Background: The Palliative Care and Rapid Emergency Screening (P-CaRES) project, spearheaded by Brown University, addresses a critical need: improving access to palliative care (PC) for emergency department (ED) patients facing life-limiting illnesses. Recognizing the ED as a crucial point of care, the P-CaRES initiative focuses on facilitating timely inpatient PC consultations through effective early screening. Building upon two prior phases dedicated to the development and validation of an innovative PC screening tool, this article delves into the project’s third and final pre-implementation phase, emphasizing the “P-cares Brown University Screening Tool”.
Objectives: This phase of the P-CaRES project set out to rigorously evaluate the “p-cares brown university screening tool” across two key dimensions: acceptability and reliability. The objectives were twofold: first, to gauge the acceptability of the P-CaRES tool among both PC and ED healthcare providers, and second, to rigorously test its reliability through the application to simulated patient scenarios presented as case vignettes. Furthermore, the study aimed to identify if variations in the tool’s reliability and perceived acceptability existed among ED providers based on their professional roles (attendings, residents, and nurses) and the extent of their clinical experience.
Methods: To achieve these objectives, the research team implemented a comprehensive two-part electronic survey distributed to ED providers across multiple medical centers within the United States. The survey’s initial segment was designed to assess the reliability of the “p-cares brown university screening tool”. This was accomplished using a series of carefully constructed case vignettes, each representing a patient scenario. To establish a definitive benchmark for accurate responses, a consensus panel of expert PC physicians meticulously reviewed and interpreted each vignette, defining a criterion standard of correct identification of unmet PC needs. The consistency of these expert interpretations was statistically validated using Gwet’s AC1 coefficient for inter-rater reliability. Subsequently, ED providers were tasked with utilizing the P-CaRES tool to evaluate the same case vignettes and determine which patients exhibited unmet palliative care needs. Provider responses were then systematically compared against the established criterion standard, as well as across different subgroups of respondents categorized by their professional role and level of experience. The second component of the survey shifted focus to acceptability, employing a modified Ottawa Acceptability of Decision Rules Instrument. This instrument utilized a 1-5 Likert rating scale to capture ED providers’ perceptions and attitudes towards the P-CaRES tool. Descriptive statistics were employed to analyze and summarize all collected data, providing a clear overview of the findings related to both reliability and acceptability.
Results: A significant response rate was achieved, with 213 ED providers from three distinct regions across the United States participating in the survey (39.4% response rate), and a substantial majority, 185 (86.9%), completing the entire survey. The feedback regarding the “p-cares brown university screening tool” was overwhelmingly positive. A large majority of ED providers expressed confidence in the tool’s practical utility, with 80.5% believing it would be useful in their daily practice. Furthermore, 87.1% found the tool to be clear and unambiguous, enhancing its ease of use. Providers also recognized the potential patient benefits, with 87.5% agreeing that utilizing the tool would likely improve patient outcomes. Importantly, 83.6% of respondents anticipated that the P-CaRES tool would contribute to a more efficient allocation of resources for severely ill patients, streamlining the process of connecting them with appropriate palliative care services. Despite these positive perceptions, a significant proportion, 78.5%, of ED providers self-reported that they currently refer patients with unmet PC needs less than 10% of the time, highlighting a potential gap in current practice. Reinforcing this point, only 10.8% of respondents felt they were already employing an effective strategy for screening or referring patients to palliative care. When applying the “p-cares brown university screening tool” to the case vignettes, ED providers demonstrated a high degree of accuracy, aligning with PC expert referrals over 88.7% of the time (95% confidence interval = 86.4% to 90.6%), and achieving an overall sensitivity exceeding 90%. Notably, these robust results remained consistent regardless of the ED provider’s role (attending, resident, or nurse) or their level of professional experience, indicating the tool’s broad applicability and reliability across different provider profiles.
Conclusion: The findings of this study strongly support the implementation of the “p-cares brown university screening tool” within emergency departments. The research demonstrates that screening for unmet palliative care needs by emergency medicine providers, using this brief, novel, and content-validated tool, is not only acceptable to providers but also reliably identifies patients in need when applied to case vignettes. This reliability holds true irrespective of the provider’s role or level of experience within the ED setting. These positive outcomes strongly advocate for the integration of the P-CaRES tool into routine ED practice. The study authors recommend proceeding with clinical trials and further research to evaluate the tool’s impact in real-world clinical settings, and such studies are currently underway to further validate and refine the “p-cares brown university screening tool” for widespread adoption and improved palliative care access in emergency medicine.
