Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review

Palliative care screening tools in Japan: cross-sectional utility study

OBJECTIVES

In Japan's ageing society, the utility of US-based and UK-based palliative care screening tools in the inpatient setting is unknown. The purpose of this study is to identify the unmet palliative care needs of patients who are admitted to an acute care hospital using the US-based and UK-based screening tools.

METHODS

This single-centre, cross-sectional study included patients who were admitted to an acute care hospital in Tokyo, Japan, from November 2019 to January 2020. We used the Supportive and Palliative Care Indicator Tool and Palliative Care Screening Tool in the Emergency Department among admitted patients.

RESULTS

126 patients (51.6%) were screened positive in total. Among these patients, the main comorbid conditions were dementia/frailty (85.7%) and neurological disease (50.8%).

CONCLUSIONS

One out of every two internal medicine inpatients at acute care hospitals may have palliative care needs. Given the lack of adequate palliative care workforce in Japan, a modified screening tool to capture the most high-risk patients may be necessary.

The Physician Surprise Question in the Emergency Department: prospective cohort study

OBJECTIVES

This study aims to test the ability of the surprise question (SQ), when asked to emergency physicians (EPs), to predict in-hospital mortality among adults admitted to an emergency room (ER).

METHODS

This prospective cohort study at an academic medical centre included consecutive patients 18 years or older who received care in the ER and were subsequently admitted to the hospital from 20 April 2018 to 20 October 2018. EPs were required to answer the SQ for all patients who were being admitted to hospital. The primary outcome was in-hospital mortality.

RESULTS

The cohort included 725 adults (mean (SD) age, 60 (17) years, 51% men) from 58 128 emergency department (ED) visits. The mortality rates were 20.6% for 30-day all-cause in-hospital mortality and 23.6% for in-hospital mortality. The diagnostic test characteristics of the SQ have a sensitivity of 53.7% and specificity of 87.1%, and a relative risk of 4.02 (95% CI 3.15 to 5.13), p<0.01). The positive and negative predictive values were 57% and 86%, respectively; the positive likelihood ratio was 4.1 and negative likelihood ratio was 0.53; and the accuracy was 79.2%.

CONCLUSIONS

We found that asking the SQ to EPs may be a useful tool to identify patients in the ED with a high risk of in-hospital mortality.

The Prognostic Value of the Modified Surprise Question in Critically Ill Emergency Department Patients

Objective: The initiation of palliative care (PC) in the emergency department (ED) is effective in improving the quality of life for seriously ill patients. This study aimed to evaluate the prognostic value of the modified surprise question (mSQ), "Would you be surprised if this patient died in the next 30 days?" as a trigger for initiating PC in critically ill ED patients. Methods: We conducted a prospective cohort study over a 6-month period in an ED, during which 22 emergency residents answered the mSQ for critically ill ED patients (Korean Triage and Acuity Scale 1 or 2). The primary outcome was the accuracy of the positive mSQ (negative response to the mSQ) in predicting 30-day mortality, and logistic regression analysis was performed to identify the prognostic factors. Results: A total of 300 patients were enrolled, and the positive mSQ group included 118 (39.3%) patients. The 30-day mortality rate of the cohort was 10.0%. The sensitivity, specificity, positive predictive value, and negative predictive value of the positive mSQ were 83.3%, 65.6%, 21.2%, and 97.3%, respectively, with a c-statistic of 0.74 and a positive likelihood ratio of 2.42. In a multivariable analysis controlling for clinically relevant variables, the odds ratio for 30-day mortality of the positive mSQ was 4.76 (95% confidence interval, 1.61-14.09; P = .005). Conclusions: The mSQ may be valuable for identifying critically ill ED patients with an increased risk of 30-day mortality. Therefore, it may be utilized as a trigger for PC consultation 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.

A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients

BACKGROUND

Palliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED).

METHODS

This prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1-3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan-Meier and log-rank tests.

RESULTS

A total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16-8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 - 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03-19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84-3.77.

CONCLUSIONS

Among older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.

Automatable end-of-life screening for older adults in the emergency department using electronic health records

BACKGROUND

Emergency department (ED) visits are common at the end-of-life, but the identification of patients with life-limiting illness remains a key challenge in providing timely and resource-sensitive advance care planning (ACP) and palliative care services. To date, there are no validated, automatable instruments for ED end-of-life screening. Here, we developed a novel electronic health record (EHR) prognostic model to screen older ED patients at high risk for 6-month mortality and compare its performance to validated comorbidity indices.

METHODS

This was a retrospective, observational cohort study of ED visits from adults aged ≥65 years who visited any of 9 EDs across a large regional health system between 2014 and 2019. Multivariable logistic regression that included clinical and demographic variables, vital signs, and laboratory data was used to develop a 6-month mortality predictive model-the Geriatric End-of-life Screening Tool (GEST) using five-fold cross-validation on data from 8 EDs. Performance was compared to the Charlson and Elixhauser comorbidity indices using area under the receiver-operating characteristic curve (AUROC), calibration, and decision curve analyses. Reproducibility was tested against data from the remaining independent ED within the health system. We then used GEST to investigate rates of ACP documentation availability and code status orders in the EHR across risk strata.

RESULTS

A total of 431,179 encounters by 123,128 adults were included in this study with a 6-month mortality rate of 12.2%. Charlson (AUROC (95% CI): 0.65 (0.64-0.69)) and Elixhauser indices (0.69 (0.68-0.70)) were outperformed by GEST (0.82 (0.82-0.83)). GEST displayed robust performance across demographic subgroups and in our independent validation site. Among patients with a greater than 30% mortality risk using GEST, only 5.0% had ACP documentation; 79.0% had a code status previously ordered, of which 70.7% were full code. In decision curve analysis, GEST provided greater net benefit than the Charlson and Elixhauser scores.

CONCLUSIONS

Prognostic models using EHR data robustly identify high mortality risk older adults in the ED for whom code status, ACP, or palliative care interventions may be of benefit. Although all tested methods identified patients approaching the end-of-life, GEST was most performant. These tools may enable resource-sensitive end-of-life screening in the ED.

Research Roundup

Synopses of a selection of recently published research articles of relevance to palliative care