key: cord-334431-qn2c83in
authors: Aaronson, Emily Loving; Daubman, Bethany-Rose; Petrillo, Laura; Bowman, Jason; Ouchi, Kei; Gipps, Alexa; Traeger, Lara; Jackson, Vicki; Grudzen, Corita; Ritchie, Christine Seel
title: Emerging palliative care innovations in the ED: a qualitative analysis of programmatic elements during the COVID-19 pandemic
date: 2020-11-06
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.10.035
sha: 
doc_id: 334431
cord_uid: qn2c83in

CONTEXT: Health systems have aspired to integrate palliative care (PC) into the emergency department (ED) in order to improve care quality for over a decade, yet there are very few examples of implemented models in the literature. The COVID-19 pandemic led to an increase in the volume of seriously ill patients in EDs and a consequent rapid increase in PC integration in many EDs. OBJECTIVE: To describe the new PC-ED delivery innovations that emerged during the COVID-19 pandemic. METHODS: For this qualitative study of PC programs in EDs, semi-structured interviews were conducted with ED and PC clinicians between June 30, 2020 and August 18, 2020. Participants were asked about PC-ED integration before, during and after COVID. We conducted a two-phased rapid analysis (RA) using a RA template and consolidated matrix to identify innovations. RESULTS: Using purposive and snowball sampling, we interviewed 31 participants, representing 52 hospitals. Several new innovations in care delivery were identified. These included elements of fully embedded PC, the use of PC extenders, technology both within the electronic medical record (EMR) and outside of it, and innovations in training emergency clinicians in primary palliative care skills to support care delivery. Most PC efforts focused on increasing goals of care conversations. Institutions that implemented these programs reported that they increased PC utilization in the ED, were well received by clinicians, and changed patient’s care trajectories. CONCLUSIONS: Several new innovations in PC-ED care delivery emerged during COVID. Many innovations leveraged different types of clinicians to deliver care, an increased physical presence of PC in the ED, and used technology to enhance care delivery. These innovations may serve as a framework for institutions as they plan for evolving needs in the ED during and after COVID. Additional research is needed to evaluate the impact of these programs and to understand their applicability beyond the pandemic.

Health systems have been interested in palliative care (PC) -emergency department (ED) integration for over a decade. 1 Despite this, few innovations in care delivery have emerged. To date, reported innovations have focused on increasing primary PC (the basic PC skills required of all clinicians) and increasing traditional consult volume. [2] [3] [4] During the early months of the COVID-19 pandemic in the United States, there was both an increase in the volume of seriously ill patients in EDs and a recognition that EDs were playing a key role in determining patients' care trajectories. This led to a recognition of the need for increased PC-ED integration.

While some PC-ED innovations have been reported in the literature [5] [6] [7] [8] [9] [10] we anticipated that COVID might lead to the emergence of many more innovative models. Our primary objectives were to describe 1) the innovations in PC-ED integration that emerged during COVID and 2) the impacts of these innovations as perceived by clinicians who were involved in the implementation efforts.

We conducted a national qualitative study to characterize innovations in PC delivery in the ED during COVID. This study was performed between June 30, 2020 and August 18, 2020. Participants were initially recruited using a homogeneous purposive sampling technique 11, 12 targeting areas of the country that had experienced surges in COVID and/or were known by a member of the study team to have had an increase in PC-ED integration. An email invitation was sent to institutions initially identified by members of the study team, indicating that participants should be clinicians and could have a background either in PC or Emergency Medicine (EM), and aimed to identify the person at the institution with the most knowledge of the PC integration efforts in the ED. We then employed snowball sampling in which we asked interviewees for assistance, based on their networks of clinical and academic colleagues, to identify sites that may have experienced increased PC-ED integration. This article adheres to the Standards for Reporting Qualitative Research (SRQR). 13 This study was approved by the Partners Healthcare Institutional Review Board.

