Palliative care in the emergency department: A qualitative study exploring barriers, facilitators, desired clinician qualities, and future directions.

OBJECTIVE: To describe the perceived qualities of successful palliative care (PC) providers in the emergency department (ED), barriers and facilitators to ED-PC, and clinicians' perspectives on the future of ED-PC. METHOD: This qualitative study using semi-structured interviews was conducted in June-August 2020. Interviews were analyzed via a two-phase Rapid Analysis. The study's primary outcomes (innovations in ED-PC during COVID) are published elsewhere. In this secondary analysis, we examine interviewee responses to broader questions about ED-PC currently and in the future. RESULTS: PC providers perceived as successful in their work in the ED were described as autonomous, competent, flexible, fast, and fluent in ED language and culture. Barriers to ED-PC integration included the ED environment, lack of access to PC providers at all times, the ED perception of PC, and the lack of a supporting financial model. Facilitators to ED-PC integration included proactive identification of patients who would benefit from PC, ED-focused PC education and tools, PC presence in the ED, and data supporting ED-PC. Increased primary PC education for ED staff, increased automation, and innovative ED-PC models were seen as areas for future growth. SIGNIFICANCE OF RESULTS: Our findings provide useful information for PC programs considering expanding their ED presence, particularly as this is the first study to our knowledge that examines traits of successful PC providers in the ED environment. Our findings also suggest that, despite growth in the arena of ED-PC, barriers and facilitators remain similar to those identified previously. Future research is needed to evaluate the impact that ED-PC initiatives may have on patient and system outcomes, to identify a financial model to maintain ED-PC integration, and to examine whether perceptions of successful providers align with objective measures of the same.

Patients with pulmonary hypertension presenting to the emergency department.

OBJECTIVES: Pulmonary hypertension (PH) patients represent a complex subset of patients in the emergency department (ED), yet little is known about their presentations and outcomes. The objective of this study is to analyze the demographics, dispositions and the rates of return visits for PH patients visiting the ED, focusing on PH patients identified as having high frequency visits. METHODS: We performed a retrospective cohort analysis of all patients with ICD-9-CM and ICD-10-CM codes corresponding to PH presenting to an academic medical center emergency department during a 21-month period. The primary outcome was patients with high frequency ED visits, defined as 4 or more visits in a 12-month period. Secondary outcomes included ED dispositions, return ED visits, hospital length of stay, and in-hospital mortality. RESULTS: Six hundred and eighty four unique patients with a coded diagnosis of PH visited the emergency department a total of 1447 times. Eighty-four patients (12.28%) were identified as having high frequency visits. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and having Group 1 PH. PH patients' admission rate was substantial at 56.60%, and their inpatient mortality was increased (6.7% vs 3.7% for all admissions from ED, P < 0.0001). CONCLUSION: PH patients in this study had frequent return ED visits, as well as elevated admission and readmission rates. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and Group 1 PH. PH patients also had increased mortality rates compared to the general ED population.

Successful Field Rewarming of a Patient with Apparent Moderate Hypothermia Using a Hypothermia Wrap and a Chemical Heat Blanket.

Hypothermia is a common problem encountered by search and rescue teams. Although mildly hypothermic patients can be rewarmed in the field and can then self-evacuate, the Wilderness Medical Society hypothermia guidelines suggest that a moderately hypothermic patient in the wilderness requires warming in a medical facility. The hypothermia prevention and management kit, developed by the US military, consists of a chemical heat blanket (CHB) and a heat-reflective shell. We present a case in which a hypothermia wrap and the CHB from a hypothermia prevention and management kit were used successfully to rewarm a patient with apparent moderate hypothermia in the field. We are unaware of previous reports of successful field rewarming of a patient with moderate hypothermia. We believe the use of the CHB in conjunction with a hypothermia wrap made field rewarming possible. We recommend that a CHB, along with the components of a hypothermia wrap, be carried by search and rescue teams when a hypothermic patient might be encountered. Although there were no documented core temperatures, we believe this case is consistent with the hypothesis that if a hypothermic patient who is found lying down and shivering is allowed to stand or walk before insulation is applied and before there has been an additional period of 30 min during which the patient continues to shiver, there may be increased afterdrop with deleterious results.

