key: cord-0955535-k03r7cpj
authors: Aaronson, Emily Loving; Petrillo, Laura; Stoltenberg, Mark; Jacobsen, Juliet; Wilson, Erica; Bowman, Jason; Ouchi, Kei; Traeger, Lara; Daubman, Bethany-Rose; Ritchie, Christine Seel; Jackson, Vicki
title: The Experience of Emergency Department Providers with Embedded Palliative Care during COVID
date: 2020-08-31
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.08.007
sha: d37c87641398800217f742fd7cd332e0f2bf1f73
doc_id: 955535
cord_uid: k03r7cpj

INTRODUCTION: Although the importance of palliative care (PC) integration in the Emergency Department (ED) has long been recognized, few formalized programs have been reported and none have evaluated the experience of ED clinicians with embedded PC. We evaluate the experience of ED clinicians with embedded PC in the ED during COVID. METHODS: ED clinicians completed a survey about their perceptions of embedded PC in the ED. We summarized responses to closed-ended items using descriptive statistics and analyzed open-ended items using thematic analysis. RESULTS: There were 134 ED clinicians surveyed. 101 replied (75% response rate). Of those that had interacted with PC, 100% indicated a benefit of having PC involved. These included freeing up ED clinicians for other tasks (89%), helping them feel more supported (84%), changing the patients care trajectory (67%), and contributing to clinician education (57%) and skills (49%). Among barriers related to engaging PC were difficulty locating them (8%) and lack of time to consult due to ED volume (5%). 98% of respondents felt that having PC in the ED was either “valuable” or “very valuable.” Open-ended responses reflected a positive impact on clinician wellness and improvement in access to high quality goal concordant care. Clinicians expressed gratitude for having PC in the ED and noted the importance of having readily available and easily accessible PC in the ED. CONCLUSION: ED clinicians’ perception of embedded PC was overall positive, with an emphasis on the impact related to task management, enrichment of PC skills, providing support for the team, and improved care for ED patients.

Emergency Departments (EDs) are the site of care for many patients with advanced lifelimiting illness, with ED visits increasing as serious illness progresses and towards the end of life. [1] [2] [3] Among this population, it has been noted that many patients have unmet palliative care (PC) needs. 4 Accordingly, there is consensus among emergency medicine's professional societies that increasing PC research and presence in the ED is important. 56 The American Board of Internal Medicine's Choosing Wisely Campaign includes recommendations not to "delay in engaging available palliative and hospice services in the emergency department for patients likely to benefit." 7 In the setting of COVID, this need has intensified. 8 Although several case studies of PC in the ED exist in the literature describing the structure or outcomes of a PC clinician dedicated exclusively to the ED (embedded) before COVID, 9 no study has reported on ED clinicians' experience of embedded PC in the ED. Similarly, although reports have begun to emerge describing the structure and patient outcomes of PC involvement in the ED during COVID, no study has reported on the ED's experience of these programs. 10 As hospitals and health systems look to design ED PC models of care delivery to respond to ongoing surges, the insights of front line providers can help inform these efforts. This study aimed to describe ED clinicians experience of an embedded PC physician in the ED during COVID, and to examine their recommendations for future integration of PC in the ED.

In March of 2020, at our urban academic ED (115,000 annual visits) in the United States, the volume of COVID-19 patients began to grow. Given this unprecedented growth, we felt that there was an urgent need to embed a palliative care clinician into the ED. We launched a pilot program that embedded a palliative care physician in the ED 7 days a week from 9 a.m-7 p.m. Five palliative care physicians served in this role. This pilot lasted 8 weeks.

In May 2020, we conducted a survey of ED clinicians (residents, attending physicians and advanced practice providers) in the ED. The survey tool (Appendix 1) was created through a collaboration between ED and PC physicians, with supervision from a licensed clinical psychology researcher with experience conducting qualitative research in palliative care and other medical settings.

The survey had both closed ended questions (pre-defined checklists ["choose all that apply"] and Likert-type scales), and three open-ended questions. Two of the questions were only asked of respondents that interacted with PC in the ED: one asked them to think of an interaction with the embedded PC clinician that went well, and to reflect on what was helpful about it; the second was to think of an interaction that did not go as they would have liked and asked them to reflect on what was not helpful about it. All participants were also asked, in their ideal world, what PC engagement in the ED would look like.

Prior to administration, the survey was tested for clarity and iteratively refined with one ED physician who had not been involved in the survey's initial design. This study was reviewed and determined to be exempt by the Partners Human Research Committee/Institutional Review Board.

