Primary Palliative Care for Emergency Medicine

急诊医学的初级姑息治疗

• 批准号: 10200957
• 负责人: Corita R Grudzen
• 金额: $ 12.6万
• 依托单位: NEW YORK UNIVERSITY SCHOOL OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-05-15 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10200957
• 关键词: Accident and Emergency department; Acute; Address; Admission activity; Advanced Malignant Neoplasm; Ambulatory Care; American; Attention; Caring; Cessation of life; Characteristics; Chronic Disease; Clinical; Communication; Consultations; Data; Day Care; Education; Educational workshop; Elderly; Emergency Care; Emergency Medicine; Emergency Situation; Emergency department visit; Equilibrium; Estrogen receptor positive; Event; Feedback; Geographic Locations; Goals; Health; Heterogeneity; Home environment; Hospitalization; Inpatients; Intensive Care Units; Intervention; Knowledge; Life; Measures; Medicare claim; Medicare/Medicaid; Outcome; Palliative Care; Patient Care; Patients; Phase; Protocols documentation; Provider; Quality of life; Randomized; Randomized Controlled Trials; Readiness; Research; Resources; Sentinel; Site; Testing; Training and Education; Variant; acute care; base; care coordination; care providers; care systems; clinical decision support; comorbidity; demographics; design; effectiveness testing; end of life care; evidence base; functional status; health care service utilization; high risk; hospice environment; improved; indexing; injured; innovation; inpatient service; medical specialties; multidisciplinary; outpatient programs; pragmatic trial; programs; routine practice; screening; simulation; skills; treatment as usual; usability

Project Abstract Emergency medicine developed as a specialty to treat the acutely ill and injured, but increasingly cares for older adults with multiple comorbid conditions. An Emergency Department (ED) visit is a sentinel event for older adults, often signifying a breakdown in care coordination and worsening clinical and functional status. Half of Americans 65 years and older are seen in the ED in the last month of life, and three-quarters visit the ED in the 6 months before death. Meanwhile, the number and rate of admissions to the Intensive Care Unit (ICU) by emergency providers have been increasing, especially among older adults. Three-quarters of older adults with serious illness have thought about end-of-life care, and only 12% want life-prolonging care. Emergency providers impact a patient's clinical trajectory by balancing the potential harms and benefits of hospitalization and connecting seriously ill, older adults with outpatient services. Until recently, little attention has been paid to aligning care plans with patient goals for older adults in the ED. To address this gap in the delivery of goal-directed emergency care of seriously ill, older adults, our team conducted a randomized controlled trial of ED-initiated palliative care consultation in advanced cancer that showed improvement in quality of life at 12 weeks. We also showed in a Center for Medicare and Medicaid Innovation project that ED- based primary palliative care innovations reduced the percentage of geriatric ED admissions to the ICU from 2.3% to 0.9% through screening for high-risk older adults, early referral to palliative care and hospice, and emergency provider training and education in palliative care principles. Whether this approach will be feasible and effective in EDs with great heterogeneity in resources is unknown. We will tailor `primary palliative care for emergency medicine' (PRIM-ER) for implementation in a diverse group of 35 EDs that vary in specialty geriatric and palliative care capacity, geographic region, payer mix, and demographics. This proposal builds upon existing research partnerships to implement and evaluate PRIM-ER on ED disposition, healthcare utilization, and survival in older adults with serious, life-limiting illness. Our hypothesis is that older adult visitors with serious, life-limiting illness cared for by providers with primary palliative care skills will be less likely to be admitted to an inpatient setting, more likely to be discharged home or to a palliative care service, and will have higher home health and hospice use, fewer inpatient days and ICU admissions at 6 months, and longer survival than those seen prior to implementation. We propose a pragmatic, cluster-randomized stepped wedge design to test the effectiveness of PRIM-ER in 35 EDs. PRIM-ER includes: 1) evidence-based, multidisciplinary primary palliative care education, 2) simulation-based workshops on communication in serious illness, 3) clinical decision support, and 4) provider audit and feedback. The specific aims are divided into a: 1) UG3 Phase, in which we will tailor the protocols to a diverse ED context and pilot test the intervention at two sites; and a 2) UH3 Phase in which we will test the intervention in a stepped wedge design in 33 EDs.

项目摘要 急诊医学是作为一种治疗急性疾病和受伤的专业而发展起来的，但越来越多的人关心 对于患有多种共病的老年人来说。急诊室（艾德）访视是一个哨兵事件， 老年人，通常意味着护理协调的崩溃以及临床和功能状态的恶化。 65岁及以上的美国人中，有一半在生命的最后一个月去了艾德，四分之三的人去了急诊室。 艾德死亡前6个月内。与此同时，入住重症监护室的人数和比率 (ICU)越来越多的人，特别是老年人。四分之三的老年 患有严重疾病的成年人考虑过临终护理，只有12%的人希望得到延长生命的护理。 急诊提供者通过平衡以下因素的潜在危害和益处来影响患者的临床轨迹： 住院治疗和连接重病，老年人与门诊服务。直到最近， 已支付调整护理计划与病人的目标，老年人在ED。为了解决这一差距， 为重病的老年人提供目标导向的紧急护理，我们的团队进行了随机 一项ED启动的晚期癌症姑息治疗咨询的对照试验， 12周的生活质量。我们还在医疗保险和医疗补助创新中心的一个项目中表明，艾德- 基于初级姑息治疗的创新降低了老年艾德进入ICU的比例， 2.3%至0.9%，通过筛查高危老年人，早期转诊到姑息治疗和临终关怀， 急救人员培训和姑息治疗原则教育。这种做法是否可行 和有效的ED与巨大的异质性资源是未知的。我们将定制"初级姑息治疗" 急诊医学”（PRIM-ER），用于在35名不同专业的急诊科医生中实施 老年病和姑息治疗能力、地理区域、付款人组合和人口统计。这一建议建立 利用现有的研究合作伙伴关系，在艾德处置、医疗保健方面实施和评估PRIM-ER 利用率和患有严重、限制生命的疾病的老年人的生存率。我们的假设是老年人 由具有初级姑息治疗技能的提供者照顾患有严重、限制生命的疾病的访客的可能性较小 住院治疗，更有可能出院回家或接受姑息治疗， 家庭健康和临终关怀的使用率更高，住院天数和6个月时的ICU入院率更低， 比实施前看到的要好。我们提出了一个实用的，集群随机阶梯楔 设计用于在35个ED中测试PRIM-ER的有效性。PRIM-ER包括：1）循证， 多学科初级姑息治疗教育，2）基于模拟的沟通讲习班， 严重疾病，3）临床决策支持，以及4）提供者审核和反馈。具体目标分为 分为：1）UG3阶段，我们将根据不同的艾德背景定制方案，并对干预措施进行试点测试 2）UH3阶段，我们将在33个ED中测试阶梯式楔形设计中的干预。