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New system to boost palliative care in emergency departments

Author: Petrina Vousden
14 March 2017

The quality of care patients with palliative care needs get in emergency departments could be boosted by a new system, according to a new study.

Doctors and nurses at St Vincent’s University Hospital, Dublin introduced new guidelines and systems for the early identification of patients with palliative care needs at the hospital’s ED as part of a project called PAL.M.ED..

The project developed a new tool – P.A.U.S.E  to identify patients previously not known to palliative medicine service at the hospital.

The patient administration system in the ED was modified to “flag” patients known previously to the Hospital’s palliative medicine service.

An education programme was delivered to all doctors and nurses working in the emergency department.

And the palliative medicine team attended the emergency department each morning to liaise with the emergency department team regarding potential referrals.

After the introduction of PAL.M.ED

  • There was an eight fold increase in referrals from the Emergency Department to the palliative medicine team.
  • About one in ten – 11 per cent – of seriously ill patients reviewed in by the special team in ED avoided a hospital admission.
  • Patients who had a palliative medicine consultation in the ED had a reduced length of stay in hospital as well as lower rate of lab tests.
  • Patients reviewed by the palliative service in the ED were more likely to be discharged back to their own home .
  • Doctors and Nurses working in the ED developed a broader understand of the nature and role of palliative medicine.
  • ED staff wanted access to the specialist palliative medicine service 24/7 after the project.

 The project, PAL.M.ED – Palliative Medicine in the Emergency Department was grant aided by the Irish Hospice Foundation.

The 12 strong study team was led by palliative care consultant Dr Eoin Tiernan and emergency medicine consultant Professor John Ryan.

Ultimately the team behind the project wanted to improve the quality of care received by patients and their families attending the ED.

 If the new system was rolled out in EDs nationwide it could lead to more patients being able to access the palliative care they need more swiftly.

Early engagement with palliative care services for patients with advanced cancer during the course of their illness has been shown to improve clinical outcomes, quality of life, and even increase survival.

The PAL.M. ED project is the first significant study of early referral of patents in the ED which includes both cancer and non-cancer patients.

The study looked at referrals to the service over a two month period in 2013 and compared them to referrals from May to June 2015 after PAL.M.ED was introduced.

It found introduction in the ED of the new system led to a significant increase in early referrals. A total of 169 patients were referred to the palliative care team over the study period in 2015 of which 90 were admitted to hospital via the ED.

The majority of patients were aged 65 and over with a third in the aged 80 plus category.

Nurses and doctors interviews for the study unanimously agreed that overcrowding and lack of privacy “impacted significantly” on the provision of palliative care in the ED. 

Each year there are approx. 20,000 admissions to St Vincent’s University Hospital. About 13,000 are admitted through the Emergency Department (ED). There are approx. 740 deaths per year in the hospital. The ED registers about 51,000 attendances per year. There are approximately 100 deaths in the ED during the same period.

A study spokesman said: “It was our opinion that we could have a greater impact on a patient’s hospital experience if we received earlier referrals.

“It was our objective to develop systems and processes to improve the detection of patients with palliative care needs who attended the ED, to improve the quality of palliative care provided in the ED itself.”

The Emergency Department is the gateway and point of entry triage for the majority of patients who are admitted.

 Though deaths in the ED do occur, end-of-life care represents just a small proportion of the potential activity of a Palliative Medicine Service in an Emergency Department.

The majority of patients with palliative care needs attending the ED will not be imminently dying, but will have an array of complex care needs, often involving complex ethical dilemmas, where a specialist Palliative Medicine Service can help.

The study said mention of palliative care in the ED may seem like an oxymoron. Many still view palliative care as synonymous with terminal care, but, in fact, this is no longer the case.

The WHO definition of Palliative Care is “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.

In particular, it adds that it “is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications”.

Featured image: Pixabay

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