An interview guide was iteratively developed with the study team, which included stakeholders from both PC and EM. The Consolidated Framework for Implementation Research was selected to inform interview guide development. 14 Questions sought to elicit information about PC integration in the ED before, during and after COVID, the process of implementation and the perceived impact of integration on clinicians and patients. The study lead, who has previous experience leading qualitative studies, underwent focused training in Rapid Analysis facilitated by a PhD qualitative researcher. All study staff that were going to be involved in data collection and analysis underwent structured training in qualitative interviewing techniques and in the Rapid Analysis technique. We conducted semi-structured interviews over Zoom. Interviews were recorded and facilitated by a member of the study team.

We performed a two-step rapid analysis. This method is a valid approach for analyzing information with the aim of informing ongoing implementation. 15 In the first step, a nonfacilitator member of the study team watched the interview and transposed the information into a structured template that was designed based on the interview guide and meant to summarize the interview. In the second step, the facilitator reviewed the summary and consolidated the information into a matrix used to identify common categories. This matrix was then reviewed by the non-facilitator interview attendee. Disagreements were resolved by consensus. Interviews were conducted until content saturation [16] [17] [18] [19] was reached.

We conducted 27 interviews, with 31 individuals (Table 1 ). Between 1-3 participants were present at each interview. These interviews represented 52 institutions, as some participants oversaw integration of PC in EDs across a system and shared the experience of several institutions. The average interview length was 51 minutes. EDs represented large academic medical centers, community hospitals, county/safety net hospitals and a rural hospital. Of the institutions interviewed, five identified no new innovations in care delivery during COVID and were only included in the analysis of the baseline models of care delivery. Rapid analysis uncovered five major categories of innovation (Table 2) . We present these, contextualized by the baseline models of care delivery before COVID, and alongside participant's perception of these programs' impact on clinicians and patients.

Before COVID-19, two predominant models of PC delivery existed at the study sites: 1) a traditional consult model in which PC was available to consult with minimal, or no education for ED staff related to PC skills and concepts; and 2) a model which provided extensive training to ED clinicians to cultivate primary PC skills. In both models, respondents reported that PC remained underutilized.

Several institutions reported social work and case management in the ED who, in addition to their routine work, had training on screening for unmet PC needs and a pathway to involve PC. One site reported a program in which a PC MD was available during the day for PC consults to the ED exclusively, three days per week. The remainder of institutions did not have a PC provider in the ED (embedded) before COVID.

The majority of programs reported no formal system for identifying patients that would benefit from PC consult. Among sites that did have triggers, these were either used to cue a formal PC consult, or to cue the EM provider to have a goals of care (GOC) conversation. No institution reported proactive case identification by PC.

All academic sites reported PC integration into the ED training curriculum. Several reported curriculums with lectures, case discussions, skills days and simulations. Two programs reported a required PC rotation for all ED residents.

J o u r n a l P r e -p r o o f In our analysis, innovations were identified in five categories: 1) the model of care, 2) staffing, 3) technology, 4) primary PC training and education and 5) case identification.

Although not reported in the literature as a model of PC-ED delivery before COVID, a fully embedded model emerged at several institutions during the pandemic where a PC provider was seated in the ED, and fully dedicated to this work. Some institutions, in the absence of a radically new model of care delivery, enhanced the traditional consult model that they had available pre-COVID. PC strengthened their presence in the ED through daily rounds or making themselves more known as a resource. One program achieved this by leveraging pre-existing EMR technology by starting a daily EpicChat. This chat was initiated by the PC consult team with the ED providers working clinically that day, indicating that the PC was available for questions and creating a thread for case-based dialog throughout the day.

Several innovations in staffing emerged to facilitate the increased ED presence. Among embedded models, many institutions used PC attending physicians, fellows, and/or social workers.

In addition to these traditionally trained PC providers, during COVID a new workforce of "PC extenders," non-PC trained clinicians who worked closely with a PC clinician, also emerged to support PC efforts. At one institution, off-service psychiatry residents underwent focused training in GOC discussions and then were embedded in the ED with PC attending and fellow supervision. Another trained ophthalmology residents to collect information on health care decision makers. A third leveraged different types of off-service residents to pre-screen the ED track board, pre-round with ED teams, and then brief the PC attending upon arrival. A fourth created a 'mobile PC consult service' that was staffed by general oncologists who proactively identified ED and ICU patients.

