Correspondence

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage:

A dedicated palliative care nurse improves access

to palliative care and hospice services in an urban ED?

To the Editor,

Patients with advanced and end-stage disease in need of symptom management, pain relief, and Care coordination often present to the Emer- gency Department (ED). Moreover, a large proportion of patients with chronically progressive and terminal illnesses lack coordination of care, es- pecially among the elderly and underserved [1]. Thus, their healthcare needs are often episodic and unplanned, with the ED being a primary source of medical care. However, for many of these patients traditional life-prolonging treatments offered by ED providers may not be concordant with their goals, and may not address the symptoms for which they sought care. Palliative care (PC) seeks to improve the quality of life for patients who are at all stages of life-threatening disease by addressing the physical, psychosocial, and spiritual needs [2,3]. Hospice care provides end-of-life PC, based on a terminal prognosis of six months or less [4,5].

Hospital PC programs have been shown to improve physical and psy- chological symptom management, caregiver well-being, and family satis- faction [3,5]. In addition, PC programs have saved significant costs to both individuals and institutions by avoiding lengthy hospital stays, which can average almost $10 000 [6]. Early PC consultation can assist with the iden- tification of those patients at the end of life who desire a transition from a curative to a comfort-focus of care. Therefore, the type of care for these patients shifts away from low-yield, burdensome, high-cost tests and treatments, which often include prolonged hospital and ICU stays [7].

The importance of implementing PC into the ED has garnered signif- icant clinical and empirical attention in the past decade [8-10]. Howev- er, the urgent and often overwhelming demands and goals of a fast- paced Inner city ED can conflict with the challenge of providing patient centered advanced care planning and symptom management. Our aca- demic urban-centered hospital with a Level 1 Trauma Center recognized the importance of providing PC services in the ED and implemented a program using a dedicated ED PC nurse to assist staff.

Beginning in 2013, a full-time PC nurse was integrated into the ED (8:00 am to 5:00 pm, Monday through Friday; PC or hospice nurse avail- able by telephone during Off hours) to help ED staff identify healthcare surrogates, assist with goals of Care discussions, identify potential PC and hospice referrals, recognize symptom management needs, and to provide support to patients and families. Data were kept on the number of PC and hospice consultations, hospice admissions, and referrals through- out the duration of implementation. We retrospectively evaluated all of the data. Our institutional review board approved these activities.

In the first year of integration of the PC nurse into the ED (March 2013 through February 2014), the nurse had direct contact with 1139 patients. The PC nurse assisted with clarification of Advance directives (AD) with

? Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Table 1

Outcomes from PC Nurse in the ED (March 2013 through February 2014)

¹ Surrogate = Healthcare Surrogate, Proxy, Durable Power of Attorney, Guardian.

695 ED patients. A surrogate for medical decisions was established in 658 patients and a Do Not Resuscitate order was obtained or executed in 53 patients. Only 181 of the 1139 (16%) patients had previously executed an AD, and 514 were addressed in the ED with the assistance of the PC nurse. In 2013, the ED referred 313 patients for PC consult services and 107 for hospice. Admissions to the ICU or hospital wards were avoided with 58 direct admissions from the ED to hospice in-patient, home, or skilled nursing facility. As a comparison, in the prior year there were 63 PC consults, 42 hospice consults with 15 direct admission from the ED. Table 1 describes further details of outcomes.

Our data illustrates the growing need for and interest in PC services in the ED which are typically neglected due to time constraints and preferen- tial avoidance [2,11]. Our data indicate that adding a PC nurse in the ED in- creased ability of the staff to assist more patients with clarification and establishment of advance directives and goals of care. Establishing these goals honored patient values and changed the trajectory of care impacting disposition of patients to the ICU’s, medical wards, or to an inpatient or out- patient hospice service. These interventions may translate into improved patient/family satisfaction [2,12], allow staff to better address the patients’ presenting problems, and promote more appropriate utilization of limited resources, which is more cost effective [13]. Refer to Table 2 for details.

Future studies should examine measureable, short- and long-term outcomes including sustainability, operational, financial, and customer service outcomes.

Mark McIntosh, MD, MPH

University of Florida Jacksonville, Department of Emergency Medicine, 655

West Eighth Street, Jacksonville, FL, 32209, USA

Corresponding author at: 655 West Eighth Street, Jacksonville

FL 32209. Tel.: +1 904 244-4046 (Office)

E-mail address: mark.mcintosh@jax.ufl.edu

0735-6757/(C) 2016

Table 2

PC Nurse in ED

Role description Funded by: Benefit(s) to ED Barriers

1. Identify and contact healthcare surrogate, access previously executed medical directives if available

Joint Partnership with local not-for-profit PC service

Additional staff to assist with establishing goals of care

Increased consults to interdisciplinary PC team exceeding service capacity

Assist with goals of care discussions 2. Identification of healthcare proxy or surrogate