Emergency departments (EDs) are often the first point of contact for individuals facing serious, life-limiting illnesses. In these critical moments, ensuring patients receive appropriate care, including palliative care when beneficial, is paramount. However, busy ED environments can present challenges in identifying patients who would benefit most from palliative care. Clinical decision support (CDS) tools are emerging as a promising solution to automate this identification process, assisting healthcare providers in adhering to best practice guidelines and ultimately improving the quality of care for older adults and those with serious illnesses.
The Primary Palliative Care for Emergency Medicine (PRIM-ER) study was initiated to explore and optimize the integration of electronic health records with CDS tools. The goal was to create a system that could proactively identify high-risk patients within the ED setting who could benefit from primary palliative care. By providing point-of-care clinical recommendations, these tools aim to bridge the gap between guideline recommendations and actual clinical practice in fast-paced emergency environments.
To develop a practical and effective CDS tool, the Emergency Department Supportive Care Clinical Decision Support (Support-ED) system was created as part of a value-based medicine initiative at NYU Langone Health’s Ronald O. Perelman Department of Emergency Medicine. The development process was multidisciplinary, ensuring a comprehensive approach. This included a thorough scoping review of existing ED palliative care screening tools to build upon prior research and best practices. A dedicated workgroup, composed of experts from various disciplines, was established to define specific patient screening criteria and identify appropriate referral services within the healthcare system. The initial design of Support-ED underwent rigorous usability testing using the System Usability Scale questionnaire to ensure it was user-friendly and practical for ED staff. Crucially, the ED workforce received comprehensive education on the background, purpose, and proper utilization of Support-ED to facilitate seamless integration into their workflow. Finally, a monitoring dashboard was implemented to track the tool’s performance and gather feedback for ongoing improvement.
The scoping review of existing tools highlighted the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a robust and validated instrument. P-CaRES served as the foundation for adapting and applying specific criteria within the newly developed CDS tool. Multidisciplinary workshops further refined the objectives of the CDS, focusing on two key goals: firstly, to accurately identify patients exhibiting indicators of serious life-limiting illness, and secondly, to streamline referrals to essential supportive services, such as palliative care teams or social work resources. The iterative design process led to the identification of three distinct patient scenarios that would trigger a clinical alert within Support-ED. These triggers were designed to be sensitive and specific, ensuring that the alert fired when it was most clinically relevant. The scenarios included: 1) the presence of an advance care planning document, indicating the patient had already considered end-of-life preferences; 2) a patient’s history of hospice disposition, suggesting a prior engagement with end-of-life care services; and 3) the identification of serious life-limiting illness based on historical and/or current clinical data points, particularly in the absence of advance care planning documentation. Continuous monitoring and feedback mechanisms were essential to the development process, revealing the need for several modifications to optimize the CDS functionality and ensure it effectively met the needs of both patients and providers.
The development and implementation of Support-ED demonstrates the potential of CDS tools to significantly enhance the delivery of primary palliative care within the emergency department setting. By proactively identifying patients who may benefit from palliative care, these tools can support clinicians in making informed decisions aligned with patient needs and preferences. Health systems considering the integration of similar CDS tools should carefully consider the importance of tailoring these systems to their unique workflows and clinical environments to maximize effectiveness and adoption. The experiences and findings from the PRIM-ER study and the development of Support-ED offer valuable insights for other health systems seeking to seamlessly integrate primary palliative care CDS systems into their existing processes of care, ultimately leading to improved patient outcomes and a more compassionate approach to end-of-life care in the emergency department.
Trial registration: ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.
