Primary Palliative Care for Emergency Medicine

急诊医学的初级姑息治疗

基本信息

批准号：
9497240
负责人：
Corita R Grudzen
金额：
$ 98.37万
依托单位：
NEW YORK UNIVERSITY SCHOOL OF MEDICINE
依托单位国家：
美国
项目类别：
财政年份：
2018
资助国家：
美国
起止时间：
2018-05-15 至 2019-04-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9497240
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 Comorbidity Consultations Data Day Care Education Educational workshop Effectiveness Elderly Emergency Care Emergency Medicine Emergency Situation Emergency department visit Equilibrium 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 base care coordination care providers care systems clinical decision support demographics design 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

项目摘要

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一种专业，以治疗急性病和受伤，但越来越关心适用于多个合并症的老年人。急诊科（ED）访问是哨兵活动老年人通常表示护理协调的故障以及临床和功能状况恶化。在生命的最后一个月，在急诊室中看到了一半65岁以上的美国人，四分之三访问 ed在死亡前的6个月中。同时，重症监护室的入院数量和率（ICU）紧急提供者一直在增加，尤其是在老年人中。四分之三的年龄患有严重疾病的成年人已经考虑过临终关怀，只有12％的人想要延长生命的护理。应急提供者通过平衡潜在的危害和益处来影响患者的临床轨迹住院并将重病的老年人与门诊服务联系起来。直到最近，很少关注已经支付了将护理计划与ED中老年人的患者目标保持一致。解决这个差距我们的团队进行了目标定向的急诊护理，我们的团队进行了随机分析在晚期癌症中进行的介绍姑息治疗咨询的对照试验显示出改善 12周的生活质量。我们还在Medicare和Medicaid创新中心中展示了Ed- 基于基本的姑息治疗创新减少了从通过筛查高风险老年人，早期转介姑息治疗和临终关怀，以及2.3％至0.9％紧急提供者培训和姑息治疗原则的教育。这种方法是否可行在资源中具有巨大异质性的ED中有效，尚不清楚。我们将量身定制`初级姑息治疗用于急诊医学（PIR-ER），用于在专业方面的35个ED组中实施老年和姑息治疗能力，地理区域，付款人组合和人口统计。该建议建立现有的研究合作伙伴关系以实施和评估Prim-er-eD处置，医疗保健使用严重的生命疾病的老年人的利用和生存。我们的假设是老年人由具有主要姑息治疗技能的提供者照顾的严重，生命障碍疾病的访客的可能性较小被接纳为住院环境，更有可能被送入家中或姑息治疗服务，并将拥有更高的家庭健康和临终关怀，住院时间较少，ICU入院6个月，更长生存比实施之前看到的生存。我们提出了一个务实的，群集的阶梯楔设计以测试35 eds中引物的有效性。引物包括：1）基于证据的，多学科初级姑息治疗教育，2）基于模拟的有关沟通的研讨会严重疾病，3）临床决策支持，以及4）提供者审核和反馈。具体目的是分配的进入：1）UG3阶段，在其中我们将规定定制为多样化的环境和试点测试干预措施在两个地点；以及一个2）UH3阶段，其中我们将以33 eds的阶梯楔形设计测试干预措施。