P011: Discerning perceived barriers and facilitators to goals of care discussion in the emergency department: A survey of emergency physicians and residents

Introduction: Patients presenting to the Emergency Department (ED) may require clarification of their goals of care (GOC) to ensure they receive treatments aligned with their values. However, these discussions can be difficult to conduct for multiple reasons, including lack of time in a busy ED, competing priorities and a limited relationship with the patient. Few studies have examined the perceived challenges faced by Emergency Physicians in conducting GOC discussions. This study sought to contextualize and discern the barriers and facilitators to having these conversations as reported by Emergency physicians. Methods: An interdisciplinary team of Emergency Medicine, Palliative Care and Internal Medicine providers developed an online survey comprised of multiple choice, Likert-scale and open-ended questions to explore four domains of GOC discussions: training; communication; environment; and personal beliefs. Invitations and scheduled reminders were sent to 275 ED physicians at six academic sites in a Canadian urban centre, including 49 EM residents. Results: 105 (46%) staff physicians and 23 (47%) residents responded with similar representation from all sites. Differences were reported in the frequency of GOC discussions: 59% of staff physicians conduct several per month whereas 65% of residents conduct less than one per month. Most agreed that GOC discussions are within their scope of practice (92%), they feel comfortable (96%), and are adequately trained (73%) to have them; however, 66% reported difficulty initiating GOC discussions. 73% believed that admitting services should conduct GOC discussions, yet acuity was noted in the comments as a major determinant with initiating GOC discussions by ED physicians. Main barriers identified were lack of time, chaotic environment, lack of advanced directives and the inability to reach substitute decision makers. 54% of respondents indicated that the availability of 24-hour Palliative Care consults would facilitate GOC discussions in the ED. Conclusion: Emergency physicians are prepared to conduct goals of care discussions, but often believe they should instead be conducted by the patient’s admitting service. Multiple perceived barriers to goals of care discussion in the ED were identified, and a majority of respondents felt that the availability of Palliative Care in the ED may facilitate these discussions.

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Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents

CJEM ◽

10.1017/cem.2018.371 ◽

2018 ◽

Vol 21 (2) ◽

pp. 211-218 ◽

Cited By ~ 8

Author(s):

Niran Argintaru ◽

Kieran L. Quinn ◽

Lucas B. Chartier ◽

Jacques Lee ◽

Paul Hannam ◽

...

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Palliative Care ◽

Descriptive Analysis ◽

Perceived Barriers ◽

Barriers And Facilitators ◽

Environmental Interventions ◽

Goals Of Care ◽

Care Services ◽

Palliative Care Services

AbstractObjectiveFew studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.MethodsA team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.ResultsSurveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).ConclusionsImportant barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

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Comfort Discussing HIV Pre-Exposure Prophylaxis with Patients Among Physicians in an Urban Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.1112 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S439-S439 ◽

Cited By ~ 2

Author(s):

Brett Tortelli ◽

Douglas Char ◽

William Powderly ◽

Rupa Patel

Keyword(s):

At Risk ◽

Emergency Department ◽

Online Survey ◽

The United States ◽

Emergency Physicians ◽

Primary Care Specialty ◽

Risk Patients ◽

Prep Awareness ◽

Exposure Prophylaxis ◽

Current Guidelines

Abstract Background HIV pre-exposure prophylaxis (PrEP) is effective but underutilized in the United States. The emergency department offers an opportunity to access at-risk individuals for PrEP referral. While several studies have described provider awareness and acceptance of PrEP, these studies have focused largely on infectious diseases, HIV, and primary care specialty physicians. Thus, PrEP awareness, knowledge, and concerns among emergency physicians remain unknown. We sought to determine provider comfort in discussing PrEP with patients among emergency physicians in Missouri. Methods We conducted an online survey among 88 emergency physicians at Washington University in St. Louis from February 2017 to March 2017 in St. Louis, Missouri. The survey included demographics, comfort discussing PrEP, having ever heard of PrEP (awareness), knowledge of the current CDC prescribing guidelines, concerns with use, and knowing local PrEP referral information. The questions were asked on a Likert scale and dichotomously categorized. We evaluated predictors of physician comfort of discussing PrEP with patients using multiple logistic regression. Results Sixty-seven participants completed the survey; 64.1% were faculty. Most (79.1%) were PrEP aware, however, only 23.9% were knowledgeable of current guidelines and 22.7% of referral information. Concerns included lack of efficacy (53.7%), side effects (89.6%), and the selection for HIV resistance (70.1%). Comfort discussing PrEP was 43.3%. When adjusting for the concern of efficacy, having PrEP knowledge (OR: 5.43; CI: 1.19–30.81) and having referral knowledge (OR: 7.82; CI: 1.93–40.98) were significantly associated with comfort in discussing PrEP. Conclusion We found moderate PrEP awareness among emergency physicians, but also high levels of discomfort in discussing PrEP with their patients. Future provider training should include addressing misinformation surrounding the concerns with PrEP use and prescribing, reviewing current guidelines, and providing local referral resources for PrEP patient care. Emergency department settings can facilitate PrEP awareness and referral to care among at-risk patients to help reduce national HIV incidence. Disclosures All authors: No reported disclosures.

