- Email: [email protected]
226 Palliative Care Domains for Emergency Medicine Resident Training: An Expert Consensus
Research Forum Abstracts Palliative Performance Scale on Admission Is a Predictor of Mortality in Hospitalized Patients Admitted Through the Emergency Department
Kuntz J, Kowalsky D, Babcock M, Kenny A/UCONN Health, Farmington, CT
Background: Emergency physicians provide treatment to acutely ill patients often without information related to the long-term prognosis. The Palliative Performance Scale (PPS) assesses functional status and is an accurate predictor of survival in palliative care and hospice patients. Its prognostic value in the emergency department (ED) has never been studied. Study Objective: To assess the utility of the PPS to predict mortality in patients admitted to the tertiary care hospital through the ED. Methods: A prospective cohort study of 123 patients admitted in November and December of 2013. PPS score was evaluated initially in the ED; followed-up assessments of PPS and mortality were obtained at 3 and 6 months. Results: PPS score at baseline was 7222. Information on 72 patients (58.5%) is available at 3 months and 53 patients (43%) at 6 months; 19 patients had confirmed deaths at 6 months. There were no differences in the age, sex, race or PPS score in those evaluated and those lost to follow-up. Categorical baseline PPS score (0-30, 40-60 and 70-100) predicted 6-month mortality (P < .001). The 6 month mortality for 5 of 7 subjects with an initial PPS score of 30 was 100% (P < .000); 2 of the 7 were lost to follow up. At enrollment, no patient was receiving palliative or hospice care. Conclusion: The PPS predicts mortality in patients admitted to the hospital through the ED. Emergency physicians do not typically predict mortality in the noncritically ill patient. The PPS is a simple tool that allows emergency physicians to identify patients at high risk for death and thus may prompt a palliative care focused discussions in this vulnerable population.
226
Palliative Care Domains for Emergency Medicine Resident Training: An Expert Consensus
Goett R, Shoenberger J, DeSandre P, Jubanyik K, Aberger K, Bigelow S, Brandtman T, Chan G, Rosenberg M, Wang D, Lamba S/Rutgers: New Jersey Medical School, Newark, NJ; Keck School of Medicine of USC, Los Angeles, CA; Emory Palliative Care Center- Emory University, Georgia, Atlanta, GA; Yale School of Medicine, New Haven, CT; St. Josephs Regional Medical Center, Patterson, NJ; North Sound Emergency Medicine, Everett, WA; Feather River Hospital, Paradrise, CA; Stanford School of Medicine, Stanford, CA; New Jersey Medical School- Rutgers University, Newark, NJ
Study Objectives: Emergency departments (ED) increasingly treat patients with advanced illness. The aging population of the United States combined with advancements in medical care have resulted in an increased number of patients living with life-limiting illness. Recently hospice and palliative medicine has been designated subspecialty of emergency medicine (EM) but little peer-reviewed literature exists on relevant palliative care (PC) domains that should be taught within emergency medicine. To date, no defined list of relevant palliative care topics for education or training exist within emergency medicine. Methods: An expert panel composed of residency leadership, palliative care fellowship leadership, and providers with dual certification in EM and PC attempted to address this gap by performing a literature-review to assess past and current PC education within emergency medicine. We took a comprehensive search of MEDLINE, CINAHL, ERIC, PsycINFO, and SCOPUS for published studies using terms including palliative care, emergency medicine, topics, education, and training. Additionally, we used citation searching to find other relevant studies from these identified articles. From these articles, recurring topics were formed into a list of relevant PC topics in emergency medicine. After further review of the topic list and literature, three common domains were formed. The PC-EM topics were then grouped under one of three main domains (EM). Finally, PC expert panel determined content validity for accuracy of terminology and necessity of each topic and domain by monthly conference call through peer feedback. Results: From this expert panel 3 domains were established: provider skill set, clinical recognition, and logistical understanding. The panel also identified a total of 23 topics. The first domain, provider skill set, included topics such as pain control, other symptom control, difficult communication, goals of care discussions, caregiver support, non-initiation of or stopping non-beneficial interventions, treating symptoms at end of life, etc. The second domain, clinical
Volume 66, no. 4s : October 2015