J o u r n a l P r e -p r o o f

All emergency attending physicians, and advanced practice providers were surveyed. As residents rotate at multiple sites, only residents rotating at the study site during the intervention were surveyed. Additionally, the survey included branching logic that accounted for the varying degrees of exposure that clinicians had to PC physicians in the ED during the study period. For example, if a clinician taking the survey had not worked in the ED in the 8 weeks of the program, the survey ended. If they had worked during the intervention period but had not interacted with the PC physician, they received only questions about the barriers to engaging PC and the reasons for not interacting with them.

Quantitative data were analyzed using descriptive statistics, including frequencies for categorical items and means (SD) for continuous items. The one question that presented a Likert scale was summarized using mean and 95% confidence intervals. We analyzed the open-ended responses using an inductive thematic analysis approach to provide an essential account of participants' responses at the semantic level and to identify patterns or themes across the responses. 11 We first reviewed the responses to the open-ended survey questions. We used the questions and responses to develop codes and then organized these codes into categories. Using Dedoose qualitative data analysis software (Version 8.0.35, Los Angeles, CA: SocioCultural Research Consultants, LLC), two team members (EA, LT) used the coding structure to code all open-ended responses in an initial 15% of surveys and examined unexpected data and/or discrepant coding until resolution. New codes were incorporated into the structure as needed. One coder (EA) then coded all open-ended responses within all remaining surveys. The study team then reviewed the coded data to identify overarching themes and exemplar quotes. We compared the themes back to the raw data and defined each theme to ensure a clear and coherent account of the data.

There were 134 clinicians invited to participate in the survey during the study period. 101 replied (75% response rate). Of these, 80 had worked in the ED during the embedded PC program. Of the clinicians that had been in the ED, 91% (73/80) had interacted with PC during their shift. The majority of respondents (75/101) had ten years of experience or less, and were male (56/101). 39.6% of respondents were attending physicians, 31.6% were residents and 28.7% were advanced practice providers (Table 1) .

Of the clinicians that had interacted with the embedded PC clinician while working in the ED (n=73), 100% of them endorsed at least one of the following pre-defined benefits from interacting with the embedded PC physician: freed them up for other tasks (89%); helped them feel more supported during their shift (84%); changed the patient's management or care trajectory (67%); contributed to their personal education about goal concordant care (57%); and added to their own skill set/confidence in practicing primary palliative care within the emergency department (49%).

The 80 clinicians who had worked in the ED during the embedded PC program were asked if they experienced any of a set of pre-defined barriers to accessing the PC clinician during their shift. Respondents endorsed difficulty locating PC (8%; 6/80); lack of time to consult due to ED volume (5%; 4/80); and the PC clinician not being available or being busy with other patients (4%; 3/80).

Respondents endorsed other pre-defined reasons for not interacting with the embedded PC clinician: there was no patient on their shift that needed a palliative care conversation (18%; 14/80); and patients on their shift were in acute clinical condition/crashing (15%;12/80). Zero respondents stated they didn't see the added value of having an embedded PC team in the ED. When asked, "overall, how valuable do you find palliative care in the ED?" on a 5 point Likert scale (1 not valuable at all; 5 very valuable), the mean response was 4.61 (95% CI 4.49-7.73). 64% (51/80) of respondents responded very valuable, 34% (27/80) responded valuable, 3% (2/80) responded neutral, and 0 respondents listed not valuable or not valuable at all (Figure 1 ).

There were 30 responses to the question asking participants to think of an interaction with the embedded PC clinician that went well, and to reflect on what was helpful about it; 9 responses to the question asking them to think of an interaction that did not go as they would have liked and asked them to reflect on what was not helpful about it, and 77 responses to the question asking participants, in their ideal world, what PC engagement in the ED would look like. When the comments related to what went well were systematically coded and analyzed, several themes emerged ( Table 2) .

First, responses reflected ED clinician gratitude and appreciation for PCs engagement in the ED (e.g. "love them, please never let them leave," "so appreciated," "all of our interactions were outstanding," "the palliative care team was an incredible resource for our group and for our critically ill patients," and "the gratitude is profound").

Second, responses reflected ED clinician perception that PC engagement elevated the quality of the care provided to patients. Some respondents explicitly noted this, such as "it improved the quality of care and the patient and family and provider satisfaction with the care delivered." Some noted the care delivered contrasted with usual care, such as: Additionally, there was a theme that emerged related to how generally helpful having PC in the ED was, with the word "helpful" appearing 58 times in the 116 the open-ended responses.

