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.

项目摘要急诊医学作为治疗重病和重伤的专业而发展起来，但越来越受到人们的关注对于患有多种合并症的老年人。急诊科 (ED) 就诊是一个哨兵事件老年人，通常意味着护理协调的崩溃以及临床和功能状态的恶化。 65 岁及以上的美国人中有一半在生命的最后一个月在急诊室就诊，四分之三的人到急诊室就诊死亡前 6 个月内的 ED。与此同时，重症监护病房的入院人数和比率急诊提供者（尤其是老年人）的重症监护室（ICU）数量一直在增加。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，但只有 12% 的人想要延长生命的护理。急救人员通过平衡潜在的危害和益处来影响患者的临床轨迹住院治疗并将重病老年人与门诊服务联系起来。直到最近还很少有人关注已获得资助，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了向重病老年人提供目标导向的紧急护理，我们的团队进行了一项随机急诊室发起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项目中展示了 ED- 基于初级姑息治疗的创新将老年 ED 入住 ICU 的比例从通过筛查高危老年人、及早转诊姑息治疗和临终关怀，将 2.3% 降至 0.9% 紧急医疗服务提供者关于姑息治疗原则的培训和教育。这种方法是否可行对于资源异质性较大的 ED 是否有效尚不清楚。我们将量身定制“初级姑息治疗” 用于急诊医学”（PRIM-ER），用于在 35 个不同专业的 ED 小组中实施老年病和姑息治疗能力、地理区域、付款人组合和人口统计数据。该提案构建基于现有的研究合作伙伴关系，实施和评估 PRIM-ER 在 ED 处置、医疗保健方面的应用患有严重、限制生命的疾病的老年人的利用率和生存率。我们的假设是老年人患有严重、危及生命的疾病并由具有初级姑息治疗技能的提供者照顾的访客的可能性较小入院治疗，更有可能出院回家或接受姑息治疗服务，并且将家庭保健和临终关怀服务的使用率更高，住院天数和 6 个月及更长时间内入住 ICU 的次数更少生存率高于实施前的生存率。我们提出了一种实用的、集群随机的阶梯楔形旨在测试 PRIM-ER 在 35 例 ED 中的有效性。 PRIM-ER 包括：1）基于证据，多学科初级姑息治疗教育，2) 基于模拟的沟通研讨会严重疾病，3) 临床决策支持，以及 4) 提供者审核和反馈。具体目标有分歧进入：1) UG3 阶段，在此阶段，我们将根据不同的 ED 环境定制方案并试点测试干预措施在两个地点； 2) UH3 阶段，我们将在 33 个 ED 中测试阶梯式楔形设计的干预措施。