Developing a novel integrated geriatric palliative care consultation program for the emergency department.
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ABSTRACT:
SUBMITTER: Stoltenberg MJ
PROVIDER: S-EPMC9742608 | biostudies-literature | 2022 Dec
REPOSITORIES: biostudies-literature
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Developing a novel integrated geriatric palliative care consultation program for the emergency department.
Stoltenberg Mark J MJ Kennedy Maura M Rico Janet J Russell Matthew M Petrillo Laura A LA Engel Kirsten G KG Kamdar Mihir M Ouchi Kei K Wang David H DH Bernacki Rachelle H RH Biese Kevin K Aaronson Emily E
Journal of the American College of Emergency Physicians open 20221211 6
With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ...[more]
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Project description:BackgroundComprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable.AimTo determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients' subsequent healthcare utilization.MethodsSecondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914-20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously.ResultsThirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7-9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2-6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5-0.9, p = .01). Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1-16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission.ConclusionAbout one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.
| S-EPMC10565963 | biostudies-literature
Project description:ObjectivesTo examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use.DesignProspective observational cohort.SettingThree U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015.ParticipantsIndividuals aged 65 and older in the ED (N = 57,287).InterventionThe intervention was first TCN contact. Controls never saw a TCN during the study period.MeasurementsWe examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits.ResultsA TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%).ConclusionTargeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.
| S-EPMC6764445 | biostudies-literature
Project description:IntroductionOver 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures.MethodsWe performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation.ResultsWe studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period.ConclusionImplementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.
| S-EPMC5468062 | biostudies-literature
Project description:IntroductionThe Emergency Department (ED) of Mbarara Regional Referral Hospital serves a largely rural population of 4 million people in western Uganda. Here, ED patients with incurable illness often have prolonged stays. Palliative care (PC) is a low-cost intervention that focuses on alleviating pain and suffering for patients with incurable disease, while improving satisfaction with care and optimizing healthcare utilization. This is especially important in low resource settings. A prior needs assessment in our ED revealed that 50% of patients have PC needs. The ED is an optimal location to initiate PC, yet this rarely happens. There is a great need to identify factors affecting initiation of ED PC in our resource-limited setting.MethodsA semi-structured questionnaire and chart review was conducted from March to August 2020. Patients admitted from the ED were assessed for PC needs. Those who met criteria were approached for inclusion and flagged for initiation of PC. The follow-up period was 7 days.ResultsSixty two percent of those subjects flagged for initiation of PC received it. By day seven, 36.1 of the study population had died. ED initiation of PC varied significantly by diagnosis, with cancer patients more likely to receive PC (p = 0.0097).ConclusionImportant barriers to PC initiation were identified in our Ugandan ED, related to diagnosis. These barriers could be overcome by improving awareness of PC amongst patients and providers alike and implementing a PC screening tool for all admissions. Future research is needed to identify other barriers, as well as strategies for improved hospital-wide uptake of PC in this resource-limited setting.
| S-EPMC8568603 | biostudies-literature
Project description:BackgroundTo investigate the value of a novel simulation-based palliative care educational intervention within an emergency medicine (EM) residency curriculum.MethodsA palliative care scenario was designed and implemented in the simulation program at an urban academic emergency department (ED) with a 3-year EM residency program. EM residents attended one of eight high-fidelity simulation sessions, in groups of 5-6. A standardized participant portrayed the patient's family member. One resident from each session managed the scenario while the others observed. A 45-min debriefing session and small group discussion followed the scenario, facilitated by an EM simulation faculty member and a resident investigator. Best practices in palliative care were highlighted along with focused learner performance feedback. Participants completed an anonymous pre/post education intervention survey.ResultsForty of 42 EM residents (95%) participated in the study. Confidence in implementing palliative care skills and perceived importance of palliative care improved after this educational intervention. Specifically, residents 1) felt EM physicians had an important role in palliative care, 2) had increased confidence in the ability to determine patient decision-making capacity, 3) had improved confidence in initiating palliative discussions/treatment, 4) believed palliative education was important in residency, and 5) felt simulation was an effective means to learn palliative care. Differences noted between PGY1 and PGY 3 training levels in survey responses disappeared post-intervention. Residents noted being most comfortable with delivering bad news and symptom management and least comfortable with disease prognostication. Residents reported time constraints and implementation logistics in the ED as the most challenging factors for palliative care initiation.ConclusionOur case-based simulation intervention was associated with an increase in both the perceived importance of ED palliative care and self-reported confidence in implementing palliative care skills. Time constraints and implementation logistics were rated as the most challenging factors for palliative care initiation in the ED.