One institution e-mailed all physicians in the organization seeking volunteers to serve as PC extenders in the ED. Over 20 physicians, primarily internists, family physicians and pediatricians whose clinical demands had decreased due to COVID, completed a training leveraging the Serious Illness Conversation Guide. 20 These clinicians were paired with a 'psychosocial partner' with a background in social work or child-life. This dyad was fully embedded in the ED with a formal process for accessing PC physician support as needed.

At several programs where a clear PC champion existed before the pandemic (either a dual trained ED-PC physician or PC nurse practitioner or social worker), that champion became entirely dedicated to the ED in their PC role. In these models, one PC clinician provided 24/7 support to the ED for the duration of the surge.

All programs with non-traditional staffing emphasized the importance of both structured, focused PC education for ED-PC clinicians as well as education for ED staff about the abilities and limitations of this new workforce.

During COVID, institutions leveraged phone or video technology to engage patients and families in ED GOC discussions. This was facilitated by diverse groups, including an in-house J o u r n a l P r e -p r o o f team of PC physicians, an off-site team of PC physicians within the same hospital system, and a team of nurses across a large multi-hospital health system.

Although one institution relied on Tele ED-PC for all COVID patients in the ED, the remainder used this as an adjunct, triaging patients to either in-person PC or tele-PC. This typically depended on the patient's ability to engage: for patients unable to engage, discussions were with off-site family and used tele ED-PC.

Almost all programs that emerged during COVID had some ED clinician education in primary palliative care skills (primary palliative care). Some organizations had a more robust foundation, and these sites chose primary PC education as the focus for innovation. At one institution, the staff had all previously completed extensive primary PC education and only added COVID specific conversation guides. One institution also rolled out nursing specific protocols to trigger GOC conversations. Many institutions used laminated resource cards.

Some institutions focused educational efforts on collating available tools in one place. One institution created a PaliED app 10 to reinforce the education that the trainees received during lectures and provide COVID-specific conversation guides. Another created a Google Doc to warehouse all COVID-specific ED-PC educational resources.

Several programs initiated proactive case identification in which PC either remotely screened the ED track-board or engaged in frequent in-person check-ins with ED staff. Criteria used for proactive case identification was either clearly specified, or informal. Formal trigger criteria often included age and a marker of potential COVID illness severity. Only one program had an automated trigger during COVID, utilizing an EMR auto-calculated mSOFA score. 21 Additionally, one program enabled nurses to place consults directly to PC.

Similarly, several sites that focused on primary PC instituted illness severity triggers to trigger a GOC conversation by the ED clinician rather than specialty-level PC consultation. One institution created a new Risk Scoring Tool which, once calculated, populated an algorithm which helped advise ED clinicians to engage in specific activities ( Figure One) .

Even as many programs tried to more systematically identify potential PC patients, they differed in the types of patients on which they focused. Some programs focused PC efforts exclusively on the "middle acuity" patients who were stable but at high risk of decompensating in the coming days. Others focused efforts on peri-intubation patients and patients who were unstable.

When asked about the type of work that PC was doing in the ED, all subjects described engaging in advanced care planning. Only three subjects cited work related to symptom management as well. All programs stated that PC's most valuable contribution in the ED during COVID was advance care planning, not symptom management. Many sites noted that the complexity and depth of this varied by patient. Several institutions noted that, rather than a traditional all-encompassing PC consult for every patient, they matched their intervention to the patient's clinical severity: i.e., identifying healthcare decision-makers for low acuity patients, having value-based GOC conversations for middle acuity patients, addressing code status for peri-intubation patients, and providing support for patients that had already been intubated.

All programs with new models of care reported that utilization increased. The five programs that reported no changes during COVID reported no change in PC utilization.

The programs with innovations in care delivery consistently reported a positive reception from ED providers, reporting that the ED found PC's presence to be helpful, and that ED teams expressed gratitude and relief. Additionally, several programs reported that the increased integration lead to a new appreciation among ED staff for the importance of PC-ED integration. Several programs perceived a cultural shift and a new understanding that PC was a core component of high-quality care in the ED. Only one program reported a concern from ED providers, which was that PC presence may increase ED length of stay.

