Healthcare professionals’ perspectives of the management of people with palliative care needs in the Emergency Department of a UK hospital

Abstract

Background: The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,’'REasons for PalLIative Care Admissions (REPLICA)’ was to explore the perspectives of ED health care professionals of hospital admission or discharge via the ED for palliative care patients. Methods: This is a sequential mixed methods study comprising i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through the ED in a West Midlands Hospital and for the rest of England; ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis. Results: Over the four years (2013 – 2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n=2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients’ admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: 1) Providing palliative care in the ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. 2) Patients go to the ED due to challenges in community management such as inappropriate referrals and no care plan in place. 3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. 4) Discussion with patient about treatment and end-of-life care needs to be outside of the EDwhilst the patient is still well enough to express their wishes. 5)Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7. Conclusions: A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community.