UH3 Project: Primary Palliative Care for Emergency Medicine (PRIM-ER)

UH3 Project: Primary Palliative Care for Emergency Medicine (PRIM-ER)

Overview

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Principal Investigators:
Headshot of Dr. Corita Grudzen

Corita R. Grudzen, MD, MSHS

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Keith Goldfeld, DrPH, MS, MPA

Sponsoring Institution: New York University Grossman School of Medicine

Collaborators:

  • Allegheny Health Network
  • Baystate Health
  • Beaumont Health System
  • Brigham and Women’s/DRCI+
  • ChristianaCare Health System
  • Henry Ford Health System
  • Icahn School of Medicine at Mount Sinai
  • Mayo Clinic Health System
  • MD Anderson Cancer Center
  • NYU Langone Health
  • Ochsner Health System
  • The Ohio State University Wexner Medical Center
  • Penn Medicine: University of Pennsylvania Health System
  • Rutgers Health
  • UCSF Health (University of California, San Francisco)
  • UF Health (University of Florida)
  • University of Utah Health
  • Yale New Haven Health

NIH Institutes Providing Oversight: National Institute on Aging (NIA)

ClinicalTrials.gov Identifier: NCT03424109

Trial Status: Completed

Study Snapshot

Trial Summary

Study question and significance: Among individuals 65 years and older in the United States, half visited the emergency department during the last month of life, and three-quarters visited the emergency department during the 6 months before death. The emergency department offers an opportunity to initiate primary palliative care for older adults with serious, lifelimiting illness. Consultation with palliative care specialists is not always available in emergency departments (typically Monday through Friday during business hours), and emergency clinicians may lack the training or tools to assist older adults who have serious, life-limiting illness in making complex medical decisions. This study aimed to assess the effect of a multicomponent intervention to initiate primary palliative care in the emergency department on hospital admission in older adults with serious, life-limiting illness.

Design and setting: Stepped-wedge, cluster randomized clinical trial including patients aged 66 years or older who visited 1 of 29 emergency departments across the United States between May 2018 and December 2022, had 12 months of prior Medicare enrollment, and had a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.

Intervention and methods: Participating emergency departments implemented a multicomponent intervention that included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for emergency department clinical staff. The primary outcome was hospital admission and the secondary outcomes included subsequent healthcare use and survival.

Findings: Over the course of the intervention, 807 emergency medicine providers (physicians, physician assistants, and nurse practitioners) and more than 2082 emergency medicine nurses received end-of-life/goals of care communication skills training. There were 98,922 initial emergency department visits during the study period. There was no difference in the rate of hospital admission in older adults with serious, life-limiting illness receiving care before (64.4%) vs after (61.3%) emergency department clinical staff receipt of a multicomponent primary palliative care intervention. There was no difference in the secondary outcomes before vs after the intervention.

Conclusions and relevance: This multicomponent intervention to initiate palliative care in the emergency department did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.

NIH Project Information

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Dr. Grudzen discusses PRIM-ER, a NIH Collaboratory Trial that will implement primary palliative care in emergency medicine across a diverse group of Emergency Departments.

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