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Bedside emergency department ultrasonography availability and use for blunt abdominal trauma in Canadian pediatric centres

CJEM ◽

10.2310/8000.2011.110475 ◽

2012 ◽

Vol 14 (01) ◽

pp. 14-19 ◽

Cited By ~ 3

Author(s):

Robin Cardamore ◽

Joe Nemeth ◽

Christine Meyers

Keyword(s):

Emergency Department ◽

Abdominal Trauma ◽

Blunt Abdominal Trauma ◽

Positive Impact ◽

Pediatric Trauma ◽

Great Majority ◽

Pediatric Emergency ◽

Perceived Barriers ◽

Emergency Physicians ◽

The Future

ABSTRACT Objectives: To quantify the current availability and use of bedside emergency department ultrasonography (EDUS) for blunt trauma at Canadian pediatric centres and to identify any perceived barriers to the use of bedside EDUS in such centres. Methods: An electronic survey was sent to 162 pediatric emergency physicians and 12 site directors from the 12 pediatric emergency departments across Canada. Results: Ninety-two percent (11 of 12) of centres completed the survey. The individual physician response rate was 65% (106 of 162), with 100% of site directors responding. Ultrasound machines were available in 45% (5 of 11) of centres. Forty-two percent (32 of 77) of emergency physicians working in equipped pediatric centres used bedside EDUS to evaluate blunt abdominal trauma (BAT). In the subgroup of staff who also worked at adults sites, the frequency of ultrasonography use for the evaluation of pediatric BAT was 75%. In the 55% (6 of 11) of centres without ultrasonography, 88% of staff intend to incorporate its use in the future and 81% indicated that they believed the incorporation of ultrasonography would have a positive impact on patient care. The main perceived barriers to the use of ultrasonography in the evaluation of BAT were a lack of training (41%) and a lack of equipment (26%). Conclusion: Bedside EDUS is currently used in almost half of pediatric trauma centres, a frequency that is significantly lower than adult centres. Physicians in pediatric centres who use ultrasonography report that it has a high utility, and a great majority of physicians at pediatric centres without EDUS plan to incorporate it in the future. The main reported barriers to its use are a lack of training and a lack of equipment availability.

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Death in the Emergency Department: A Retrospective Analysis of Mortality in a Swiss University Hospital

Emergency Medicine International ◽

10.1155/2019/5263521 ◽

2019 ◽

Vol 2019 ◽

pp. 1-9

Author(s):

Eric P. Heymann ◽

Alexandre Wicky ◽

Pierre-Nicolas Carron ◽

Aristomenis K. Exadaktylos

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Palliative Care ◽

Retrospective Analysis ◽

Clinical Severity ◽

University Hospital ◽

Advanced Directives ◽

Risk Of Death ◽

Public Data ◽

Patients At Risk

Acute treatment in emergency medicine revolves around the management and stabilization of sick patients, followed by a transfer to the relevant medical specialist, be it outpatient or inpatient. However, when patients are too sick to be stabilized, i.e., when the care provided in the Emergency Department (ED) may not be sufficient to enable transfer, death may occur. This aspect of emergency medicine is often overlooked, and very few public data exist regarding who dies in the ED. The following retrospective analysis of the mortality figures of a Swiss university hospital from January 1st 2013 to December 31st 2016 attests to the fact that with an incidence of 2.6/1,000, death does occur in the ED. With a broad range of aetiologies, clinical severity at presentation has a high correlation with mortality, a finding that reinforces the necessity of good triage system. Our analysis goes on to show that however (in)frequent death in the ED may be, there exists a lack of advanced directives in a majority of patients (present in only 14.8% of patients during the time of study), a worrying and often challenging situation for Emergency Medicine (EM) teams faced with premorbid patients. Furthermore, a lack of such directives may hinder access to palliative care, as witnessed in part by the fact that palliative measures were only started in 16.6% of patients during the study. The authors hope this study will serve as a stepping stone to promote further research and discussion into early identification methods for patients at risk of death in the ED, as well as motivate a discussion into the integration of palliative care within the ED and EM training curriculum.

