key: cord-0888631-hlhwmlfu authors: Dundin, Andrew; Siegert, Callie; Miller, Diane; Ouchi, Kei; Lakin, Joshua R.; Bernacki, Rachelle; Sciacca, Kate title: A Pivot to Palliative: An Interdisciplinary Program Development in Preparation for a Coronavirus Patient Surge in the Emergency Department date: 2020-08-22 journal: J Emerg Nurs DOI: 10.1016/j.jen.2020.08.003 sha: 92eca90da8083787665fef7fdfc382cfe0522c0b doc_id: 888631 cord_uid: hlhwmlfu nan Contributions to Emergency Nursing Practice 1 2 • Literature related to palliative care in the emergency department highlights the prominent 3 need for emergency nurses and palliative care clinicians to better understand their 4 respective roles and responsibilities to improve palliative care for emergency department 5 patients. 6 • The primary outcomes of this project were to develop a program template, process and 7 educational and support resources for emergency nurses focused on improving palliative 8 care in the emergency department during the COVID pandemic. 9 • Key implications for emergency nursing practice include the potential to tailor, replicate, 10 and test our program to improve palliative care in other emergency department settings. As the coronavirus pandemic continues to unfold in the United States, the healthcare 26 sector faces harrowing challenges of overloaded systems, unknown viral impact and considerable 27 mortality. American healthcare institutions must tailor a swift and strategic response at their local 28 facilities to ensure high quality and compassionate patient care. In the pandemic timeline, 29 Massachusetts was several weeks behind the patient surges that occurred in Seattle and New 30 York City. Witnessing the severe system strain from these cities, Massachusetts hospitals' 31 disaster plans included deploying resources and clinicians in novel ways. One of our hospital's 32 strategies involved an increased focus on the role of palliative care in the ED setting. 33 While numbers are still emerging, the demographics of COVID patients in Massachusetts 34 are overrepresented by patients from nursing homes, those over the age of 70, and those with 35 racial and ethnic minority identities 1 . As elderly patients with multiple comorbidities are at an 36 increased risk of death 2,3 ,an extreme demand on our local healthcare system was anticipated 37 with this influx of patients potentially needing end-of-life (EOL) care. 38 Brigham & Women's Hospital is a 793-bed, Harvard-affiliated, Magnet-recognized 39 hospital located in the Longwood Medical Area of Boston. Its 60-bed, Level 1, emergency 40 department sees 63,000 patient visits annually and services patients from metro Boston, 41 throughout the nation, and from 120 countries. As a leader in the Boston healthcare network and 42 a care provider for a dense, urban setting measures needed to be taken quickly as the coronavirus 43 pandemic evolved. In response to a potential patient surge and as part of pandemic disaster 44 planning, we projected that rapid collaboration between palliative care and emergency 45 department staff was needed to meet the needs of critically ill, COVID positive patients 46 presenting to the emergency department. We developed a multi-pronged program designed to 47 provide optimal care for COVID-positive patients in our large, metropolitan emergency 48 department. The program, program tools, and program development process are provided here to 49 serve as a guide for emergency clinicians, palliative nurses, nurse practitioners, and nursing 50 leadership looking to establish similar programs within their institutions. 51 Palliative care is specialized healthcare for people with serious illnesses. Palliative care 53 focuses on providing symptom relief, communication, and psychosocial/spiritual support with 54 the goal of improving quality of life for patients and their families 4 . While end-of-life (EOL) care 55 is one element of this specialty, palliative care and EOL care are not synonymous. Palliative care 56 involvement is appropriate at any stage of serious illness, providing an extra layer of support in 57 conjunction with treatment provided by other medical teams 5 .Palliative care aims to alleviate 58 suffering, a shared goal of emergency department clinicians. Despite this shared goal, a 59 knowledge gap exists regarding the optimal delivery of palliative care in the emergency 60 department 6 . Models of palliative care delivery differ between institutions depending on 61 department size and volume, and currently optimal models of department-based palliative care 62 have not been rigorously studied 6 . 63 The priority focus of emergency nursing has traditionally been geared towards lifesaving 64 and life-sustaining interventions. A fast-paced setting, the emergency department is characterized 65 by rapid throughput processes which can hinder the necessary nurse-patient empathic bonding 66 that enables effective palliative care 7 . In addition to these obstacles, the perception of palliative 67 care in the emergency department presents a challenge to collaboration between the specialties. The ENA has identified the need for additional palliative and EOL education and 79 mentorship, calling upon emergency nurses to be directly involved in quality improvement 80 initiatives around palliative care and EOL care across the care continuum 10 . Similar initiatives 81 also exist in emergency medicine. The American College of Emergency Physicians (ACEP) has 82 developed online resources and tools for their members, seeking to support ED physicians in 83 providing palliative care 11 . 84 In addition to professional calls to action formal work has been done in the interest of 85 greater collaboration between emergency care and palliative care. An integrative program has 86 been developed called The Improving Palliative Care in Emergency Medicine (IPAL-EM) 87 project which guides ED providers to incorporate palliative care into standard practice 12 . 88 Aligning with the IPAL-EM basic and advanced integration categories, we sought out ways 89 through our program to connect emergency and palliative care clinicians with shared a common 90 goal via novel processes and protocols 12 . Our workgroup's overarching goal was to support 91 emergency nurses during a COVID patient surge in providing compassionate patient care (both 92 J o u r n a l P r e -p r o o f palliative and EOL) through the development and implementation of educational and clinical 93 support tools. 