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Leveraging Emergency Department Information Systems to Address Palliative Care Needs of ED Patients During the COVID Pandemic

Tan, Audrey J; Swartz, Jordan; Wilkins, Christine; Grudzen, Corita
The arrival of the COVID-19 pandemic to hospitals in New York City stressed our emergency departments (ED) with high patient volume, stresses on hospital resources and the arrival of numerous high acuity, critically ill patients. Amid this time, we sought to leverage the ED Information Systems (EDIS), to assist in connecting critically ill patients, their families, and providers in the ED with palliative care resources. We discuss 4 innovative, thoughtful solutions to assist ED providers in identifying and addressing the acute and unique palliative care needs of COVID patients.
PMID: 34463145
ISSN: 1938-2715
CID: 5011672

Development and protocol for a nurse-led telephonic palliative care program

Tan, Audrey J; Yamarik, Rebecca; Brody, Abraham A; Chung, Frank R; Grudzen, Corita
BACKGROUND:The COVID-19 pandemic has resulted in a profound transformation of health care delivery toward telemedicine models. PURPOSE/OBJECTIVE:We present the structure of a nurse-led telephonic palliative program and operational metrics to influence further development of tele-palliative programs. METHODS:The nurses engage with seriously ill patients for 6 months with the goal of discussing advance care planning (ACP) and addressing self-identified issues related to their illness. FINDINGS/RESULTS:Of the first 100 program graduates, 78% were actively engaged and 51% named a health care agent and/or engaged in ACP. Of the 18 patients who died during the study, 13 (72%) were enrolled in hospice services. DISCUSSION/CONCLUSIONS:Our preliminary results indicate that seriously ill patients are willing to engage with nurses and to participate with discussions on ACP. CONCLUSION/CONCLUSIONS:Given the gaps in health care exposed by the COVID-19 pandemic, this innovative program serves as an important model for bringing palliative care directly to patients.
PMID: 33485590
ISSN: 1528-3968
CID: 4799522

Nurse-Led Telephonic Palliative Care: Report from the PCORI-Funded Emergency Medicine Palliative Care Access (EMPallA) Randomized Controlled Trial (FR407A) [Meeting Abstract]

Tan, A; Yamarik, R; Cho, J; Grudzen, C
Objectives: * Identify components of a new mode of palliative care delivery for the growing population of patients with advanced illness discharged from the ED. * Discuss success and challenges for the delivery of a nurse-led telephonic palliative care program. Original Research Background: The demand for palliative care has outstripped the supply of trained physicians. Nurse-led telephonic palliative care is a potential model to address the growing need for palliative care. Research Objectives:: * Describe the development of a novel nurse-led telephonic palliative care program for seriously ill patients who are discharged from the Emergency Department (ED). * Describe the program implementation. * Share preliminary operational and clinical outcomes.
Method(s): The nurse-led telephonic palliative care program is part of the EMPallA research study, a large Patient-Centered Outcomes Research Institute (PCORI)-funded randomized controlled trial comparing facilitated, outpatient specialty palliative care to nurse-led telephonic case management for seriously ill patients after an ED visit. Three palliative care certified nurses, under supervision of a Hospice and Palliative Medicine (HPM) physician, provided telephonic care to patients across seven states. Patients received weekly calls from the telephonic nurse for six months.
Result(s): Of the first 100 patients who completed the telephonic arm intervention, 78 patients (78%) were actively engaged, while 9 patients were lost to follow-up and 13 patients withdrew. Eighteen patients (18%) died during the intervention and, of those, 11 (61%) enrolled in hospice prior to death. The average caseload per nurse was 18 patients per week and an average of 10 calls were made to each patient over the six-month period. Telephonic nurses made a total of 206 outgoing calls or emails to the patient's care teams and received an average of 222 responses.
Conclusion(s): Preliminary results show that seriously ill patients and their caregivers are willing to engage with telephonic nurses. A majority of patients remained engaged throughout the six-month intervention, and nearly two-thirds of patients who died utilized hospice prior to death. Implications for Research, Policy or Practice: This model has the potential to augment traditional physician-led outpatient palliative care and may be preferable for many patients who have difficulty traveling to a clinic setting for palliative care.
ISSN: 1873-6513
CID: 4295802

Design and implementation of a clinical decision support tool for primary palliative Care for Emergency Medicine (PRIM-ER)

Tan, Audrey; Durbin, Mark; Chung, Frank R; Rubin, Ada L; Cuthel, Allison M; McQuilkin, Jordan A; Modrek, Aram S; Jamin, Catherine; Gavin, Nicholas; Mann, Devin; Swartz, Jordan L; Austrian, Jonathan S; Testa, Paul A; Hill, Jacob D; Grudzen, Corita R
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/ Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.
PMID: 31992301
ISSN: 1472-6947
CID: 4294142

Treating pain and prognosticating in metastatic cancer

Chapter by: Tan, Audrey
in: Palliative Skills for Frontline Clinicians: Case Vignettes in Everyday Hospital Medicine by
[S.l.] : Springer International Publishing, 2020
pp. 23-28
ISBN: 9783030444136
CID: 4580292

Development and Protocol for a Nurse-Led Telephonic Palliative Care Program [Meeting Abstract]

Yamarik, Rebecca; Tan, Audrey; Cho, Jeanne; Grudzen, Corita
ISSN: 0885-3924
CID: 4525822

Primary Palliative Care for Emergency Medicine (PRIM-ER): Protocol for a Pragmatic, Cluster-Randomised, Stepped Wedge Design to Test the Effectiveness of Primary Palliative Care Education, Training and Technical Support for Emergency Medicine

Grudzen, Corita R; Brody, Abraham A; Chung, Frank R; Cuthel, Allison M; Mann, Devin; McQuilkin, Jordan A; Rubin, Ada L; Swartz, Jordan; Tan, Audrey; Goldfeld, Keith S
INTRODUCTION/BACKGROUND:Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness. METHODS AND ANALYSIS/UNASSIGNED:This is the protocol for a pragmatic, cluster-randomised stepped wedge trial to test the effectiveness of PRIM-ER in 35 EDs across the USA. The intervention includes four core components: (1) evidence-based, multidisciplinary primary palliative care education; (2) simulation-based workshops; (3) clinical decision support; and (4) audit and feedback. The study is divided into two phases: a pilot phase, to ensure feasibility in two sites, and an implementation and evaluation phase, where we implement the intervention and test the effectiveness in 33 EDs over 2 years. Using Centers for Medicare and Medicaid Services (CMS) data, we will assess the primary outcomes in approximately 300 000 patients: ED disposition to an acute care setting, healthcare utilisation in the 6 months following the ED visit and survival following the index ED visit. Analysis will also determine the site, provider and patient-level characteristics that are associated with variation in impact of PRIM-ER. ETHICS AND DISSEMINATION/UNASSIGNED:Institutional Review Board approval was obtained at New York University School of Medicine to evaluate the CMS data. Oversight will also be provided by the National Institutes of Health, an Independent Monitoring Committee and a Clinical Informatics Advisory Board. Trial results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT03424109; Pre-results.
PMID: 31352424
ISSN: 2044-6055
CID: 4010352

News: Palliative Extubation in the ED (Yes, the ED)

Tan, Audrey
ISSN: 1054-0725
CID: 2469932

Emergency medicine and palliative care : a timely and necessary collaboration

Tan, Audrey
ISSN: 1054-0725
CID: 2390952

Medical students and dying patients

Tan, Audrey
PMID: 24331443
ISSN: 1937-7010
CID: 2316422