UH3 Project: Primary Palliative Care for Emergency Medicine (PRIM-ER)
Principal Investigator: Corita R. Grudzen, MD, MSHS, FACEP
Sponsoring Institution: New York University School of Medicine
NIH Institutes Providing Oversight: National Institute on Aging (NIA), National Center for Complementary and Integrative Health (NCCIH)
Program Official: Robin Boineau (NCCIH)
Project Scientist: Marcel Salive (NIA)
ClinicalTrials.gov Identifier: NCT03424109
Trial Status: Not yet recruiting
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 of age 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 has 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.
The PRIM-ER Demonstration Project will address this gap in the delivery of goal-directed emergency care of older adults. Using a pragmatic, cluster-randomized, stepped-wedge design, PRIM-ER will implement primary palliative care in emergency medicine across a diverse group of 35 EDs that vary in specialty geriatric and palliative care capacity, geographic region, payer mix, and demographics. The PRIM-ER intervention includes evidence-based, multidisciplinary primary palliative care education; simulation-based workshops on communication in serious illness; clinical decision support; and provider audit and feedback. The intervention will be piloted at 2 sites in the UG3 phase and tested in the remaining 33 EDs in the UH3 phase. The 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 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.
Primary Palliative Care for Emergency Medicine (PRIM-ER): protocol for a pragmatic, cluster-randomised, stepped wedge design to test the effectiveness of primary palliative care education, training and technical support for emergency medicine. BMJ Open. 2019;9(7):e030099.