recognition, compromised topics of dying trajectories, prognostication, rapid PC assessment, identifying the dying patient, complications of cancer, and ethnic, spiritual, and cultural issues around end of life. The last domain, logistical understanding, encompassed advanced directives, ethical and legal issues, multidisciplinary team/support systems: team and local resources, and transitions across care systems. Conclusion: Literature review and expert panel consensus identified key palliative care topics and domains relevant to EM resident training that will hopefully be beneficial to emergency physicians in numerous ways. These recognized areas can serve as the foundation for palliative care education within emergency medicine. Our next steps include mapping these PC topics to emergency medicine accredited council of graduate medical education (ACGME) resident milestones. Concurrently along this mapping, our panel is developing unique palliative care milestones for the EM resident education. In the future, we hope to that our EM-PC milestones from the topic list will serve as a model and starting point for further EM residency education and curriculum. Incorporating palliative care into the beginning of EM training will empower future EM providers and ensure better patient care.
227
Risk-Benefit Analysis of Lumbar Puncture to Evaluate for Nontraumatic Subarachnoid Hemorrhage in Adult Emergency Department Patients With Headache
Migdal VL, Wu WK, Long D, McNaughton CD, Ward MJ, Self WH/Vanderbilt University, Nashville, TN
Study Objectives: Current clinical practice guidelines recommend lumbar puncture (LP) after a normal computed tomography (CT) scan of the head to evaluate for subarachnoid hemorrhage (SAH) in patients presenting with severe nontraumatic headache. However, advances in CT technology have resulted in increased sensitivity for SAH, making it unclear if LP offers significant diagnostic benefit after a normal CT. Our objects were: (1) To calculate the proportion of patients who undergo LP to evaluate for SAH after a normal head CT with SAH diagnosed on LP results. (2) To compare the proportion of patients diagnosed with SAH by LP results with the proportion of patients who experienced an LP-related complication. Methods: This was a retrospective, observational study of adult ED patients at a single academic hospital who presented with headache and underwent LP to evaluate for SAH following a normal head CT from July 1, 2010 to June 30, 2013. To be included, patients must have had documentation of “the worse headache of life,” “thunderclap headache,” or specific documentation indicating LP was completed to evaluate for SAH. The medical records of each patient were reviewed for LP results and LP-related complications. LP results classified as indicating a SAH included: 1) xanthochromia in cerebrospinal fluid (CSF); or 2) red blood cells (>1 10 6/mm3) in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit to the ED or clinic due to symptoms related to the LP. Results: In this 3-year study, 302 patients underwent a LP to evaluate for SAH after a normal head CT; 2 (0.66%) patients were diagnosed with SAH based on LP results (Table). Both of these patients had known intracranial aneurysms at the time of LP. Eighteen (5.96%) patients experienced a LP-related complication (p<0.001 compared to proportion with a SAH diagnosed). Twelve (3.97%) of these patients returned to the ED with low-pressure, post-LP headaches, including 4 treated with a blood patch. Four (1.32%) patients had severe pain and 2 (0.66%) patients had contaminated CSF cultures leading to return visits. No patients had an infectious or hemorrhagic complication from LP. Interestingly, 32 (10.6) patients had alternative diagnoses other than SAH identified based on LP results, including 19 with viral and 5 with bacterial meningitis (Table). Conclusion: The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. In this 3-year study, only 2 patients (0.66%), both who had known intracranial aneurysms prior to LP, had SAH diagnosed based on LP results. More patients experienced a complication related to LP than had SAH diagnosed. Alternative diagnoses, in particular meningitis, were frequently identified on LP results. These results support the notion that LP may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with imaging demonstrating no intracranial aneurysm, but ˇ
225
Annals of Emergency Medicine S83
Kuntz J, Kowalsky D, Babcock M, Kenny A/UCONN Health, Farmington, CT