Emergency Palliative Care: Patient With Cancer Diagnosis and Escalating Symptom Burden.

In this segment of the emergency department (ED) palliative care (PC) case series, we present a patient with advanced cancer not yet followed by PC or on hospice, who presents to the ED overnight with worsening nausea, vomiting, and acute on chronic abdominal pain. The ED team works to stabilize and treat the patient, reaches out to his oncologist, and seeks remote support and guidance from the on-call PC clinician. After a rapid "just-in-time" training, the ED clinician is able to have a focused goals-of-care conversation with the patient and his family and make person-centered recommendations. The patient is briefly admitted to the intensive care unit for ongoing medical optimization and symptom management, and then subsequently discharged home on hospice in alignment with his elucidated goals.

Common Mistakes and Evidence-based Approaches in Goals-of-Care Conversations for Seriously Ill Older Adults in Cardiac Care Unit.

For older adults with serious, life-limiting illnesses near the end of life, clinicians frequently face difficult decisions about the medical care they provide because of clinical uncertainty. This difficulty is further complicated by unique challenges and medical advancements for patients with advanced heart diseases. In this article, we describe common mistakes encountered by clinicians when having goals-of-care conversations (e.g., conversations between clinicians and seriously ill patients/surrogates to discuss patient's values and goals for clinical care near the end of life.). Then we delineate an evidence-based approach in goals-of-care conversations and highlight the unique challenges around decision-making in the cardiac intensive care unit.

Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report.

CASE: A 39-year-old man with a chronic Achilles rupture status post (1) failed primary repair and (2) secondary xenograft repair with graft rejection, resulting in a 12-cm Achilles tendon defect, which was reconstructed utilizing an Achilles bone block allograft and flexor hallucis longus (FHL) tendon transfer. At 15-year follow-up, the patient reported good functionality and satisfaction with the repair, with positive patient-reported outcome measures. Physical examination revealed excellent strength and range of motion. Magnetic resonance imaging confirmed the integrity and incorporation of the Achilles/FHL graft composite. CONCLUSION: This case study provides valuable insight into successful long-term management of complex chronic Achilles ruptures with large defects.

Patterns of national emergency department utilization by fee-for-service Medicare beneficiaries with dementia.

BACKGROUND: Individuals with Alzheimer's disease and related dementias (ADRD) often face high acute care clinical utilization and costs with unclear benefits in survival or quality of life. The emergency department (ED) is frequently the site of pivotal decisions in these acute care episodes. This study uses national Medicare data to explore this population's ED utilization. METHODS: Retrospective cohort study of persons aged ≥66 years enrolled in traditional Medicare with a Chronic Condition Warehouse diagnosis of dementia. Primary 1-year outcome measures included ED visits with and without hospitalization, ED visits per 100 days alive, and health-care costs. A multivariate random effects regression model (clustered by county of residence), adjusted for sociodemographics and comorbidities, examined how place of care on January 1, 2018, was associated with subsequent ED utilization. RESULTS: In 2018, 2,680,006 ADRD traditional Medicare patients (mean age 82.9, 64.2% female, 9.4% Black, 6.2% Hispanic) experienced a total of 3,234,767 ED visits. Over half (52.2%) of the cohort experienced one ED visit, 15.5% experienced three or more, and 37.1% of ED visits resulted in hospitalization. Compared with ADRD patients residing at home without services, the marginal difference in ED visits per 100 days alive varied by location of care. Highest differences were observed for those with hospitalizations (0.48 visits per 100 days alive, 95% confidence interval [CI] 0.47-0.49), skilled nursing facility (rehab/skilled nursing facility [SNF]) stays (0.27, 95% CI 0.27-0.28), home health stays (0.25, 95% CI 0.25-0.26), or observation stays (0.82, 95% CI 0.77-0.87). Similar patterns were observed with ED use without hospitalization and health-care costs. CONCLUSIONS: Persons with ADRD frequently use the ED-particularly those with recent hospitalizations, rehab/SNF stays, or home health use-and may benefit from targeted interventions during or before the ED encounters to reduce avoidable utilization and ensure goal-concordant care.

