key: cord-0721721-x9jhxgjj
authors: Liberman, Tara; Roofeh, Regina; Chin, Jessica; Chin, Kelly; Razack, Bibi; Aquilino, Joseph; Herod, Sarah Healey; Amato, Teresa
title: Remote Advance Care Planning in the Emergency Department During COVID-19 Disaster: Program Development and Initial Evaluation
date: 2021-09-30
journal: J Emerg Nurs
DOI: 10.1016/j.jen.2021.09.006
sha: d9e81915a81a817f902555047c246d1cb01e665a
doc_id: 721721
cord_uid: x9jhxgjj

BACKGROUND: The COVID-19 pandemic caused an unprecedented surge of patients presenting to emergency departments and forced hospitals to adapt to provide care to patients safely and effectively. The purpose here was to disseminate a novel program developed under disaster conditions to address advanced care planning communications. METHODS: A program development and initial evaluation was conducted for the Remote Goals of Care program, which was created for families to communicate patient goals of care and reduce responsibilities of those in the emergency department. RESULTS: This program facilitated 64 remote goals of care conversation, with 72% of conversations taking place remotely with families of patients who were unable to participate. These conversations included discussions of patient preferences for care, including code status, presence of caregivers or surrogates, understanding of diagnosis and prognosis, and hospice care. Initially, this program was available 24 hours per day, 7 days per week, with gradual reduction in hours as needs shifted. 7 nurses who were unable to work in COVID-positive environments but were able to continue working remotely were utilized. Lessons learned include the need for speed and agility of response and the benefit of established relationships between traditionally siloed specialties. Additional considerations include available technology for patients and families and expanding the documentation abilities for remote nurses. A logic model was developed to support potential program replication at other sites. DISCUSSION: Upon initial evaluation, Remote Goals of Care Program was well received and demonstrated promise in in decanting the responsibility of goals of care discussions from the emergency department to a calmer, remote setting. In future iterations, additional services and technology adjustments can be made to make this program more accessible to more patients and families. Other facilities may wish to replicate our Remote Goals of Care Program described here.

established relationships between traditionally siloed specialties. Additional considerations include 25 available technology for patients and families and expanding the documentation abilities for remote 26 nurses. A logic model was developed to support potential program replication at other sites. 27

Discussion: Upon initial evaluation, Remote Goals of Care Program was well received and demonstrated 28 promise in in decanting the responsibility of goals of care discussions from the emergency department 29 to a calmer, remote setting. In future iterations, additional services and technology adjustments can be 30 made to make this program more accessible to more patients and families. Other facilities may wish to 31 replicate our Remote Goals of Care Program described here. 32

Problem Description 37

In late 2019, first reports of human transmission and circulation of the SARS-CoV-2 virus in Wuhan, China began to make global headlines. 1 Those with pre-existing comorbidities, particularly hypertension, cardiovascular disease, diabetes, 46 and chronic obstructive pulmonary disease, are at increased morbidity and mortality for COVID-19. 3, 4 In 47 addition to presence of comorbidities, older age has been identified as a significant risk factor for severe 48 disease and mortality. 5 During the COVID-19 surge in New York, many of the patients presenting to the 49 emergency department were older adults and those with chronic comorbidities. It became imperative 50 during the peak of the pandemic to speak with patients and families and clarify goals of care as an early 51 intervention to help avoid unwanted use of scarce resources. 52

Prior to the onset of the COVID-19 pandemic, Goals of Care (GOC) and Advance Care Planning (ACP) 53 discussions, often including family and loved ones, were standard of care for patients presenting to the 54 hospital with multiple comorbidities, advanced illness, or advanced age. 6, 7 The addition of the COVID-19 55 pandemic magnified the need for GOC and ACP discussions as ensuring goal-concordant care and 56 avoiding unwanted intervention became a pressing concern for most health care systems. 8 Traditionally, 57 GOC and ACP discussions can be an iterative process involving multiple discussions and a significant time 58 investment for clinicians, patients, and families. The COVID-19 pandemic placed additional time and resource pressure on the health care providers who would usually be involved in these conversations 60 due to the increasing volume of high acuity patients presenting to the ED. This led to some clinicians 61 being utilized in roles where they did not have specialty training, including GOC conversations. In 62 addition to the limited providers available, most patients in the emergency department were not able to 63 have family accompany them to admission due to a no visitation rule that was put in place to protect 64 patients, families, and staff. 65

Aims 66

The implications of this new clinical reality required attempts to find alternative routes to conduct 67 these conversations in an innovative manner. Building upon previous strong relationships between the 68 Division of Geriatrics and Palliative Medicine and the Emergency Medicine Service Line, a Remote Goals 69 of Care Program was established to have these vital conversations and facilitate communication with 70 families during the height of the COVID-19 pandemic. 9, 10 The goal of this program was to provide a 71 resource for advance care planning and GOC conversations for patients who may have been unable to 72 have these conversations and who could not have loved ones present to identify their wishes. 73