Background: Emergency physicians provide treatment to acutely ill patients often without information related to the long-term prognosis. The Palliative Performance Scale (PPS) assesses functional status and is an accurate predictor of survival in palliative care and hospice patients. Its prognostic value in the emergency department (ED) has never been studied. Study Objective: To assess the utility of the PPS to predict mortality in patients admitted to the tertiary care hospital through the ED. Methods: A prospective cohort study of 123 patients admitted in November and December of 2013. PPS score was evaluated initially in the ED; followed-up assessments of PPS and mortality were obtained at 3 and 6 months. Results: PPS score at baseline was 7222. Information on 72 patients (58.5%) is available at 3 months and 53 patients (43%) at 6 months; 19 patients had confirmed deaths at 6 months. There were no differences in the age, sex, race or PPS score in those evaluated and those lost to follow-up. Categorical baseline PPS score (0-30, 40-60 and 70-100) predicted 6-month mortality (P < .001). The 6 month mortality for 5 of 7 subjects with an initial PPS score of 30 was 100% (P < .000); 2 of the 7 were lost to follow up. At enrollment, no patient was receiving palliative or hospice care. Conclusion: The PPS predicts mortality in patients admitted to the hospital through the ED. Emergency physicians do not typically predict mortality in the noncritically ill patient. The PPS is a simple tool that allows emergency physicians to identify patients at high risk for death and thus may prompt a palliative care focused discussions in this vulnerable population.
226
Palliative Care Domains for Emergency Medicine Resident Training: An Expert Consensus
Goett R, Shoenberger J, DeSandre P, Jubanyik K, Aberger K, Bigelow S, Brandtman T, Chan G, Rosenberg M, Wang D, Lamba S/Rutgers: New Jersey Medical School, Newark, NJ; Keck School of Medicine of USC, Los Angeles, CA; Emory Palliative Care Center- Emory University, Georgia, Atlanta, GA; Yale School of Medicine, New Haven, CT; St. Josephs Regional Medical Center, Patterson, NJ; North Sound Emergency Medicine, Everett, WA; Feather River Hospital, Paradrise, CA; Stanford School of Medicine, Stanford, CA; New Jersey Medical School- Rutgers University, Newark, NJ
Study Objectives: Emergency departments (ED) increasingly treat patients with advanced illness. The aging population of the United States combined with advancements in medical care have resulted in an increased number of patients living with life-limiting illness. Recently hospice and palliative medicine has been designated subspecialty of emergency medicine (EM) but little peer-reviewed literature exists on relevant palliative care (PC) domains that should be taught within emergency medicine. To date, no defined list of relevant palliative care topics for education or training exist within emergency medicine. Methods: An expert panel composed of residency leadership, palliative care fellowship leadership, and providers with dual certification in EM and PC attempted to address this gap by performing a literature-review to assess past and current PC education within emergency medicine. We took a comprehensive search of MEDLINE, CINAHL, ERIC, PsycINFO, and SCOPUS for published studies using terms including palliative care, emergency medicine, topics, education, and training. Additionally, we used citation searching to find other relevant studies from these identified articles. From these articles, recurring topics were formed into a list of relevant PC topics in emergency medicine. After further review of the topic list and literature, three common domains were formed. The PC-EM topics were then grouped under one of three main domains (EM). Finally, PC expert panel determined content validity for accuracy of terminology and necessity of each topic and domain by monthly conference call through peer feedback. Results: From this expert panel 3 domains were established: provider skill set, clinical recognition, and logistical understanding. The panel also identified a total of 23 topics. The first domain, provider skill set, included topics such as pain control, other symptom control, difficult communication, goals of care discussions, caregiver support, non-initiation of or stopping non-beneficial interventions, treating symptoms at end of life, etc. The second domain, clinical
Volume 66, no. 4s : October 2015
recognition, compromised topics of dying trajectories, prognostication, rapid PC assessment, identifying the dying patient, complications of cancer, and ethnic, spiritual, and cultural issues around end of life. The last domain, logistical understanding, encompassed advanced directives, ethical and legal issues, multidisciplinary team/support systems: team and local resources, and transitions across care systems. Conclusion: Literature review and expert panel consensus identified key palliative care topics and domains relevant to EM resident training that will hopefully be beneficial to emergency physicians in numerous ways. These recognized areas can serve as the foundation for palliative care education within emergency medicine. Our next steps include mapping these PC topics to emergency medicine accredited council of graduate medical education (ACGME) resident milestones. Concurrently along this mapping, our panel is developing unique palliative care milestones for the EM resident education. In the future, we hope to that our EM-PC milestones from the topic list will serve as a model and starting point for further EM residency education and curriculum. Incorporating palliative care into the beginning of EM training will empower future EM providers and ensure better patient care.
