Faculty Bibliography

BACKGROUND:The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. METHODS:A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. RESULTS:The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. CONCLUSIONS:CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.

The left ventricular outflow tract (LVOT) velocity time integral (VTI) is an easily measured echocardiographic stroke volume index analog. Low values predict adverse outcomes in left ventricular failure. We postulate the left ventricular VTI may be a signal of right ventricular dysfunction in acute pulmonary embolism, and therefore a predictor of poor outcomes. We retrospectively reviewed echocardiograms on all Pulmonary Embolism Response Team activations at our institution at the time of pulmonary embolism diagnosis. Low LVOT VTI was defined as ⩽ 15 cm. We examined two composite outcomes: (1) in-hospital death or cardiac arrest; and (2) shock or need for primary reperfusion therapies. Sixty-one of 188 patients (32%) had a LVOT VTI of ⩽ 15 cm. Low VTI was associated with in-hospital death or cardiac arrest (odds ratio (OR) 6, 95% CI 2, 17.9; p = 0.0014) and shock or need for reperfusion (OR 23.3, 95% CI 6.6, 82.1; p < 0.0001). In a multivariable model, LVOT VTI ⩽ 15 remained significant for death or cardiac arrest (OR 3.48, 95% CI 1.02, 11.9; p = 0.047) and for shock or need for reperfusion (OR 8.12, 95% CI 1.62, 40.66; p = 0.011). Among intermediate-high-risk patients, low VTI was the only variable associated with the composite outcome of death, cardiac arrest, shock, or need for reperfusion (OR 14, 95% CI 1.7, 118.4; p = 0.015). LVOT VTI is associated with adverse short-term outcomes in acute pulmonary embolism. The VTI may help risk stratify patients with intermediate-high-risk pulmonary embolism.

Background: The diagnosis of spinal cord compression is often delayed. Classic presentations are frequently variable or absent, leading to a lower clinician index of suspicion. Many patients with compressive lesions do not have the classic signs of rectal or urinary sphincter dysfunction or saddle anesthesia. Signs and symptoms may also evolve over course of an emergency department (ED) encounter. To facilitate rapid diagnosis and treatment of this high morbidity condition, a spinal emergency protocol was developed as part of a quality assurance endeavor.
Method(s): A multi-disciplinary group including emergency medicine, neurology, neurosurgery, and radiology created and implemented a protocol for use in patients presenting to the ED with concern for spinal cord compression. The protocol outlines specific trigger conditions, imaging choices, management strategies, and accountabilities for each involved specialty. All patients presenting to ED who received any spinal MRI from September 2016 to November 2018 were analyzed through chart review to determine whether the spinal emergency protocol was used. Time from MRI order to study start and time from MRI order to MRI read were analyzed for each of these groups. The two sample Wilcoxon test (Mann-Whitney test) was used to evaluate statistical significance.
Result(s): During this time period, 54 patients were evaluated for spinal compressive disease not using the spinal emergency protocol and 24 patients were evaluated using the protocol. The median time from MRI order to initiation of study in patients not on the protocol was 2.75 hours (IQR 1.37-4.37 hours) and for patients on the protocol the median time was 1.58 hours (IQR 1.13-1.97 hours) p value less than 0.01. The median time from MRI order to radiology read for patients not on the protocol was 5.30 hours (IQR 3.59-6.23 hours) and for patients on the protocol was 3.85 hours (IQR 2.72-4.28 hours) p value less than 0.01.
Conclusion(s): The introduction of a spinal emergency protocol led to a significant reduction in the time to the initiation and completion of definitive imaging in this high risk population. While this analysis was conducted at a single site, the implementation of similar protocols in other EDs could lead to reduction in time to diagnosis of spinal cord compression

Background: Older adults visit Emergency Departments (ED) more often and have repeated visits, compared with younger individu-als. Cognitive impairment may drive ED use and may be more preva-lent in ED settings; yet it is often unrecognized, potentially resulting in suboptimal discharge planning. Cognitive screening is not routine ED care and staff are not typically trained in proper procedures.
Method(s): Using a volunteer workforce of college students and recent graduates provides an opportunity for clinical training as cogni-tive screeners and increases opportunities for system change. Volunteers screened for cognitive impairment among English and Spanish speaking patients who were admitted to a large academic ED and were likely to be discharged to home. We targeted patients >= 75 years and requested screening with the MiniCog$sup$

Early palliative care consultation ha the potential to provide comfort to patients and families, and decrease costs and length of stay.