pain Symptom Manage 2020; 59:372-383.e1. [PMID: 31586580 DOI: 10.1016/j.jpainsymman.2019.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022]
Abstract
CONTEXT There is growing interest in providing palliative care (PC) in the emergency department (ED), but relatively little is known about the efficacy of ED-based PC interventions. A 2016 systematic review on this topic found no evidence that ED-based PC interventions affect patient outcomes or health care utilization, but new research has emerged since the publication of that review. OBJECTIVES This systematic review provides a concise summary of current literature addressing the impact of ED-based PC interventions on patient-reported or family reported outcomes, health care utilization, and survival. METHODS We searched PubMed, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature from inception until September 1, 2018 and reviewed references. Eligible articles evaluated the effects of PC interventions in the ED on patient-reported or family reported outcomes, health care utilization, or survival. RESULTS We screened 3091 abstracts and 98 full-text articles with 13 articles selected for final inclusion. Two articles reported the results of a single randomized controlled trial, whereas the remaining 11 studies were descriptive or quasi-experimental cohort studies. More than half of the included articles were published after the previous systematic review on this topic. Populations studied included older adults, patients with advanced malignancy, and ED patients screening positive for unmet PC needs. Most interventions involved referral to hospice or PC or PC provided directly in the ED. Compared with usual care, ED-PC interventions improved quality of life, although this improvement was not observed when comparing ED-PC to inpatient PC. ED-PC interventions expedited PC consultation; most studies reported a concomitant reduction in hospital length of stay and increase in hospice utilization, but some data were conflicting. Short-term mortality rates were high across all studies, but ED-PC interventions did not decrease survival time compared with usual care. CONCLUSION Existing data support that PC in the ED is feasible, may improve quality of life, and does not appear to affect survival.
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Affiliation(s)
- Jennifer G Wilson
- Department of Emergency Medicine, Stanford University, Stanford, California, USA.
| | - Diana P English
- Division of Hospice and Palliative Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Clark G Owyang
- Division of Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Erica A Chimelski
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA; Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca A Aslakson
- Divisions of Critical Care and Hospice and Palliative Medicine, Departments of Medicine & Anesthesiology, Stanford University, Stanford, California, USA
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16
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Saunders S, Killackey T, Kurahashi A, Walsh C, Wentlandt K, Lovrics E, Scott M, Mahtani R, Bernstein M, Howard M, Tanuseputro P, Goldman R, Zimmermann C, Aslakson RA, Isenberg SR. Palliative Care Transitions From Acute Care to Community-Based Care-A Systematic Review. J Pain Symptom Manage 2019; 58:721-734.e1. [PMID: 31201875 DOI: 10.1016/j.jpainsymman.2019.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/31/2019] [Accepted: 06/05/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Although the literature on transitions from hospital to the community is extensive, little is known about this experience within the context of palliative care (PC). OBJECTIVE We conducted a systematic review to investigate the impact of receiving palliative care in hospital on the transition from hospital to the community. METHODS We systematically searched MEDLINE, Embase, ProQuest, and CINAHL from 1995 until April 10, 2018, and extracted relevant references. Eligible articles were published in English, included adult patients receiving PC as inpatients, and explored transitions from hospital to the community. RESULTS A total of 1514 studies were identified and eight met inclusion criteria. Studies were published recently (>2012; n = 7, 88%). Specialist PC interventions were delivered by multidisciplinary care teams as part of inpatient PC triggers, discharge planning programs, and transitional care programs. Common outcomes reported with significant findings consisted of length of stay (n = 5), discharge support (n = 5), and hospital readmissions (n = 6) for those who received inpatient PC. Most studies were at high risk of bias. CONCLUSION Heterogeneity of study designs, outcomes, findings, and poor methodological quality renders it challenging to draw conclusions regarding PC's impact on the transition from hospital to home. Further research should use standardized outcomes with randomized controlled trial and/or propensity matched cohort designs.
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Affiliation(s)
- Stephanie Saunders
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Tieghan Killackey
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Allison Kurahashi
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Chris Walsh
- Library Services, Sinai Health System, Toronto, Ontario, Canada; School of Communications and Nursing, George Brown College, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Emily Lovrics
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Mary Scott
- Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Ramona Mahtani
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Mark Bernstein
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Russell Goldman
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Division of Palliative Care, University Health Network, Toronto, Ontario, Canada; Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca A Aslakson
- Department of Medicine and Anesthesiology, Stanford University, Stanford, California, USA
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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17
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Advanced liver fibrosis and care continuum in emergency department patients with chronic hepatitis C. Am J Emerg Med 2018; 37:286-290. [PMID: 30409463 DOI: 10.1016/j.ajem.2018.08.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/25/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND FIB-4, a non-invasive serum fibrosis index (which includes age, ALT, AST, and platelet count), is frequently available during ED visits. Our objective was to define 1-year HCV-related care outcomes of ED patients with known HCV, for the overall group, and both those with and without advanced fibrosis. METHODS As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were identified retrospectively via medical record review. Components of FIB-4 were abstracted, and patients with an FIB-4 > 3.25 were classified with advanced fibrosis and characterized with regards to downstream HCV care continuum outcomes at one-year after enrollment. RESULTS Of the 113 patients with known HCV, 38 (33.6%) had advanced fibrosis. One-year outcomes along the HCV care continuum after ED encounter for 'all' 113, 75 'without advanced fibrosis', and 38 'advanced fibrosis' patients, respectively, were as follows: agreeing to be linked to care [106 (93.8%), 72 (96.0%), 34 (89.5%)]; LTC [38 (33.6%), 21 (28.0%), 17 (44.7%)]; treatment initiation among those linked [16 (42.1%), 9 (42.9%), 7 (41.2%)]; sustained virologic response 4 weeks post-treatment among those treated [15 (93.8%), 9 (100.0%), 6 (85.7%)]; documented all-cause mortality [10 (8.8%), 3 (4.0%), 7 (18.4%)]. Notably, 70% of those who died had advanced fibrosis. For those with advanced liver fibrosis, all-cause mortality was significantly higher, than those without (18.4% versus 4.0%, p = 0.030). CONCLUSIONS Over one-third of HCV-infected ED patients have advanced liver fibrosis, incomplete LTC, and higher mortality, suggesting this readily-available FIB-4 might be used to prioritize LTC services for those with advanced fibrosis.
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