The remainder of these responses were related to direct patient care behaviors (such as discussing goals of care, code status or serious illness; or spending significant time with patients and families), characteristics (highly skilled, thoughtful, helpful) and the benefits (such as changing the care trajectory; or learning from the PC team) of the embedded palliative care physicians in the ED.

When asked to think of an interaction with the embedded palliative care clinician that did not go as they would have wanted and what was not helpful about it, 9 respondents provided free text answers. The participants identified two main barriers to PC integration: lack of PC clinician availability or timely response and the time intensive nature of serious illness conversations:

"We had the PGY4 accompany the Palliative Care attending to go call the family and discuss medical status, goals of care. This process took about 25 minutesand that's a very long time to have the Acute PGY4 out of commission"

Among the responses related to barriers one respondent offered the following concern:

"I just have one concern, sometimes as ED 

When asked, in an ideal world what would palliative care engagement look like in the ED to best support their work, 77 respondents provided free-text replies. Similar to the other questions, some contextualized this in the challenges of the current model, and their own limited experience:

"With palliative care consults normally, they often cannot see patients quickly enough to change management." "We don't have a lot of experience with pal care so sometimes I don't even realize the role they can provide."

The remaining comments related to both the logistics of the service (24/7 availability, being readily available, engaging early with cases as they arrive, proactive case identification) as well as the content of the work (engaging in teaching and education, debriefing, and closing the loop with the ED team).

In this single center study of ED clinicians' experience with embedded palliative care in the ED, we identified several benefits, barriers and suggestions for ideal models of care delivery. ED clinicians had generally favorable experiences, citing benefits related to both patient care, such as changing patients' care trajectory and improving the quality of care, as well as benefits related to their own experience, such as freeing them up for other tasks, contributing to their education, and helping them feel more supported. Reported barriers were primarily related to the availability of PC (especially overnight) and the challenges of engaging PC in the setting of high acuity patients.

There has long been interest in increased integration of PC subspecialty teams into EDs, and this study provides insight into ED clinicians perception of some of the potential benefits of doing this. Our results elucidate both the actions that were most commonly identified as beneficial as well as the reason they were helpful. These results may present a path forward for the optimization of PC integration in the ED both in the context of a pandemic, and perhaps outside of it. By offering insight into both helpful behaviors and the reasons that the ED team found them helpful during COVID, institutions can design programs for ED PC integration during COVID with these goals in mind. Additionally, our findings represent an opportunity to test which of these may continue to present value outside of a pandemic.

As noted by respondents, some of the actions that were most commonly identified as beneficial related to conducting goals of care conversations, being readily available, teaching, collaborating and debriefing with the ED clinicians.

The reasons clinicians gave for deeming PC integration beneficial included both positive effects on patients and effects on the care team. Related to patient care, the majority of respondents (67%) believed that PC involvement in the ED changed their patient's care trajectory, with a clear theme emerging in the open ended responses related to the role that having PC in the ED played in improving the quality, and the goal concordant nature, of the care.

Related to the effect on the care team, 89% reported it freed them up to do other tasks. In addition, in both the closed and open-ended responses, respondents noted the positive effect that having palliative care in the ED had on their ability to feel more supported during their shift and on their general wellness, with 84% of respondents noting that it helped them feel more supported on their shift. Understanding that ED physicians have the highest rate of burnout compared to all specialties, 12 it is not surprising that so much effort has focused on identifying solutions to mitigate this. Interestingly, as noted in Ravi Katari's recent commentary, 13 despite acknowledging that many of the key drivers of burnout are related to the work environment, most of the solutions have focused on individual resiliency tactics. Identifying a modifiable factor in the clinical environment, such as embedding a PC clinician, that is perceived to cultivate wellness offers a particularly important finding that has not yet been identified in the literature.

The impact of having PC in the ED during COVID was also noted to improve the learning and education of the care team. This was noted in both in the quantitative results as well as in both the closed and open-ended responses, with respondents noting the important role that having this specialist in the ED played in their own skill development. While the focus in the ED PC literature on increasing primary palliative care has largely focused on classroom training programs, 14-17 this model of "at-the-elbow" education may be particularly valuable and warrants further study.

Interestingly, when asked about barriers to palliative care engagement, or about interactions that did not go well, only one respondent offered a concern. This was related to challenges associated with determining optimal timing for goals of care conversations. Prior work by Grudzen et al. exploring the attitudes of ED providers demonstrated several other concerns including challenges reconciling the two cultures and medico-legal concerns. 18 Almost 10 years later, in our study, these issues were not raised.