94 In anticipation of a COVID patient surge, emergency department and palliative care 96 leaders (nurses, nurse practitioners, physicians, and social workers) identified the need for swift 97 collaboration between the two departments. Our interdisciplinary group worked to understand 98 the workflow of both the emergency department and the palliative care consult services, and to 99 identify and address knowledge and practice gaps. The initial work group included physician 100 leaders from both the emergency department and palliative care, a staff nurse from the 101 emergency department, and a palliative care nurse practitioner (NP). Our collaborative strategy 102 embraced two of the four tenets recommended by the IPAL-EM toolkit including 1) launching a 103 palliative care initiative addressing department-specific palliative care needs and deficiencies, 104 and 2) recruiting ED-palliative care champions to participate in the work 12 . 105 The emergency nurse and the palliative care NP worked together to identify ED-specific 106 nursing concerns. To better understand these concerns the palliative care NP and emergency To date there has been no surge of EOL-specific care in our emergency department as 145 had been anticipated during the disaster planning. The specific deliverables from our process 146 included a template for improving palliative care access in the emergency department and the 147 educational/ clinical support tools. Table 1 . highlights each educational and support tool, its 148 description and access method. Our digital resources can be accessed online at 149 www.pallicovid.app. Appendix A provides an example of one of our clinical support tools to 150 assist emergency nurses with EOL symptom management. Table 2 . provides a logic model for 151 the reader to guide in the replication of our program. Our program has included the development 152 and implementation of tools and support mechanisms as indicated but has yet to execute 153 evaluation metrics at this time. The strengths of our program include our rapid cycle learning and adaption process, the 203 comprehensive support provided through our 24-hr/7-days-a-week palliative nurse coverage and 204 the development of educational and clinical support tools available to nurses in hard copy or 205 digital format. A rapid cycle learning process, accomplished in our program through our in-206 J o u r n a l P r e -p r o o f person clinician rounding and bi-weekly team meetings, is identified in the literature as the 207 process that may be best suited for quickly developing new interventions in uncertain and 208 changing times 16,17 . The 24-hr/7-days-a-week palliative support model was also utilized in New 209 York with positive outcomes as our program also experienced 18 . Educational and clinical 210 support tools to address symptom management are a shared focus of other institutions working to 211 support emergency nurses 19 . 212 Challenges and barriers to collaboration and implementation of this program included 213 factors that are commonplace e.g. clinician time and availability to contribute to the program. 214 The challenge of launching a program in the emergency department was threatened by a lack of 215 initial emergency nursing leadership focus due to competing concerns in the department related 216 to COVID-19. Leadership buy-in is recognized as a critical component of success 17 and was 217 ultimately provided to our program throughout our process. In addition to time and attention, 218 space and physical access to the emergency department presented a problem as workgroup 219 meetings were hindered by physical distancing, and concerns around infection control and PPE 220 utilization. This is a current challenge for many in the healthcare sector and technology has been 221 utilized to address these concerns 20 . A virtual meeting platform was easily utilized for our 222 emergency department/palliative care workgroup sessions. 223 Evaluation metrics for our program have not been formally executed at this time due to 224 limitations related to COVID-19. We found that evaluation of rapidly implemented initiatives 225 and interventions is a shortcoming for many during COVID times and is an area of increased 226 study 16, 17, 21, 22 . Our shared logic model presents a list of recommended metrics that could be 227 preferences with a lack of patient family/support presence, and with limited training regarding 283 palliative care principles. As the role of palliative care in the emergency department has been 284 explored, yet not well defined, palliative care clinicians were also challenged to learn the 285 workflow and practices of the emergency department to best serve this patient population. In this 286 publication, we have provided a template of our process aimed to improve palliative care 287 delivery in the emergency department through educational and support resources. Rapid learning 288 processes and communication between nurse representatives from the two specialties allowed for 289 the development of both in-the-moment support and educational tools. The implementation of 290 this program demonstrates that an interdisciplinary and collaborative approach to addressing 291 these challenges can yield a supportive program during a COVID positive patient surge, while 292 developing a working relationship between emergency nursing and palliative care. By working 293 together in a crisis, nurses within these two specialties found a path to supporting patient care 294 that will last beyond the pandemic itself. 295 Institute for Healthcare Improvement (IHI). (n.d.) How To Improve Working on working together. A 348 systematic review on how healthcare professionals contribute to interprofessional 349 collaboration Increasing Critical Care Nurse 352 Engagement of Palliative Care During the COVID-19 Pandemic Quality and safety in the time of Coronavirus: design better, learn 355 faster Quality 358 improvement during the COVID-19 pandemic A 361 beacon for dark times: palliative care support during the coronavirus pandemic End-of-life care in the Emergency Department for the patient imminently 366 dying of a highly transmissible acute respiratory infection Innovation in response to the COVID-19 pandemic 370 crisis The State of Health Care Quality Measurement in 372 the Era of COVID-19: The Importance of Doing Better Informing emergency care for COVID 19 patients: The COVID 19 Emergency Department Quality Improvement Project protocol Evaluation 379 tools for interdisciplinary palliative care learning experiences: a literature review Decisions by default: incomplete and contradictory MOLST in emergency care The authors wish to thank Dr. Jessica Castner, PhD, RN-BC, FAEN, FAAN for her 297 critical review and invaluable guidance in finalizing this manuscript.