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Emergency Department Nurses' Perceived Barriers and Facilitators to Caring for Stroke Patients

Journal of Neuroscience Nursing ◽

10.1097/jnn.0b013e318235b30f ◽

2011 ◽

Vol 43 (5) ◽

pp. 244-245

Author(s):

&NA;

Keyword(s):

Emergency Department ◽

Perceived Barriers ◽

Barriers And Facilitators ◽

Stroke Patients ◽

Emergency Department Nurses

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P020: Paramedic comfort with providing palliative support: pre-implementation survey

CJEM ◽

10.1017/cem.2016.196 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S84-S85

Author(s):

A. Carter ◽

M. Arab ◽

M. Harrison ◽

J. Goldstein ◽

J. Jensen ◽

...

Keyword(s):

Palliative Care ◽

Crisis Management ◽

Online Survey ◽

Training Session ◽

Likert Scale ◽

Point Scale ◽

Goals Of Care ◽

And Training ◽

Healthcare Need ◽

Do So

Introduction: Paramedics are sometimes called for crisis management and relief of symptoms or for patients receiving palliative care. To address the mismatch between the system protocols and resources, and patient’s goals of care, a new protocol, new medications, and an 8-hour training program Learning Essentials Approach to Palliative Care (LEAP) were implemented in our provincial EMS system. Methods: Prior to attending their training session paramedics received an invitation to complete an online survey regarding their comfort, confidence, and attitudes toward delivering palliative care. Comfort and confidence questions were scored on a 4-point Likert scale, while attitudes toward specific aspects of care were scored on a 7-point Likert scale. Descriptive statistics were calculated. Identifiers will permit linkage of these responses to a repeat survey post-implementation. Results: 188 (58%) paramedics completed the survey of the 325 who opened the link. 134 (68%) were male with a mean age of 38.5 years. 95 (50%) were primary care paramedics. The average experience as a paramedic was 12.7 years, with an estimated mean number of palliative calls per year of 9.6 each. On a 4 point scale, most (156, 83%) were comfortable with providing care to someone with palliative goals, and 130 (69.1%) were comfortable providing care without transport. Only 82 (43.6%) were confident they had the tools to deliver this care, and 76 (40.4%) were confident they could do so without transport to hospital. On a 7 point scale, paramedics disagreed with the statement “caring for dying persons is not a worthwhile experience for me”, median 7 (IQR 5-7). Paramedics also disagreed with the statement “Dying persons make me feel uneasy”, median 5 (IQR 4-6). Conclusion: Prior to the implementation of the new protocol, medications, and training, most paramedics were comfortable with the concept of providing care with palliative goals and felt that caring for dying persons is a worthwhile experience, but they were not confident that they have the tools and resources to do so. This suggests paramedics would be open to system improvements to meet an unmet healthcare need for crisis management of patients with palliative goals of care.

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What’s in a name? A qualitative exploration of what is understood by “palliative care” in the emergency department

Palliative Medicine ◽

10.1177/0269216314560801 ◽

2015 ◽

Vol 29 (4) ◽

pp. 293-301 ◽

Cited By ~ 18

Author(s):

Jennifer Weil ◽

Tracey J Weiland ◽

Heather Lane ◽

George A Jelinek ◽

Mark Boughey ◽

...

Keyword(s):

Emergency Department ◽

Palliative Care ◽

Focus Groups ◽

Advanced Cancer ◽

Emergency Departments ◽

Healthcare Professionals ◽

Emergency Physicians ◽

Emergency Nurses ◽

Telephone Interviews ◽

Palliative Care Services

Background: The understanding of what palliative care is, and which patients may benefit from palliative care, has important implications for optimal patient care in all areas of health provision. Aim: To explore the understanding of palliative care by healthcare professionals caring for patients with advanced cancer attending emergency departments. Design: Qualitative study, with two phases: the first, a series of focus groups with healthcare professionals from various disciplines and settings caring for patients with advanced cancer presenting to emergency departments; the second, semi-structured telephone interviews with emergency healthcare professionals across Australian States and Territories, including outside metropolitan centers. The data were audio-recorded and transcribed, with analysis undertaken using a qualitative thematic analysis. Setting/participants: Saturation of themes was reached after 8 focus groups (22 emergency nurses, 21 emergency physicians, 6 oncologists, 6 hospital palliative care clinicians, and 28 community palliative care clinicians) and 11 telephone interviews (8 emergency physicians and 3 emergency nurses), a total of 94 participants. Results: The overarching theme was that healthcare professionals held contradictory understandings of palliative care and its application in the emergency department; subthemes highlighted these inconsistencies when the term “palliative” is used, in understandings of and engagement with palliative care services and in perceptions about the practical utility of palliative care. Conclusion: There are entrenched contradictions and tensions surrounding the term “palliative care”; confronting these is likely to require more than re-branding, and will promote better care for this vulnerable patient group in the emergency department.

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