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Barriers to Integrating Palliative Care into Emergency Departments Persist Despite Heightened Interest During COVID-19

Key findings

  • During summer 2020, Massachusetts General Hospital researchers interviewed 31 providers at 52 institutions that integrated palliative care (PC) into the emergency department (ED) before or during the COVID-19 pandemic
  • After discussing their current experiences, the interviewees were asked to reflect on ED–PC integration more generally
  • The respondents identified five key qualities of PC providers working in the ED who were perceived as "successful": autonomous, competent, flexible, fast and fluent in ED language and culture
  • Four barriers to ED–PC integration emerged: the ED environment, limited access to PC providers, the ED perception of PC and the ED financial model that favors rapid patient disposition
  • ED–PC integration might be facilitated by proactive identification of patients who would benefit from PC, ED-focused PC education and tools, increased PC presence in the ED, and micro- and macro-level data supporting ED–PC

Even before the COVID-19 pandemic began, there was nascent interest in integrating palliative care (PC) into the emergency department (ED). Studies over the past decade identified key barriers as limited PC staffing, the ED culture of aggressive care and lack of training.

Research also resulted in recommendations for facilitating ED–PC integration, including customized education, use of automated triggers to identify patient needs and increased PC visibility in the ED.

In the July 1, 2021 issue of the Journal of Pain and Symptom Management, Massachusetts General Hospital researchers reported on a nationwide qualitative study that identified five types of innovations in delivering PC services in the ED during COVID-19. Now, in a secondary analysis of the interviews, the researchers present the first data on barriers to and facilitators of ED–PC integration since the start of the pandemic.

The update, by senior author Emily Aaronson, MD, MPH, assistant chief quality officer and attending physician in the Department of Emergency Medicine at Massachusetts General Hospital, and first author Alexa Gips, MD, of the University of Colorado, and colleagues, was published in Palliative & Supportive Care.

Study Methods

Between June 30 and August 18, 2020, the interviewers conducted 27 interviews with 31 ED and PC providers, most of them physicians. The interviewees represented 52 institutions that had integrated PC into the ED.

After discussing their current experiences during the pandemic, interviewees were asked to reflect on ED–PC integration more generally. Analysis of the transcripts uncovered five key qualities of PC providers working in the ED who were perceived as successful, four principal barriers to ED–PC, and four principal facilitators.

Qualities of Successful PC Providers in the ED

  • Autonomous—Able to work independently; confident in their role, their expertise and the value they bring
  • Competent in clinical skills such as communication and rapport building as well as in systems (e.g., electronic medical recordkeeping, logistics of the institution)
  • Flexible—Comfortable working amid the chaos with incomplete information
  • Fast—Performs assessments and provides recommendations rapidly; focuses on specific consult questions and gives clear, timely answers
  • Fluent in ED language and culture—Cognizant of the specific demands on emergency medicine providers; knowledgeable about ED terminology; demonstrates a feeling of being "in the trenches" with ED teams

Barriers to ED–PC Integration

  • ED environment—Sensitive conversations are difficult in the chaos of the ED with incomplete information and limited private space; quick patient turnover makes relationship-building a challenge
  • Limited access to PC providers, who are typically present during business hours whereas ED caseloads peak in the late afternoon and evening
  • ED perception of PC—Many ED teams do not consider patients' PC needs to be within their scope; their focus on flow and disposition may limit in-depth goal-based discussions and lead them to default to more aggressive care
  • Lack of a supportive financial model—PC may slow patient dispositions in the ED to the department's financial detriment

Facilitators of PC–ED Integration

  • Proactive patient selection—Remove from ED providers the burden of identifying patients who would benefit from PC, for example by having PC clinicians do that or by using automated triggers
  • ED-focused PC education—Should have principal terminology, electronic medical recordkeeping and tools for shared decision-making that are tailored to the ED
  • Increased PC presence, for example, an embedded in-person provider or on-call expert support from someone known to the department
  • Evidence base—Show ED teams data on the benefits of PC to individual patients, how ED–PC integration can improve patient-centered outcomes and how PC affects hospital operational metrics such as length of stay and resource utilization

Toward the Future

COVID-19 catalyzed an explosion of interest in ED–PC integration. This real-world study documents the barriers discussed in earlier research but also identifies ample approaches to improving ED–PC cooperation. Given the current interest in value-based care, a notable opportunity is the early identification of patients who would prefer less aggressive treatment.

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