Emergency Department Embedded Palliative Care Service Creates Value for Health Systems

Emergency department discharges directly to hospice: Longitudinal assessment of a streamlined referral program

INTRODUCTION

80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice.

METHODS

We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS).

RESULTS

202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21).

CONCLUSION

In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there.

Care conundrum in the emergency department: The gap between clinician awareness and patient expectations surrounding advance directives

OBJECTIVES

Clinicians in the emergency department (ED) frequently encounter seriously ill patients at a time when advance directives may be pivotal in improved clinician decision-making. The objectives of this study were to identify the prevalence of advanced directives in ED patients, as well as patterns of advance care discussions between patients and providers. This study describes patients' perceptions and expectations of such serious illness discussions in an emergency care setting with the expectation of including patients as strategic members of the care team.

METHODS

Trained research assistants in two emergency departments surveyed patients over age 65, or their caregivers, from July 2016 to August 2018. Patients were verbally administered a standard survey tool related to advance directives and advance care planning.

RESULTS

497 out of 877 patients completed surveys (59.4%). 50% of patients reported having an advance care planning document. The large majority (92%) of patients with an advance directive had not been asked about it during their ED visit. When questioned about their personal preferences, 79% of patients thought emergency physicians should be aware of their wishes regarding life-sustaining treatments and end-of-life care. Paradoxically, only 38% expressed a desire to discuss advance care plans with an ED clinician.

CONCLUSIONS

Older patients expect emergency clinicians to be aware of their care preferences, yet most are not asked about these care preferences in the ED. The large gap between patient preference and reality suggests the need for more targeted discussion by ED clinicians and translation of patient perspectives into system healthcare improvements. Future studies should explore barriers to advance care planning in the ED as well as patient preferences for these conversations to support a true healthcare learning system.

In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19

OBJECTIVE

The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic.

METHODS

This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission.

RESULTS

Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed.

CONCLUSION

This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.

Emergency Palliative Care: Nongoal Concordant Care and Time-Limited Trials in the Emergency Department

When advance care plans are not communicated or goals are in conflict, significant family and clinician distress may result. The distress is especially high when potentially nongoal concordant care is expected by surrogates in the emergency department (ED). To demonstrate the effect of off-hour, phone consultations by palliative care clinicians in reducing the family and clinician distress when nongoal concordant care is expected in the ED. A partnership between palliative care and emergency medicine can decrease the burden of decision making and provide opportunities for modeling a goals-of-care discussion by experts in this important procedure.

Telephone advice lines for adults with advanced illness and their family carers: a qualitative analysis and novel practical framework

BACKGROUND

Telephone advice lines have been recommended internationally to support around-the-clock care for people living at home with advanced illness. While they undoubtedly support care, there is little evidence about what elements are needed for success. A national picture is needed to understand, improve and standardise service delivery/care.

AIM

To explore telephone advice lines for people living at home with advanced illness across the four UK nations, and to construct a practical framework to improve services.

DESIGN

A cross-national evaluation of telephone advice lines using structured qualitative interviews. A patient and public involvement workshop was conducted to refine the framework.

SETTING/PARTICIPANTS

Professionals with responsibilities for how palliative care services are delivered and/or funded at a local or regional level, were purposively sampled.

RESULTS

Seventy-one interviews were conducted, covering 60 geographical areas. Five themes were identified. Availability: Ten advice line models were described. Variation led to confusion about who to call and when. Accessibility, awareness and promotion: It was assumed that patients/carers know who to call out-of-hours, but often they did not. Practicalities: Call handlers skills/expertise varied, which influenced how calls were managed. Possible responses ranged from signposting to organising home visits. Integration/continuity of care: Integration between care providers was limited by electronic medical records access/information sharing. Service structure/commissioning: Sustained funding was often an issue for charitably funded organisations.

CONCLUSIONS

Our novel evidence-based practical framework could be transformative for service design/delivery, as it presents key considerations relating to the various elements of advice lines that may impact on the patient/carer experience.

[End-of-life care in the emergency department-Indications for admission and spectrum of care-State of the art]

BACKGROUND

Emergency departments (EDs) and ED observation units provide care for a wide range of medical emergencies, serving patients of all ages and conditions. This includes palliative care for patients who are rapidly deteriorating. However, there is limited knowledge about the incidence, reasons for ED visits, modes of arrival, symptoms, leading diagnoses, and the emergency care provided to these patients until the time of death.

METHOD

This retrospective, exploratory study was conducted at the 754-bed Kliniken Maria Hilf academic teaching hospital in Moenchengladbach, Germany. It included patients who died in the ED resuscitation rooms or ED observation unit between 1st of July 2018 and 30th of June 2023. We utilized routine data to analyze the reasons for ED visits, modes of arrival, symptoms, diagnoses and the medical care provided. We also examined differences between oncologic and non-oncologic patients as well as between those requiring cardiopulmonary resuscitation (CPR) and those who did not. The study was approved by an ethics committee and categorical data were analyzed using the χ2-test with Yates correction. P-values < 0.05 were considered significant due to the exploratory nature of the study.

RESULTS

During the study period 168,328 patients were treated in the ED, with 43% admitted to the hospital. Of these, 262 died in the ED or ED observation unit. The primary mode of arrival was emergency medical services for 234 patients (89%). The most common symptoms were impaired consciousness (n = 198; 76%) and dyspnea (n = 83; 32%), among a range of others. Comparing non-oncologic (n = 214) and oncologic patients (n = 48), the former showed significantly higher rates of impaired consciousness (174/214 vs. 24/48; p = 0.0001), while dyspnea was more prevalent in oncologic patients (57/214 vs. 26/48; p = 0.0002). Among patients who underwent CPR (n = 147) and those who did not (n = 115), no statistical differences were found in levels of consciousness but a significant difference in dyspnea (prior to cardiac arrest) was noted (31/147 vs. 52/115; p = 0.0001). Palliative status was documented in 88 cases (34%), with palliative care initiated in only 58 (21%). Only three patients (1%) were receiving specialized outpatient palliative care (SAPV). The most common medical interventions were invasive ventilation (n = 160; 61%), opioid administration (n = 145; 55%), CPR (n = 143; 55%), and crystalloid administration (n = 90; 34%). Structured communication with relatives occurred in 188 cases (72%).

CONCLUSION

The incidence of death in a large German ED was approximately one patient per week. These patients typically presented with symptoms common in critically ill non-trauma cases. The low incidence of SAPV patients (1%) suggests its potential to reduce ED admissions. Oncologic patients were a minority, possibly due to effective outpatient care and lower mortality within the first 24 h after ED admission. Emergency palliative care in the ED could alleviate the burden on intensive care units. Training ED staff in acute palliative care and establishing procedural standards for such care are essential to maintain high-quality treatment, given the frequency of palliative cases in the ED.

Best Practices in End of Life and Palliative Care in the Emergency Department

Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.

Developing a novel integrated geriatric palliative care consultation program for the emergency department

With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.