The perception of the PC providers doing work in the ED was largely positive. Several programs noted the meaningfulness of playing an impactful role in the pandemic and felt it was gratifying to be so warmly welcomed by the ED. Programs reported that being in the ED both showed the PC team gaps in care and rewarded them as they filled those unmet needs. Relatedly, they appreciated being involved more 'upstream.'

Challenges for the PC providers doing this work included the solitude of the work (working alone rather than in a typical interdisciplinary PC team) and the pressure of implicit expectations that PC involvement would result in limitations on life-sustaining treatment independent of patient goals.

All of the programs that experienced some degree of increased PC-ED integration felt their work impacted patient care. Several programs highlighted nuanced, time-intensive conversations that could not have occurred without their presence. Many reported that this, in turn, facilitated more goal-concordant care. Specific examples included avoiding invasive procedures or admissions to higher levels of care when these were not aligned with patients' wishes. One program reflected on the impact their conversations had on the remainder of the hospitalization even without an acute change in the ED itself, such as 1) identifying a surrogate decision maker that mitigated subsequent family conflict and 2) giving patients an opportunity to articulate goals that families could refer to when they subsequently could no longer speak for themselves.

Several interviewees reported that PC's presence in the ED enabled ED patients to have their emotions attended to in a way that they suspected otherwise may not have happened. Two programs that integrated case managers into the embedded PC team in the ED noted that they were able to re-direct ED patients back to hospice or connect them with initial hospice placement which they suspected otherwise may have been challenging without their presence.

None of the new models of care delivery persisted unaltered after the COVID surge. Instead, these models were operational for the weeks to months of the peak surge and subsequently deconstructed. While some institutions reported new, less resource-intense models emerging after the surge, many reported returning to pre-COVID models of PC in the ED. Almost all sites reported increased ED interest in PC with increased consult volumes, a new appreciation of PC, and heightened interest in primary PC skill attainment.

In this qualitative study, we describe innovations in PC delivery that emerged during COVID across diverse medical institutions around the country. In doing so, we also explored the pre-COVID landscape of PC in the ED. This paper is the first to describe how several institutions attempted PC-ED integration during COVID and identifies five distinct areas for innovation.

Two previous case studies have reported on individual programs that emerged during COVID in detail, [6] [7] [8] and a third outlined a comprehensive hospital-wide strategy including ED plans, which ultimately was not activated. 22 Our study adds a more comprehensive look at the breadth of new models and innovations.

During a pandemic that required restrictions on family presence in hospitals, the innovations in technology enhanced PC provide a model for how this work can be conducted if these circumstances recur. In keeping with the literature from other care areas, [23] [24] [25] here several models emerged that suggest the feasibility of doing this work in some EDs.

Interestingly, these innovations were reportedly uniformly well received by the ED clinicians. This builds on prior single site data suggesting that ED clinicians find increased PC presence better both for their patients and for their own wellbeing. 26 Our study further suggests that the experience of the PC clinicians was also largely positive. It is important to note that one site raised a theoretical concern related to PC involvement in the ED resulting in increased ED length of stay. Understanding the importance of ED throughput and the evidence that ties overcrowding to poor quality outcomes, 27 it will be critical for future work evaluating the impact of integrating PC in the ED to assess this as a balancing measure.

One of the nuanced challenges that was raised related to the pressure PC teams felt to advance goals quickly. This was reported by several sites as an implicit expectation that PC involvement would result in limitations on life-sustaining treatment independent of patient goals. To this end, part of continued ED education in PC should include foundational training in goalconcordant care. It will be critical that PC's involvement in the ED does not get conflated with pre-rationing or crisis standards of care, which are unrelated to the function and mission of PC.

In the setting of a rapid increase in ED acuity, the importance of diversifying the ED workforce to ensure high quality care is critical. In several models, a variety of providers were brought into the ED to facilitate GOC conversations while allowing ED providers to prioritize their other duties. Previous work has reported on ED providers interest in being freed from this time-intensive task during COVID, 26 and embedding non-ED clinicians in the ED to have these conversations may hold promise.