Design 75 A program development and retrospective evaluation design was utilized. The health system 76 Institutional Review Board approved this study and waived the need for informed consent. Informed 77 consent waiver was approved by the Institutional Review Board as collection and review of patient data 78 was performed via retrospective chart review. 79 Program was developed to continue communication with families of patients in the emergency 93 department to understand the goals and needs of the patients. As a pragmatic choice, this program 94 utilized nurses who were unable to work in COVID-positive environments, but could continue working 95 remotely via telehealth to supplement the clinical resources within the emergency departments (Table  96 1). Initially, the program included 7 Remote Nurses from various specialties, including pain 97 management, medical/surgical, emergency, and operating room nursing. As staffing needs changed in 98 the hospitals, the size of the Remote Goals of Care program was reduced to accommodate. The program 99 began in April 2020 and provided remote goals of care support 24 hours per day, 7 days per week using 100 7 nurses covering 4. Record (EMR), in July 2020. Study data were collected and managed using REDCap electronic data 137 capture tools. 12, 13 138

Deidentified demographic data were collected from the medical record. Primary outcomes included 139 details of early GOC discussion in EDs and disposition after GOC discussions. Goals of Care were defined 140 as Code Status, with options being DNR and/or DNI, and Full code (CPR and intubation desired). Other 141 potential topics of discussion during these conversations included appointment of a health care proxy, 142 diagnosis, treatment, prognosis, chaplaincy, and hospice. 143

Due to the disaster context in which this program was initiated and the retrospective nature of data 145 collection, the study was not designed to provide analysis on statistically significant changes for patient 146 outcomes. To provide context for the patients that were included in the program, demographic details 147 and descriptive statistics are reported. As changes in health outcomes cannot be reported, this program 148 was evaluated based on the logic model provided in Table 1 . 149 150

We included 64 patients for whom a health care professional was consulted to have a remote GOC 152 conversation between April -June 2020. Across the health system, all 64 patient records were reviewed 153 and included for analysis. Table 2 Table 4 presents the disposition outcomes for the patients who received Remote Goals of Care 169 conversations upon presenting to the ED. 80% of patients were admitted to the hospital, 8% died while 170 in the ED, and 10% were discharged from the ED directly to inpatient or home hospice. Of the patients 171 admitted to the hospital from the ED, 28% expired prior to discharge, 28% were discharged to a skilled 172 nursing or assisted living facility, and 19% were discharged to inpatient or home hospice (Figure 2) . Of 173 the patients who died during hospitalization, 55% remained full code after the GOC conversation with 174 the Remote Nurse. Of all patients who had Remote GOC Conversations, 28% were discharged to hospice 175 either from the hospital or directly from the ED. allowing these conversations to occur in the non-traditional, but much calmer, environment of remote 202 tele-health, they could be deeper and more meaningful towards providing goal concordant care, as 203 evidenced by the noteworthy proportion of discharges to hospice for these patients. Establishing and 204 documentation of health care proxies were also vitally important for patients who were later admitted 205 to the hospital, as this documentation clarified appropriate contacts at a time when families were 206 unable to visit patients in the hospital. 207

As hospitals and emergency departments begin to transition back to pre-pandemic operations, this 208

Remote GOC program can continue to be useful for patients presenting to the emergency department 209 who would benefit by GOC conversations prior to inpatient admission. Although these conversations can 210 be lengthy, they are important for directing decision making and connection to appropriate resources 211 directly from the emergency department. This style of remote care provision is also transferable to 212 additional specialties and health care needs. While tele-nursing has been utilized in rural communities 213 for some years, the global pandemic has sparked innovations in telenursing and patient care in a way 214 that is more universal. 15-18 This shift toward increased access to telehealth services is in line with 215 previous programs that are able to provide robust patient care at home, including programs for dialysis 216 and palliative medicine. 19, 20 This Remote GOC program and other telehealth based programs will 217 continue to grow as a viable option for emergency departments as reimbursement for telemedicine 218 evolves and expands. 21, 22 219

This article provides an outline of a Remote Goals of Care program implemented in New York during 220 the height of the first COVID-19 surge. This program was able to gather advanced care planning 221 information and provide goals of care conversations with detail and nuance. This program was especially 222 valuable during the time that families could not accompany patients to the ED setting to provide context 223 for patient wishes. Although this program was pragmatically implemented and was not designed to 224

show statistically significant changes, future studies should examine if these conversations improved adherence to goal concordant care. This program is valuable in that it is easily modifiable and 226 transferable to many settings and specialties and utilizes the telehealth format that will likely continue 227 to grow out of the COVID-19 pandemic. 228

Limitations 229

Although the Remote Goals of Care program was a valuable use of resources during the first surge of 230 the COVID-19 pandemic, there were areas of the program that could be improved upon. First, the 231 technology used was a sometimes significant barrier for patients and families. The communication 232 software utilized by the remote nurses was sometimes difficult to navigate for families outside of the 233 hospital, especially for those who did not have a stable internet connection or familiarity with remote 234 communication software. Within the emergency department, having the remote nurse contact the 235 patient was equally difficult. The hectic ED environment was not conducive to video conferencing and 236 the patients included in this program were mostly older, with less experience with the needed 237 technology and no family to support them. Additionally, patients who had sensory difficulties, including 238 hearing loss, vision loss, or cognitive decline, in addition to their reason for presenting to the emergency 239 department, were less able to participate in conversations. Even when the remote nurses were able to 240 have GOC discussions with families, the staff within the emergency department was still required to 241 contact the families to give status updates regarding the patient during a particularly tense time. ED 242 staff was also required to complete MOLST documentation within the emergency department, as these 243 forms are still completed on paper and require the presence of the patient or family to complete. 244

Although an electronic MOLST process is available in New York State, it is not currently utilized by the J o u r n a l P r e -p r o o f 

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The authors have no disclosures or conflicts of interest to report