COVID-19 Prompted Integrating Palliative Care into Emergency Departments
- The volume of seriously ill patients in many U.S. emergency departments (EDs) increased dramatically during the first surge of the COVID-19 pandemic
- The unprecedented volume has revealed the need to accelerate efforts to integrate palliative care (PC) into EDs
- Researchers in the Division of Palliative Care and Geriatric Medicine at Massachusetts General Hospital and the Mongan Institute Center for Aging and Serious Illness now provide an update on five innovations in palliative care for EDs
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During the first surge of the COVID-19 pandemic, the volume of seriously ill patients in many U.S. emergency departments (EDs) skyrocketed and emergency clinicians recognized they were playing a key role in determining patients' care trajectories. This led to a recognition of the need to accelerate nascent efforts to integrate palliative care (PC) into EDs.
In the Journal of Pain and Symptom Management, Massachusetts General Hospital researchers, led by Emily Aaronson, MD, MPH, assistant chief quality officer and attending physician in the Department of Emergency Medicine, and 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, and colleagues. report on a national qualitative study that identified five types of innovations in delivering PC services in the ED as a result of COVID-19.
The study, performed between June 30 and August 18, 2020, initially recruited clinicians in areas of the country that had experienced COVID-19 surges and/or at sites known by a study team member to have increased PC–ED integration. Subsequently, interviewees were asked to refer colleagues from other sites.
The study team, which included both PC and ED clinicians, developed a guide that was used to conduct videoconference interviews of 31 individuals from 52 institutions (29 physicians, one nurse practitioner and one social worker). Twelve interviewees normally practice in PC only, seven in emergency medicine only, and 12 in both. Large academic medical centers, community hospitals, county/safety-net hospitals and a rural hospital were represented.
Five institutions reported no changes in PC delivery during COVID-19. Analysis of the other interviews identified five overlapping categories of innovations: changes in model of care, changes in staffing, tele-PC, PC training for non-PC clinicians and new methods of case identification.
Changes to Model of Care
At several institutions, a PC provider was fully embedded in the ED. At others, PC providers made daily rounds in the ED or otherwise made themselves more known as a resource. One PC consult team achieved this by starting a daily chat in the electronic medical records system, indicating PC was available for questions and creating a thread for case-based dialogue.
Changes to PC Staffing
Non–PC-trained clinicians sometimes worked closely with PC clinicians. At various institutions:
- Off-service psychiatry residents were trained in goals-of-care (GOC) discussions, then were embedded in the ED with supervision from PC
- Ophthalmology residents were trained to collect information on surrogate decision-makers
- Different types of off-service residents prescreened the ED track board, prerounded with ED teams and then briefed the PC attending physicians on arrival
- A mobile consult service, staffed by general oncologists, identified ED and ICU patients who needed PC services
- Physicians whose clinical demands had decreased because of COVID-19 were trained in conducting serious illness conversations, then were paired with a social worker or child life specialist and fully embedded in the ED, with a formal process for accessing PC physician support as needed
Telephone conference and videoconference technology were used to engage patients and families in GOC discussions. These were variously facilitated by an in-house team of PC physicians, an offsite team of PC physicians within the same hospital system and a team of nurses across a large multihospital health system.
PC Training for Non-PC Clinicians
Almost all programs that emerged during COVID-19 educated ED clinicians in primary PC skills. One also developed nursing-specific protocols about when GOC conversations should take place. Some institutions focused their educational efforts on collecting COVID-19–specific tools into a single electronically accessible resource.
Changes to Case Identification
Several programs initiated procedures in which PC clinicians either remotely screened the ED track board or frequently checked with ED staff in person. One program enabled nurses to place consults directly to PC. Several sites created systems to trigger a GOC conversation by the ED clinician rather than wait for specialty PC consultation.
Post-Surge Models of Care
None of the new models of care persisted unaltered after the COVID-19 surge, but some institutions continued less resource-intense versions. ED clinicians at almost all sites reported increased PC consult volumes, a new appreciation of PC and heightened interest in attaining PC skills.
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