Pilot of Embedded Palliative Care Early in COVID-19 Was Well Received by Emergency Clinicians
Key findings
- A survey of 134 emergency department (ED) clinicians inquired about their experiences during an eight-week pilot program of having an embedded palliative care (PC) physician in the ED early in the COVID-19 pandemic
- The 101 respondents found PC engagement valuable (4.61 on a five-point Likert scale) and endorsed multiple benefits, including improvements in goal-concordant care
- PC engagement also improved ED clinicians' own experience, such as freeing them up for other tasks, contributing to their education about goal-concordant care and helping them feel more supported
- The principal barriers cited were related to the availability of PC and the challenges of engaging PC in the setting of high-acuity patients
- ED clinicians unanimously indicated they would like to have ongoing access to a PC physician embedded in the ED
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Earlier this year, researchers at Massachusetts General Hospital published a letter describing how they integrated palliative care (PC) into the emergency department (ED) in response to the initial outbreak of COVID-19 in Boston. They launched a pilot program in which one of five palliative care physicians was embedded in the ED seven days a week from 9 am to 7 pm.
To gauge the success of the program, Christine Seel Ritchie, MD, MSPH, director of research in the Division of Palliative Care and Geriatric Medicine and director of the Mongan Institute Center for Aging and Serious Illness at Mass General, Vicki A. Jackson, MD, MPH, chief of the Division of Palliative Care and Geriatric Medicine, Emily Aaronson, MD, MPH, assistant chief quality officer and attending physician in the Department of Emergency Medicine, and colleagues conducted a formal survey of ED clinicians. Their encouraging findings appear in the Journal of Pain and Symptom Management.
Study Details
The pilot study lasted eight weeks, and 134 ED clinicians were surveyed in May 2020. Of the 101 respondents, 40% were attending physicians, 31% were residents and 29% were advanced practice providers. 80 respondents had worked in the ED during the embedded PC program.
Benefits
73 clinicians said they had interacted with the embedded PC physician. 100% of them endorsed at least one of the benefits suggested in the survey. These included:
- Freed them up for other tasks—89%
- Helped them feel more supported during their shift—84%
- Changed the patient's management or care trajectory—67%
- Contributed to their education about goal-concordant care—57%
- Added to their skillset/confidence in practicing PC within the ED—49%
When asked, "Overall, how valuable do you find PC in the ED?" on a Likert scale (1=not valuable at all; 5=very valuable), the average response was 4.61.
30 respondents answered a free-text question asking them to reflect on an interaction with the PC physician that went well. The main themes that emerged were gratitude and perceptions that PC engagement elevated the quality of patient care and achieved goal-concordant care.
Barriers
Some of the 80 clinicians who worked in the ED during the pilot program endorsed prespecified explanations for not accessing the PC physician during their shift:
- No patient needed a PC conversation—18%
- Patients were in acute clinical condition/crashing—15%
- Difficulty locating PC—8%
- Lack of time to consult because of ED volume—5%
- The PC physician was unavailable or busy with other patients—4%
No respondent said they did not see the value of an embedded PC.
Nine respondents answered a free-text question asking them to reflect on an interaction that did not go as they would have liked. The main barriers identified were lack of PC physician availability (e.g., at night), lack of timely response and the lengthy time required for serious illness conversations.
The Ideal World
77 respondents answered a free-text question asking what PC engagement in the ED would look like in their ideal world. They were unanimous in wanting a PC presence in the ED to continue. Comments also mentioned the importance of having a PC physician readily available and engaging early in the patient's ED course.
Value Outside the Pandemic?
As a new disease that created a surge of serious and critically ill patients, COVID-19 may have created a particularly receptive environment for embedded PC in the ED. Clinicians there may have been more acutely aware of the importance of PC and more willing than usual to partner with subspecialists.
Still, these findings are concordant with previously published research—and the consensus of emergency medicine's professional societies—concluding that palliative medicine improves the care of patients in the ED.
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