Article, Palliative Care

A dedicated palliative care nurse improves access to palliative care and hospice services in an urban ED


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American Journal of Emergency Medicine

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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)

Advance directives addressed in ED


Established previously


Addressed in ED


Not addressed

Surrogate for medical decisions1


Established previously


Addressed in ED


Do not resuscitate order

Established Previously


Addressed in ED


Disposition from the ED

Admitted to hospital

776 (68%)


42 (4%)

Admitted to hospice

62 (5%)


33 (3%)

Long term care facility

2 (0.2%)


224 (20%)

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: [email protected]

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
  • Only able to provide services 40 hours per week excluding evenings, nights and weekends
  • Assist and train ED staff to identify appropriately patients for PC or hospice referrals
  • Facilitated communication with patient’s physicians
  • Triage to hospital based PC service or hospice 4. Allows for rapid triage of consults to palliative care or hospice
  • Assist Case management to coordinate inpatient or outpatient hospice admission
  • Ensures symptom management is initiated in ED
  • Provide support to medical staff 6. Worked with case management to coordinate Transfer of patients requesting and meeting hospice criteria
  • Provide patient and/or family support 7. Provides another option for disposition of patients
  • Ensure symptom management

    David Monticalvo, MPH1 University of Florida Jacksonville, Center for Health Equity and Quality Research, 580 West 8th Street, T60, Jacksonville, FL, 32209, USA

    E-mail address: [email protected]

    Tammie Quest, MD

    Palliative Care Center, Emory Woodruff Health Science Center, 1525 Clifton

    Rd, Atlanta, GA 30329, USA E-mail address: [email protected]

    Belena Adkins, RN2 Suzanne Bell, RN

    UF Health, Department of Emergency Medicine, 655 West Eighth Street

    Jacksonville, FL, 32209, USA E-mail addresses: [email protected] (B. Adkins),

    [email protected] (S. Bell)

    Sarah Rausch Osian, PhD3

    University of Florida Jacksonville, Department of Emergency Medicine, 655

    West Eighth Street, Jacksonville, FL, 32209, USA University of Florida Jacksonville, Center for Health Equity and Quality Research, 580 West 8th Street, T60, Jacksonville, FL, 32209, USA

    E-mail address: [email protected]

    1 Current Address: University of Florida Health Proton Therapy Institute, 2015 N. Jefferson

    Street, Jacksonville, FL 32206.

    2 Current Addresse: 4576 Shaves Bluff, MacClenny FL 32063.

    3 Current Addresse: 7903 SE 12th circle, Ocala, FL.


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      Acute dyspnea by diaphragmatic excursion: practicality sustainable in ED?

      To the Editor,

      We read with great interest the article published by Bobbia et al [1] in- vestigating the feasibility of using diaphragmatic excursion (DE) mea- surements in emergency department (ED) patients with acute dyspnea as a diagnostic tool. Although the study investigates a possibly promising approach to improving the effectiveness of initial care of patients with respiratory distress, there are several limitations to the study which need to be addressed before asserting recommendations for its application.

      To begin, the study used a single-center design, comprising patients from a single ED of one academic center. The methods of this trial will need to be replicated in several EDs with the inclusion of demographically different patient populations to limit the potential confounding biases. The study also has low power, which can be attributed to its small sample size, with n = 24. The mean age of these patients was 80 years, with no patients younger than 60 years included in the trial. A trial with a larger sample size and a more diverse patient population is required. Further- more, the training of the operators could have been insufficient. In our opinion, an improvement in the study design would be to add more sub- stantive training, which could improve feasibility, intraobserver, and in- terobserver DE measurements especially for the left diaphragm. The evaluators were unable to perform the Ultrasonographic evaluation of the left diaphragm. The investigators studied only the right DE for the inter- observer reproducibility. Ultimately, there was unintentional variability in data measurements by the researchers. Although the authors stated that