Quantitatively, no respondents selected the option of "I don't see the added value of palliative care in the ED." Although resistance to engaging palliative care has been documented in other specialties, 19 and concern was previously raised about the possibility that palliative care would not be well received in the ED, 20 this was not the case in our study. Our findings align more closely with prior wok which showed that focus groups of ED providers were receptive to PC consults in the ED. 18 In this single center study during COVID, ED clinicians indicated no objectives to palliative care's engagement. Instead, a theme of gratitude emerged in the free text comments. What is not known is the role that COVID played in creating a particularly receptive environment for embedded PC in the ED. It is possible that in the setting of the pandemic, there was a more acute recognition of the importance of, and willingness to partner with, palliative care in the ED. Additionally, it is possible that the clinical environment and patient mix shifted so dramatically that the need that was being met would not otherwise exist. However, our findings do align with previously published literature reporting that although most emergency medicine clinicians have had little or no formal training in PC skills they view palliative medicine as valuable in improving the care of patients in the ED, and have interest in more PC integration. [21] [22] [23] The highest response rate to any individual qualitative question related to the ideal model for ongoing palliative care in the ED (77 responses). The respondents unanimously wanted to see ongoing engagement of PC subspecialty clinicians in the ED. This question also yielded some clear recommendations related to the importance of PC being readily available and engaging early in the patient's ED course. These suggestions would all likely require an embedded PC resource in the ED. It would likely be challenging to achieve this type of rapid involvement leveraging a consult model which relies on a PC clinician responsible for other areas of the hospital.

Additionally, the importance of proactive case identification emerged in the free text fields related to ideal models of care. Respondents noted that their lack of experience with palliative care limited their ability to effectively identify cases that would benefit from their involvement. This reported lack of recognition may explain why 18% of respondents felt that no patients on their shift had palliative care needs.

When describing the behaviors that respondents would like to see integrated into a model moving forward, working directly with patients and families to have discussions about goals of care emerged as an important aspect of the work. Interestingly, respondents in our study did not mention symptom management, despite this being a frequently discussed area for increased education and clinical improvement in previous ED-PC studies. This may be a result of different needs for patients presenting during the COVID pandemic, local differences in symptom management training for ED clinicians, or clinicians failing to recognize inadequately treated symptoms.

There are several limitations to our study. The experience that we were evaluating was of a fully embedded palliative care physician in the ED during the COVID pandemic. Most programs that have been previously described leverage either PC consulting physicians (not fully embedded) or an advanced practice provider. As such, it is possible that these findings may not be generalizable to these different program structures, or to a clinical environment in the absence of COVID. The generalizability of our findings is also limited by the fact that it was conducted at a single site with a well-developed palliative care consult service. As a survey, we are limited by response bias and the results only represent the views of those that elected to respond. This concern is somewhat offset by the high response rate. These results captured subjective reports and may not translated into objective findings. For example, although 67% of respondents reported that PC engagement changed the care trajectory of their patients, we are not able to verify that this was indeed the case.

J o u r n a l P r e -p r o o f

We sought to understand ED clinicians perception of an embedded palliative care physician in the ED during COVID. ED clinicians had a generally favorable experience, citing several benefits to palliative care's engagement in the ED, demonstrating a perceived impact on both patients (changing their care trajectory, improving the quality of care) and clinicians (freeing them up for other tasks, contributing to their education and helping them feel more supported). Although some barriers (related to the availability of PC or acuity of patients) were noted, there was consensus that the ED clinicians surveyed would like to see ongoing engagement of PC in the ED. Future research should focus on understanding the impact of this model of care delivery in the absence of COVID, as well as evaluating patient outcomes associated with embedded PC in the ED. 

Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff

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No patient on my shift was at the point of needing a palliative care conversation

Patient(s) were in acute clinical condition

Did you face any barriers to accessing the embedded palliative care clinician during a shift?

Couldn't locate them 6. Lack of time to consult with them due to ED

Did you have other reasons for not interacting with the embedded palliative care clinician during a shift? 1. No patient on my shift was at the point of needing a palliative care conversation

Patient(s) on my shift were in acute clinical condition

Please think of any interactions with the embedded palliative care clinician that went well. What was helpful about it?

Please think of any interactions with the embedded palliative care clinician that did not go as you would have wanted. What was not helpful about it?

In your ideal world, what would palliative care engagement look like in the ED to best support your work