Quality improvement project increases consultations. 

Takeaways:

• The fast-paced environment of the emergency department makes it difficult to have lengthy care goal conversations, even with patients who chronic, progressive illnesses.
• Studies indicate that palliative care consults in the ED can improve patient quality of life.
• An urban Magnet-recognized hospital established a palliative care protocol for its ED.

Patients with chronic, progressive illnesses frequently visit the emergency department (ED), where aggressive life-support measures take place. The ED’s intense, fast-paced, time-limited environment makes it difficult for clinicians to pause for lengthy, time-sensitive conversations about care goals, so palliative care typically isn’t offered. According to Argintaru and colleagues, ED physicians report barriers such as lack of a relationship with the patient, the patients’ expectations, or an inability to reach a surrogate decision-maker. However, a study by Manfredi and colleagues indicates that palliative care consultation in the ED results in improved quality of life, decreased health costs, and reduced resource utilization. Early palliative care consultation and a provider team comfortable with discussing palliative care with patients may prompt care goal clarification consistent with a patient’s wishes and preferences. (See Palliative care vs. hospice: Know the difference.)

Palliative care opportunity

NewYork-Presbyterian Lower Manhattan Hospital (LMH), a small, urban, Magnet®-recognized hospital within a large New York City healthcare system, serves diverse communities, including Chinatown, the Financial District, and the Lower East Side of Manhattan. Annually, it receives between 30,000 and 40,000 patient visits. Most patients seen in the ED come from neighborhoods where 33% of the population is 65 years and over, 31% live in poverty, and 35.7% are foreign-born. Initiating palliative care services for these populations has compounding challenges, including varying cultural beliefs about the disease process, dying, and end-of-life care. Addressing the health needs of diverse populations requires healthcare providers with effective communication skills.

In 2017, LMH launched a palliative care service. The number of consults steadily increased, with the highest rates in intensive care and medical/surgical units. In the ED, palliative care consultations were comparatively low. In addition, ED staff had limited awareness of these services. The ED serves as the “front door to the hospital,” where patients first arrive and are evaluated; early aggressive, life-saving measures occur before goals of care conversations can be held, making it a key location for expanding palliative care services. Early goals of care conversations can facilitate a better understanding of a patient’s preferences before implementing aggressive interventions.

To advance palliative care services in the ED and improve care, a team consisting of ED providers, nurses, and leadership, along with palliative care nurses and physician providers, developed and implemented a quality improvement (QI) project.

What we wanted to achieve

This QI project had three primary goals. We wanted to increase early palliative care consultations, improve palliative care services in the ED by developing evidence-based criteria to select patients who might benefit, and generate awareness of palliative care criteria among ED nurses and providers.

We also wanted to increase ED nurse and provider knowledge and perceptions of palliative care with the aim of improving efficacy when they initiate conversations with patients and families about achievable and meaningful goals for care, especially in stressful decision-making situations. Meeting this goal might contribute to establishing early clarification of a plan of appropriate clinical care that aligns with patient and family preferences.

How we did it

A palliative care nurse practitioner (NP) and clinical nurse program coordinator adapted criteria from the Center to Advance Palliative Care as a guide for selecting patients in the ED who might benefit from palliative care interventions. The simple and specific evidence-based criteria included the following:

All adult (>17 years old) patients in the ED with at least one of the following conditions:

• Chronic obstructive pulmonary disease on home oxygen
• Dementia or neurologic disease
• End-stage renal disease
• Heart failure
• Stage 4 cancer

Also, any one of these criteria, in combination with the existing condition, would apply:

• Difficult-to-control symptoms related to serious illness such as pain, dyspnea, or psychological or spiritual distress
• More than three recent ED visits or hospitalizations with the same symptoms
• Patient or family request for palliative care needs

The palliative care NP attended several ED meetings and nursing huddles to provide education about clinicians’ roles in palliative care and to discuss consultation criteria. Education also focused on clinicians’ patient advocacy role and emphasized the need for nurse–provider collaboration to ensure appropriate consults. In addition, the NP taught ED nurses how to assess patients using the palliative care criteria and explained that, if they feel comfortable, they can initiate conversations about the concept of palliative care with patients and families.

Monthly educational sessions included discussion of cultural considerations and palliative care case study presentations (30-minute sessions, consisting of a 20-minute case presentation and 10 minutes for questions and answers). In addition, the NP provided ED clinical team members with direct contact information and hours of operation for the palliative care team.

