Introduction
The emergency department (ED) plays a vital role in the healthcare journey of individuals facing serious, life-limiting illnesses. Ensuring these patients receive optimal care, aligned with their needs and preferences, is paramount. However, busy ED environments can present challenges in consistently identifying patients who could benefit from palliative care. Clinical decision support (CDS) tools offer a promising solution to this issue. By automating the identification process, CDS tools can assist healthcare providers in adhering to best-practice guidelines and improving the quality of care delivered to older adults and others who may benefit from palliative care services. This article explores the development and implementation of a CDS tool, known as Support-ED, designed to enhance primary palliative care within the emergency medicine setting.
Development of the Support-ED Clinical Decision Support Tool
The Support-ED tool emerged from a value-based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. Its creation involved a multidisciplinary approach, ensuring a comprehensive and user-centered design. The development process began with a thorough scoping review of existing ED palliative care screening tools to identify best practices and validated instruments. This review highlighted the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a strong foundation for adaptation. Subsequently, a dedicated workgroup, comprising experts from various disciplines, was established. This group focused on defining specific patient screening criteria and identifying appropriate referral services within the healthcare system. The initial design of Support-ED underwent usability testing, utilizing the System Usability Scale questionnaire to gather feedback and refine the tool’s interface and functionality. Crucially, education and training sessions were conducted for the ED workforce to ensure they understood the background, purpose, and practical application of Support-ED in their daily workflows. Finally, a dashboard was created to monitor the tool’s performance and collect feedback for ongoing improvements.
Key Objectives and Functionality of Support-ED
The multidisciplinary workshops established two core objectives for the CDS tool. Firstly, Support-ED aimed to accurately identify patients presenting to the ED who exhibited indicators of serious life-limiting illness. This identification process is crucial for initiating timely palliative care considerations. Secondly, the tool was designed to facilitate seamless referrals to essential support services, such as specialized palliative care teams or social work, ensuring patients receive comprehensive care beyond the immediate ED visit. The iterative design process led to the development of specific patient scenarios that trigger clinical alerts within the Support-ED system. These alerts are activated in three primary situations: 1) when a patient’s electronic health record indicates the presence of an advance care planning document, signifying pre-existing considerations for end-of-life care; 2) when a patient has a documented history of hospice disposition, suggesting prior engagement with palliative or end-of-life care services; and 3) when a combination of historical and current clinical data points strongly suggests a serious life-limiting illness, even in the absence of an advance care planning document. This multifaceted trigger system ensures a broad yet targeted approach to patient identification.
Outcomes and Modifications for Improved CDS Functionality
Post-implementation monitoring and feedback collection proved invaluable in identifying areas for refinement and optimization of the Support-ED tool. The feedback received indicated a clear need for several modifications to enhance the CDS functionality and ensure its seamless integration into the ED workflow. These modifications were crucial for improving the tool’s effectiveness and user acceptance within the fast-paced emergency department environment.
Conclusion: The Role of CDS Tools in Enhancing Palliative Care Delivery
Clinical decision support tools like Support-ED hold significant potential as effective instruments in the implementation of primary palliative care quality improvement initiatives. By proactively identifying patients who could benefit from palliative care, CDS tools can help healthcare systems bridge the gap between best-practice guidelines and actual clinical practice in the ED. However, it is essential for health systems to thoughtfully tailor their CDS implementations to align with their specific workflows, resources, and patient populations. The lessons learned from the development and implementation of Support-ED offer valuable insights for other health systems seeking to effectively integrate a primary palliative care CDS system into their emergency department processes, ultimately leading to improved care for patients facing serious illness.
Trial Registration
ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.
