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

Abstract

IntroductionEmergency 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 analysisThis 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 disseminationInstitutional 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 numberNCT03424109; Pre-results

The Experience of Emergency Department Providers With Embedded Palliative Care During COVID

“…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 , 15 , 16 , 17 this model of “at-the-elbow” education may be particularly valuable and warrants further study.…”

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

“…The system was developed as part of an institutionally sponsored Value-Based Management initiative and an NIH grant titled, "Primary Palliative Care for Emergency Medicine (PRIM-ER)." [22]To develop Support-ED, creators of the tool devised a multistep process to ensure a comprehensive and practical tool was implemented. These steps included: 1) a scoping review of existing ED palliative care screening tools; 2) creation of a multidisciplinary workgroup to identify patient screening criteria and appropriate referral services; 3) initial design and usability testing using the System Usability Scale (SUS) questionnaire; 4) education of the ED workforce on the Support-ED background, purpose and use, and 5) the creation of a dashboard to monitor frequency of alert firing and correlation with targeted actions.…”

“…Similarly, all full-time emergency nurses completed an online nurse-focused didactic course on primary palliative care knowledge and skills. Further details regarding the PRIM-ER protocol can be found in the previously published study protocol paper [22]. Immediately following these sessions, education on Support-ED was provided including the purpose and specific workflows associated with each of the alerts.…”

“…To date (as of December 2019), the PRIM-ER research team has successfully aided in the implementation of a tailored Support-ED within the first 10 sites enrolled in the PRIM-ER intervention. Each site will deploy Support-ED in a stepped-wedge, randomized design [22]. To best tailor Support-ED to the unique workflows and environments of each participating site, interviews were conducted with key local stakeholders comprised of palliative care, emergency nursing, social work/case management, informatics, and ED operations representatives.…”

Emerging Palliative Care Innovations in the ED: A Qualitative Analysis of Programmatic Elements During the COVID-19 Pandemic

“…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.…”