Speaker

Corita R. Grudzen, MD, MSHS, FACEP
Fern Grayer Chair in Oncology Care and the Patient Experience
Division Head, Supportive and Acute Care Services
Memorial Sloan Kettering Cancer Center
Professor of Emergency Medicine
Weill Cornell Medical College

Slides

Keywords

Palliative Care, Emergency Medicine, PRIM-ER

Key Points

• Past research found that inpatient palliative care, when triggered by an ED visit, improves quality of life and decreases health care use, but what happens when patients leave the ED? How can we better help patients going home and trigger community-based palliative care?

• The default approach in the ED is “pedal to the metal,” to do everything and initiate life-saving procedures instead of taking a step back, looking at the records to see if the patient has a DNR or medical orders for life-sustaining treatment. The default is to do everything instead of taking a step back to look and see if there are prior records.

• The goal of the PRIM-ER intervention is system and provider change. It is modeled on the theory of planned behavior, that to change behavior, you have to change intentions by changing their attitudes, cultural norms, and perceived behavioral control (is it achievable).

• The PRIM-ER intervention had multiple components. The first was an evidence-based, multidisciplinary primary palliative care education, which involved the End-of-Life Nursing Education Consortium (ELNEC), using a modified version of the intensive care module, and an emergency medicine module from Education in Palliative and End-of-Life Care (EPEC-EM). The second component was simulation-based workshops on serious illness communication. The third component was clinical decision support (CDS), and the fourth component was provider audit and feedback, which were contextualized to the local ED feedback.

• For the clinical decision support, the study wanted to identify patients who already had advanced planning documents (active ACP). The second core function was to identify patients who are already enrolled in hospice. Finally, there are patients with serious life-limiting illness who do not have information about their wishes or preferences but would benefit from a goals of care conversations.

• The PRIM-ER aims were to test the effectiveness of PRIM-ER on ED disposition and healthcare use in older adults with serious, life-limiting illness using a pragmatic, cluster-randomized stepped wedge design in 33 EDs and to describe barriers and facilitators to implementation at the micro- (individual), meso- (department and institutional), and macro- (health system) level. The hypothesis was that PRIM-ER will reduce ED disposition to acute care and 6-month healthcare use for older adult patients with serious, life-limiting illness.

• The interventions were piloted at 2 sites and eventually studied at 18 sites/33 EDs across the country. The study was stepped-wedge in design with new sites starting every 3 weeks during the course of the trial, except for 6 months during the COVID-19 pandemic. The primary outcome was acute care admission. The secondary outcomes were ED revisits, inpatient days, hospice use, and home health use, and survival defined as 6 months from the ED visit.
• To be included in the study, patients had to make an ED visit at one of the participating sites, be 66 years or older, and have one-year mortality of at least 30 percent. Patients were excluded if they resided at a nursing facility or were already on hospice.
• PRIM-ER found that a multi-level, complex primary palliative care intervention in 33 EDs did not decrease acute care disposition in older adults at high risk for short-term mortality, but reduced ED revisits at 6 months. Nurses and providers are willing and able to use new skills, especially those deemed clinically relevant. Electronic CDS tools must be thoughtfully tailored to unique workflows and environments.

Discussion Themes

– What other options were generally available at these Eds (inpatient hospice, outpatient hospice, case managers, etc.)? How do you explain the link between the intervention and reduced repeat ED visits? In terms of the 33 EDs, there are many different variations on the options that were available to providers. We tried to develop greater connections and a sweep of options to understand the options in each community and strengthen the ties. There was a reduction in ED visits. We are now funded to do a similar study in dementia with ED revisit as primary outcome. As ED providers we have a little more control. We know why a patient made the visit to the ED and can refer them to other services.

– As you reflect on this trial, what are the big takeaways for you as a trialist? We presented this first to the health systems and our collaborators, and it was the most satisfying and fun work I have been a part of. We changed so much – we improved communication, got people excited, even though our outcome was not successful. It was the process that was fun and made a difference through the training we provided. The primary outcome is hard to pick. It feels random even though we put a lot of thought into it. We figured out we did not choose the correct primary outcome.