| S-EPMC5842635 | biostudies-literature
Project description: Not available
| S-EPMC7335492 | biostudies-literature
Project description:Study objectiveThe objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs).MethodsWe analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively.ResultsOver the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common.ConclusionThere has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed.
| S-EPMC10015385 | biostudies-literature
Project description:ImportanceThere has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers.ObjectiveTo evaluate the association of GED programs with Medicare costs per beneficiary.Design, setting, and participantsThis cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups.InterventionsTreatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period.Main outcomes and measuresThe main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter.ResultsOf the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED.Conclusions and relevanceAmong Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.
| S-EPMC7921898 | biostudies-literature
Project description:ObjectiveTo describe a feasibility pilot study for older adults that addresses the digital divide, unmet health care needs, and the 4Ms of Age-Friendly Health Systems via the emergency department (ED) follow-up home visits supported by telehealth.Data sources and study settingData sources were a pre-implementation site survey and pilot phase individual-level patient data from six US Department of Veterans Affairs (VA) EDs.Study designA pre-implementation survey assessed existing geriatric ED processes. In the pilot called SCOUTS (Supporting Community Outpatient, Urgent care & Telehealth Services), sites identified high-risk patients during an ED visit. After ED discharge, Intermediate Care Technicians (ICTs, former military medics), performed follow-up telephone, or home visits. During the follow-up visit, ICTs identified "what matters," performed geriatric screens aligned with Age-Friendly Health Systems, observed home safety risks, assisted with video telehealth check-ins with ED providers, and provided care coordination. SCOUTS visit data were recorded in the patient's electronic medical record using a standardized template.Data collection/extraction methodsSites were surveyed via electronic form. Administrative pilot data extracted from VA Corporate Data Warehouse, May-October 2021.Principle findingsSite surveys showed none of the EDs had a formalized way of identifying the 4 M "what matters." During the pilot, ICT performed 56 telephone and 247 home visits. All home visits included a telehealth visit with an ED provider (n = 244) or geriatrician (n = 3). ICTs identified 44 modifiable home fall risks and 99 unmet care needs, recommended 80 pieces of medical equipment, placed 36 specialty care consults, and connected 180 patients to a Patient Aligned Care Team member for follow-up.ConclusionsA post-ED follow-up program in which former military medics perform geriatric screens and care coordination is feasible. Combining telehealth and home visits allows providers to address what matters and unmet care needs.
| S-EPMC9843080 | biostudies-literature
Project description:ImportanceThe delivery of palliative care is not standard of care within most emergency departments (EDs).ObjectiveTo compare quality of life, depression, health care utilization, and survival in ED patients with advanced cancer randomized to ED-initiated palliative care consultation vs care as usual.Design, setting, and participantsA single-blind, randomized clinical trial of ED-initiated palliative care consultation for patients with advanced cancer vs usual care took place from June 2011 to April 2014 at an urban, academic ED at a quaternary care referral center. Adult patients with advanced cancer who were able to pass a cognitive screen, had never been seen by palliative care, spoke English or Spanish, and presented to the ED met eligibility criteria; 136 of 298 eligible patients were approached and enrolled in the ED and randomized via balanced block randomization.InterventionsIntervention participants received a comprehensive palliative care consultation by the inpatient team, including an assessment of symptoms, spiritual and/or social needs, and goals of care.Main outcomes and measuresThe primary outcome was quality of life as measured by the change in Functional Assessment of Cancer Therapy-General Measure (FACT-G) score at 12 weeks. Secondary outcomes included major depressive disorder as measured by the Patient Health Questionnaire-9, health care utilization at 180 days, and survival at 1 year.ResultsA total of 136 participants were enrolled, and 69 allocated to palliative care (mean [SD], 55.1 [13.1] years) and 67 were randomized to usual care (mean [SD], 57.8 [14.7] years). Quality of life, as measured by a change in FACT-G score from enrollment to 12 weeks, was significantly higher in patients randomized to the intervention group, who demonstrated a mean (SD) increase of 5.91 (16.65) points compared with 1.08 (16.00) in controls (P = .03 using the nonparametric Wilcoxon test). Median estimates of survival were longer in the intervention group than the control group: 289 (95% CI, 128-453) days vs 132 (95% CI, 80-302) days, although this did not reach statistical significance (P = .20). There were no statistically significant differences in depression, admission to the intensive care unit, and discharge to hospice.Conclusions and relevanceEmergency department-initiated palliative care consultation in advanced cancer improves quality of life in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study.Trial registrationclinicaltrials.gov Identifier: NCT01358110.
| S-EPMC9252442 | biostudies-literature