Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs

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.

A study of the factors associated with emergency department visits in advanced cancer patients receiving palliative care

Purpose

Several studies demonstrated that cancer patients visited the emergency department (ED) frequently. This indicates unmet needs and poor-quality palliative care. We aimed to investigate the factors that contribute to ED visits among patients with advanced cancer in order to identify strategies for reducing unnecessary ED visits among these patients.

Methods

A retrospective study was conducted between January and December, 2019. Eligible patients were previously enrolled in the comprehensive palliative care program prior to their ED visit. All patients older than 18 were included. Patients were excluded if they had died at the initial consultation, were referred to other programs at the initial consultation, or had an incomplete record. The trial ended when the patients died, were referred to other palliative programs, or the study ended. The time between the initial palliative consultation and study endpoints was categorized into three groups: 16 days, 16–100 days, and > 100 days, based on the literature review. To investigate the factors associated with ED visits, a logistic regression analysis was conducted. The variables with a P value < 0.15 from the univariate logistic regression analysis were included in the multiple logistic regression analysis.

Results

Among a total of 227 patients, 93 visited the ED and 134 did not. Mean age was 65.5 years. Most prevalent cancers were colorectal (18.5%), lung (16.3%), and hepatobiliary (11.9%). At the end, 146 patients died, 45 were alive, nine were referred to other programs, and 27 were lost to follow-up. In univariate logistic regression analysis, patients with > 100 days from palliative consultation (OR 0.23; 95%CI 0.08, 0.66; p-value 0.01) were less likely to attend the ED. In contrast, PPS 50–90% (OR 2.02; 95%CI 1.18, 3.47; p-value 0.01) increased the ED visits. In the multiple logistic regression analysis, these two factors remained associated with ED visits:> 100 days from the palliative consultation (OR 0.18; 95%CI 0.06, 0.55; p-value 0.01) and PPS 50–90% (OR 2.62; 95%CI 1.44, 4.79; p-value 0.01).

Conclusions

There was reduced ED utilization among cancer patients with > 100 days of palliative care. Patients having a lower PPS were associated with a lower risk of ED visits.

Emergency Department Embedded Palliative Care Service Creates Value for Health Systems

Background: Emergency department (ED)-initiated palliative care consultation facilitates goal-concordant care while stewarding resource utilization. Delivery models are being piloted without clear operational and financial sustainability. Objective: To demonstrate that embedding a palliative care consultation service in the ED is clinically meaningful, operationally viable, and yields significant return on investment (ROI). Methods: Quasi-experimental study from August 17, 2020 to August 17, 2021. We established an ED-embedded palliative care consultation service at a 350-bed urban community hospital with 45,000 annual ED visits. A singe palliative care provider stationed in the main ED workstation area from 11 am to 7 pm daily. Matched analysis compared ED-embedded consultations against Floor and intensive care unit (ICU) consultations originating from usual practice. Results: ED consultations increased 10x, without cannibalization, to become the hospital's primary source of palliative care consultations. Clinical outcomes were meaningful, with 49% changing code status, 11% admitting to lower level of care, 11% avoiding hospitalization, 17% newly referred to hospice, and 21% newly referred to palliative care clinic. ED length of stay (LOS) did not lengthen, and ED staff strongly agreed that the service was valuable and unobtrusive. Compared with Floor, ED consultations had 8.1 days shorter hospital LOS (3.0 vs. 11.1 days, p < 0.01) with $5,974 lower median direct costs for index hospitalization ($6,211 vs. $12,005, p < 0.01). Compared with ICU, ED consultations had 4.2 days shorter hospital LOS (3.0 vs. 7.2 days, p < 0.01) with $9,332 lower median direct costs for index hospitalization ($14,093 vs. $23,425, p < 0.01). ROI was 6.7x net of foregone revenue and labor expenses. Conclusions and Relevance: This ED-embedded palliative care consultation service was clinically meaningful, operationally viable, and delivered a 6.7x ROI. ED-palliative partnerships present a quadruple aim opportunity to improve care for seriously ill patients.

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

OBJECTIVES

This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED).

METHODS

A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs).

RESULTS

A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%.

CONCLUSIONS

This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.