227
Risk-Benefit Analysis of Lumbar Puncture to Evaluate for Nontraumatic Subarachnoid Hemorrhage in Adult Emergency Department Patients With Headache
Migdal VL, Wu WK, Long D, McNaughton CD, Ward MJ, Self WH/Vanderbilt University, Nashville, TN
Study Objectives: Current clinical practice guidelines recommend lumbar puncture (LP) after a normal computed tomography (CT) scan of the head to evaluate for subarachnoid hemorrhage (SAH) in patients presenting with severe nontraumatic headache. However, advances in CT technology have resulted in increased sensitivity for SAH, making it unclear if LP offers significant diagnostic benefit after a normal CT. Our objects were: (1) To calculate the proportion of patients who undergo LP to evaluate for SAH after a normal head CT with SAH diagnosed on LP results. (2) To compare the proportion of patients diagnosed with SAH by LP results with the proportion of patients who experienced an LP-related complication. Methods: This was a retrospective, observational study of adult ED patients at a single academic hospital who presented with headache and underwent LP to evaluate for SAH following a normal head CT from July 1, 2010 to June 30, 2013. To be included, patients must have had documentation of “the worse headache of life,” “thunderclap headache,” or specific documentation indicating LP was completed to evaluate for SAH. The medical records of each patient were reviewed for LP results and LP-related complications. LP results classified as indicating a SAH included: 1) xanthochromia in cerebrospinal fluid (CSF); or 2) red blood cells (>1 10 6/mm3) in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit to the ED or clinic due to symptoms related to the LP. Results: In this 3-year study, 302 patients underwent a LP to evaluate for SAH after a normal head CT; 2 (0.66%) patients were diagnosed with SAH based on LP results (Table). Both of these patients had known intracranial aneurysms at the time of LP. Eighteen (5.96%) patients experienced a LP-related complication (p<0.001 compared to proportion with a SAH diagnosed). Twelve (3.97%) of these patients returned to the ED with low-pressure, post-LP headaches, including 4 treated with a blood patch. Four (1.32%) patients had severe pain and 2 (0.66%) patients had contaminated CSF cultures leading to return visits. No patients had an infectious or hemorrhagic complication from LP. Interestingly, 32 (10.6) patients had alternative diagnoses other than SAH identified based on LP results, including 19 with viral and 5 with bacterial meningitis (Table). Conclusion: The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. In this 3-year study, only 2 patients (0.66%), both who had known intracranial aneurysms prior to LP, had SAH diagnosed based on LP results. More patients experienced a complication related to LP than had SAH diagnosed. Alternative diagnoses, in particular meningitis, were frequently identified on LP results. These results support the notion that LP may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with imaging demonstrating no intracranial aneurysm, but ˇ
225
Annals of Emergency Medicine S83