Primary Palliative Care for Emergency Medicine

项目摘要 急诊医学发展成为一种治疗急病和伤员的专业，但也越来越受到关注 适用于患有多种并存疾病的老年人。急诊科(ED)访问是一种哨兵事件 老年人，通常意味着护理协调能力的崩溃以及临床和功能状况的恶化。 一半65岁及以上的美国人在生命的最后一个月会去急诊室，四分之三的人会去 死前6个月的ED。与此同时，重症监护病房的入院人数和入院率 急救人员的重症监护病房(ICU)一直在增加，尤其是在老年人中。四分之三的老年人 患有严重疾病的成年人考虑过临终关怀，只有12%的人想要延长生命的护理。 急诊提供者通过平衡以下各项的潜在危害和益处来影响患者的临床轨迹 住院并将重病老年人与门诊服务联系起来。直到最近，很少有人关注 一直致力于使护理计划与急诊室老年人的患者目标保持一致。为了解决这一差距， 为重症老年人提供有目标的急救服务，我们团队进行了一项随机的 ED启动的晚期癌症姑息治疗咨询的对照试验显示 12周时的生活质量。我们还在医疗保险和医疗补助创新中心的一个项目中展示了Ed- 基于初级姑息治疗的创新降低了老年急诊室入住ICU的比例 2.3%至0.9%，通过筛查高危老年人，及早转介到姑息治疗和临终关怀，以及 急救提供者在姑息治疗原则方面的培训和教育。这种方法是否可行？ 而在资源异质性很大的EDS中是否有效，目前尚不清楚。我们将量身定做初级姑息治疗 用于急救医学(PRIM-ER)，在由35名不同专业的急救人员组成的不同小组中实施 老年和姑息治疗能力、地理区域、支付者组合和人口统计。这项建议建立了 在现有研究伙伴关系的基础上实施和评估关于ED处置、医疗保健的Prim-ER 对患有严重、限制生命的疾病的老年人的利用率和存活率。我们的假设是老年人 由具有初级姑息护理技能的提供者护理的患有严重、限制生命的疾病的访客将不太可能 住进住院环境，更有可能出院或接受姑息治疗服务，并将 家庭健康和临终关怀使用率更高，住院天数和6个月内入住ICU的人数更少，而且更长时间 存活率高于实施前的水平。我们提出了一种实用的、集群随机的阶梯楔形 设计在35个急诊室中测试PRIM-ER的有效性。PRIM-ER包括：1)以证据为基础， 多学科初级姑息关怀教育，2)以模拟为基础的交流讲习班 严重疾病，3)临床决策支持，以及4)提供者审计和反馈。具体目标是有分歧的 进入：1)UG3阶段，在此阶段，我们将针对不同的ED环境定制协议，并对干预进行试点测试 在两个地点；和2)UH3阶段，在33个急诊室中，我们将以阶梯式楔形设计测试干预。

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.