Just as ED provider capacity was stretched, so, too, was PC team capacity. The models that emerged leveraging both off-service providers with focused training and advanced practice providers may prove promising. The concept of 'level loading,' or balancing work within a system, seems well applied here: taking services that had less work than normal during the pandemic and re-deploying them to areas with more. If these programs are scaled, it will be important to identify the necessary training for these clinicians and to ensure a well-defined scope of practice.

Identifying the right types of clinicians for these roles is also important. One possible lesson comes from the program that used volunteer PC extenders, which felt clinicians selfselected for strong communication skills or interest in PC. Some specialties also may be particularly well suited to this work; the programs that leveraged psychiatrists reflected on their strong communication training, and those that leveraged pediatricians reflected on their experience with multigenerational decision making.

Interestingly, two of the institutions that developed models of fully embedded PC did so with a single dedicated provider in the ED. At one site, it was reported that this person worked for over 60 days uninterrupted. Although there are many examples of heroics during the pandemic, 28 for models to be scalable they will likely have to be based on sustainable staffing models that can be stood up in the absence of an individual champion.

Our study found that sites reported GOC conversations as the primary work of palliative care in the ED. It is not clear if this is a reflection of the comfort of ED clinicians with symptom management or if this would be different in a different patient population. For example, understanding that COVID is a primarily respiratory disease, it may have been that symptoms were primarily related to dyspnea which ED clinicians were more comfortable managing and this would not be the case with a population with more pain symptoms. More research is needed to understand the generalizability and implications of this finding.

As EDs grapple with the challenges associated with integrating PC, 1 some elements of the models identified here may provide inspiration. In addition to leveraging PC extenders, such as social workers who are already available in many EDs, the idea of targeted tasks matched to patient acuity may offer promise. Although ED clinicians have endorsed challenges related to limited time to have complete GOC conversations in the ED, several programs we spoke with innovated an algorithmic approach to 'task-matching' that may be useful outside of COVID.

Methodologically, we chose to employ Rapid Analysis techniques to complete this study. Although this did not result in an in-depth content analysis of participants comments or inclusion of participant quotes, this method is a valid approach for analyzing information with the aim of informing ongoing implementation. 15 Additionally, this method has been shown to much more rapidly produce results. As surges of COVID continue, this method proved an effective way to quickly analyze a large volume of information and provide the programmatic level of detail that were in keeping with our aims.

This analysis is not intended to be a representative sample of EDs across the United States. Instead, we aimed to identify and describe particularly innovative models of care delivery with the aim of disseminating these programmatic designs to aid other institutions as they face similar situations.

Additionally, it is important to note that these models of care delivery were developed and deployed during COVID. As such, it is not clear which, if any, of the elements would be well received in the absence of a pandemic. For example, although study participants reported unanimous support from the ED for PC's presence, we do not know if their presence would be similarly received in less exceptional circumstances.

The generalizability of these findings is limited by the study sample. In an effort to identify new models of care delivery, we purposefully worked to identify institutions where innovation had occurred. As such, the models that we describe often rely on access to PC trained clinicians and may be difficult to adapt to all care settings. Similarly, many of the participating sites had access to technology that may not be uniform across all institutions. In identifying interview participants, we aimed to speak with the person at the institution with the most knowledge of the PC integration efforts in the ED. Our study sample was heavily weighted towards physicians. In a specialty that is inherently interdisciplinary, it is possible that important perspectives were missed by not including a more diverse set of role groups in our interviews.

Our study describes the structure and function of these programs but did not aim to assess their efficacy. Although we were able to gain insight into how the programs were received by both ED and PC physicians, this was as reported by the program's champion. More work is needed to determine how effective these were and their associated outcomes. Additionally, we did not explore the business models associated with these models, and the sustainability of these models may also be related to the local reimbursement environment.

Following the initial wave of the COVID pandemic, there was a recognition of the need to accelerate integration of PC in the ED. Several important innovations in care delivery emerged from this.

Overall, the content of these integrated teams' work was primarily around GOC conversations. In general, ED-PC integration efforts were reportedly well received by both ED and PC providers and, anecdotally, may have resulted in improved patient care. However, more work is needed to objectively evaluate the impact of these models of care delivery on patient outcomes and to understand their potential applicability and value beyond the pandemic. J o u r n a l P r e -p r o o f 

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