Any staff member, patient, or family member can initiate a palliative care referral. However, a referral from anyone other than the treating physician requires that a palliative care consultant review the case with the ED provider before the official referral is placed. The NP encouraged ED nurses to participate in conversations the palliative care team has with patients and families. Frequently, the palliative care NP leads the patient and family conversation to ensure an efficient assessment. Knowing the challenges the ED clinical environment presents for initiating palliative care, the NP prioritized evaluating ED patients as soon as possible after receiving a consult request.

We tracked the number of ED palliative care consults and the code status outcomes of goals of care conversations. We also developed a survey to assess ED provider and nurse knowledge and perceptions of palliative care in their care setting. We distributed the survey before and after the intervention. (See What do ED clinicians know about palliative care?)

What we learned

Since the inception of the palliative care service in 2017, consultations directly from the ED had been low, ranging from one in 2018 to 11 in the first three quarters of 2021. After implementing the QI project in October 2021, ED consults increased significantly from 12 in the fourth quarter of 2021 to 22 in the first quarter of 2022. The primary admitting diagnoses for 2022 consults included septic shock, metastatic cancer, cerebrovascular accident, dementia, and cardiac arrest. Average patient age was 86 years.

Prior to consultation, 14 (64%) patients were full code and eight (36%) had do-not-intubate (DNI)/do-not-resuscitate (DNR) orders. After consultation, six (27%) patients remained full code and 16 (73%) had DNI/DNR orders. Out of 22 PC consultations from the ED, 11 (50%) patients transitioned to comfort care with median time from consult to comfort care of 2.3 days. Four (36%) patients who transitioned to comfort care died in hospital hospice.

Using the pre- and post-intervention survey, we measured ED clinician knowledge, attitudes, and perceptions of palliative care. Before the intervention, 47% of clinicians (n=30) either “agreed” or “strongly agreed” that palliative care services were provided in the ED; after the intervention, 83% “agreed” or “strongly agreed.” Before the intervention, 30% of respondents reported that, in the last 30 days, at least one palliative care consult had been placed for a patient under their care; after the intervention, 50% responded that they had cared for at least one patient who received a palliative care consultation.

Average scores for knowledge-based questions increased from 64% correct responses before the intervention to 78% after. When asked if palliative care consults should be placed in the ED, 87% of respondents agreed before the intervention and 100% agreed after. Before the intervention, 63% of respondents reported that they “agreed” or “strongly agreed” that ED clinicians understood the importance of palliative care; after the intervention, 83% of respondents “agreed” or “strongly agreed.”

Culture of advocacy

During this 6-month project, palliative care consults initiated in the ED increased substantially, and we saw improvement in the knowledge and positive perceptions of the service, which likely contributed to addressing goals of care early in patients’ hospitalization. Research has shown that palliative care improves patient satisfaction, lessens symptom burden, decreases length of stay, and reduces the rate of hospitalization. Early initiation of palliative care consultations in the ED for those who meet criteria allows patients and families to benefit from these outcomes sooner and may prevent inappropriate downstream use of acute care services.

Time constraints, prioritization of acute care and stabilization, lack of rapport with patients and families, and unexpected clinical courses make effective palliative care consultation difficult in the ED. Despite these barriers, we developed an innovative ED process that helped to increase early consultations. Staff engagement and collaboration between the ED clinicians and palliative care team aided identifying appropriate patients using the referral criteria. Educating ED nurses and providers about the essential role of palliative care and its integration into ED practice proved critical to the project’s success. We didn’t make assumptions about nurses’ knowledge of end-of-life stages, which helped us create an education plan tailored to them. Education also helped bridge gaps the ED team may experience when caring for the diverse community the hospital serves. Understanding the end-of-life beliefs of various cultures is key to navigating difficult conversations.

By engaging an interprofessional ED team with palliative care experts, we demonstrated the benefits of early consultation. Using the Magnet model as a framework, this project fostered a culture where nurses serve as patient advocates across the care continuum. (See A framework to advance palliative care in the ED.)

Anna Krakowski is a palliative care nurse practitioner at NewYork-Presbyterian Lower Manhattan Hospital. Karen Antequera is a clinical program coordinator in the emergency department and intensive care unit at NewYork-Presbyterian Lower Manhattan Hospital. Alexandra Shelley is a Magnet program director at NewYork-Presbyterian Lower Manhattan Hospital in New York City, New York. David Bodnar is interim director of the emergency department at NewYork-Presbyterian Lower Manhattan Hospital. Brenna Farmer is vice chief of clinical services at NewYork-Presbyterian Brooklyn Methodist Hospital. Rhoda Redulla is director of nursing excellence and Magnet recognition at NewYork-Presbyterian Lower Manhattan Hospital. Joan Halpern is vice president and chief nursing officer at NewYork-Presbyterian Lower Manhattan Hospital.

References

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Key words: Palliative care, Magnet, emergency department