Clinician Perspectives on Virtual Specialty Palliative Care for Patients With Advanced Illnesses.

Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.

Impact of Around-the-Clock Mental Health Staffing on Emergency Department Management of Patients Who Deliberately Self-Harm.

OBJECTIVE: Emergency departments (EDs) offer opportunities to deliver critical frontline suicide prevention services via assessment, safety planning, and linkages with community-based mental health care after discharge. Because mental health crises can occur at any time, this study sought to evaluate whether around-the-clock mental health staffing in the ED influences the likelihood of providing these evidence-based mental health services. METHODS: ED nursing leadership from a national sample of 406 hospitals completed a survey on the ED management of patients who deliberately self-harm, including availability of mental health staff (psychiatrists, psychiatric nurses, psychologists, social workers, other mental health professionals). Analyses examined whether around-the-clock mental health staffing was associated with provision of key assessments, safety planning, and discharge practices, controlling for hospital characteristics. RESULTS: There were no significant differences in the extent to which EDs with and without around-the-clock mental health staff routinely completed recommended assessment practices (71% and 70%, respectively). EDs with around-the-clock mental health staff were more likely than their counterparts to routinely provide two recommended safety planning practices (59% vs. 27%, p<0.001; adjusted odds ratio [AOR]=3.76) and were more likely to routinely schedule follow-up outpatient care (44% vs. 21%, p=0.002; AOR=3.26). CONCLUSIONS: Around-the-clock mental health coverage in the ED is associated with routine provision of key safety planning and discharge practices. EDs should have consistent access to staff either in person or remotely to facilitate the delivery of evidence-based mental health practices.

The Relationship Between Evidence-Based Practices and Emergency Department Managers' Perceptions on Quality of Care for Self-Harm Patients.

OBJECTIVE: To understand the extent to which implementation of evidence-based practices affects emergency department (ED) nurse managers' perceptions of quality of care provided to deliberate self-harm patients. METHODS: ED nursing leadership from a nationally representative sample of 513 hospitals completed a survey on the ED management of deliberate self-harm patients, including the quality of care for deliberate self-harm patients on a 1 to 5 point Likert-type scale. Unadjusted and adjusted analyses, controlling for relevant hospital characteristics, examined associations between the provision of evidence-based practices and quality of care. RESULTS: The overall mean quality rating was 3.09. Adjusted quality ratings were higher for EDs that routinely engaged in discharge planning (ß = 0.488) and safety planning (ß = 0.736) processes. Ratings were also higher for hospitals with higher levels of mental health staff (ß = 0.368) and for teaching hospitals (ß = 0.319). CONCLUSION: Preliminary findings suggest a national institutional readiness for further implementation of evidence-based practices for deliberate self-harm patients.

If You Could Change 1 Thing to Improve the Quality of Emergency Care for Deliberate Self-harm Patients, What Would It Be? A National Survey of Nursing Leadership.

INTRODUCTION: Emergency departments increasingly treat patients for deliberate self-harm. This study sought to understand emergency department nursing leadership perspectives on how to improve the quality of emergency care for these patients. METHODS: ED nursing managers and directors from a national sample of 476 hospitals responded to an open-ended question asking for the 1 thing they would change to improve the quality of care for self-harm patients who present in their emergency departments. We identified and coded key themes for improving the emergency management of these patients, then examined the distribution of these themes and differences by hospital characteristics, including urbanicity, patient volume, and teaching status. RESULTS: Five themes regarding how to improve care for deliberate self-harm patients were identified: greater access to hospital mental health staff or treatment (26.4%); better access to community-based services and resources (26.4%); more inpatient psychiatric beds readily accessible (20.9%); separate safe spaces in the emergency department (18.6%); and dedicated staff coverage (7.8%). Endorsement of findings did not differ based on hospital characteristics. DISCUSSION: ED nursing leadership strongly endorsed the need for greater access to both hospital- and community-based mental health treatment resources for deliberate self-harm patients. Additional ED staff and training, along with greater continuity among systems of care in the community, would further improve the quality of emergency care for these patients. Broad policies that address the scarcity of mental health services should also be considered to provide comprehensive care for this high-risk patient population. KEY WORDS: Emergency department management of self-harm; Mental health care; Emergency nursing care.