Differences in code status practice patterns among emergency clinicians working in Japan and the United States.

OBJECTIVE: This study aimed to examine self-reported code-status practice patterns among emergency clinicians from Japan and the U.S. METHODS: A cross-sectional questionnaire was distributed to emergency clinicians from one academic medical center and four general hospitals in Japan and two academic medical centers in the U.S. The questionnaire was based on a hypothetical case involving a critically ill patient with end-stage lung cancer. The questionnaire items assessed whether respondent clinicians would be likely to pose questions to patients about their preferences for medical procedures and their values and goals. RESULTS: A total of 176 emergency clinicians from Japan and the U.S participated. After adjusting for participants' backgrounds, emergency clinicians in Japan were less likely to pose procedure-based questions than those in the U.S. Conversely, emergency clinicians in Japan showed a statistically higher likelihood of asking 10 out of 12 value-based questions. CONCLUSION: Significant differences were found between emergency clinicians in Japan and the U.S. in their reported practices on posing procedure-based and patient value-based questions. PRACTICE IMPLICATIONS: Serious illness communication training based in the U.S. must be adapted to the Japanese context, considering the cultural characteristics and practical responsibilities of Japanese emergency clinicians.

A Hospice Transitions Program for Patients in the Emergency Department.

Importance: Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. Objective: To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. Design, Setting, and Participants: This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. Main Outcome and Measures: The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. Results: This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). Conclusions and Relevance: In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

Improving morale from the ground up. Grassroots tips to make your workplace better.

In our profession, where we help people every single day, there's no reason to not enjoy coming to work Remind yourself of that as long as it takes to feel it inherently. Keep a positive attitude and make sure you don't feed the workplace morale problem yourself. By keeping an eye on your own needs and making sure you're keeping yourself happy, maintaining this positive attitude can be effortless. Setting the example by your own behavior will induce change in the moods of those around you, whether you know it or not. Good luck, stay safe and have fun out there.

Goals of Care Conversations Documented By an Embedded Emergency Department-Palliative Care Team During COVID.

Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.

Best Practices in End of Life and Palliative Care in the Emergency Department.

Three-quarters of patients over the age of 65 visit the emergency department (ED) in the last six months of their lives. Approximately 20% of hospice residents have ED visits. These patients must decide whether to receive emergency care that prioritizes life support, which may not achieve their desired outcomes and might even be futile. The patients in these end-of-life stages could benefit from early palliative care or hospice consultation before they present to the ED. Furthermore, early integration of palliative care at the time of ED visits is important in establishing the goals of the entire treatment.

Diagnosis and Management of Pulmonary Embolism.

Pulmonary embolism is a challenging pathology commonly faced by emergency physicians, and diagnosis and management remain a crucial skill set. Inherent to the challenge is the breadth of presentation, ranging from asymptomatic pulmonary emboli to sudden cardiac death. Diagnosis and exclusion have evolved over time and now use a combination of clinical decision calculators and updates to the classic d-dimer cutoffs. Management of pulmonary emboli revolves around appropriate anticoagulation, which for most of the patients will comprise newer oral agents. However, there remains a substantial degree of practice variation and ambiguity when it comes to higher risk patients with submassive or massive pulmonary emboli.

Primary palliative care recommendations for critical care clinicians.

Palliative care is an interdisciplinary care to optimize physical, psychosocial, and spiritual symptoms of patients and their families whose quality of life is impaired by serious, life-limiting illness. In 2021, the importance of providing palliative care in the intensive care unit (ICU) is well recognized by various studies to alleviate physical symptoms due to invasive treatments, to set patient-centered goals of care, and to provide end-of-life care. This paper summarizes the evidence known to date on primary palliative care delivered in the ICU settings. We will then discuss the potential benefits and harms of primary palliative care so that critical care clinicians are better equipped to decide what services might best improve the palliative care needs in their ICUs.

Mapping the future for research in emergency medicine palliative care: A research roadmap.

BACKGROUND: The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE: The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS: Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS: Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS: There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.