Research Note: Continuing care and emergency medical services: A collaborative approach for urgent end of life care in the community

By | 16th May 2017
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Continuing care and emergency medical services: A collaborative approach for urgent end of life care in the community
Julia Arsenault MAHSR, NP; Carmel Montgomery MN, RN; Colleen Berean MHS, RN; Charlotte Pooler PhD, RN; Cheryl Cameron MEd ACP; Robert Sharman MA, RN, ACP; Ingrid de Kock DA, MBChB
Alberta Health Services. Edmonton, Alberta, Canada
Contact: julia.arsenault@ahs.ca

Introduction

The aim of palliative and end of life (PEOL) care is to relieve suffering and to improve the quality of life of people with a progressive life-limiting or life-threatening illness.  Increased supports and services are often required for this population, as symptoms can intensify near the end of life.  For palliative patients in the community, this may include emergency department (ED) visits and acute care admissions to manage symptoms or unexpected events.
Alberta Health Services (AHS) is an integrated provincial health system in Canada that encompasses acute care services, community care programs, and emergency medical services (EMS).  Within the Edmonton Zone of AHS, which serves a population of approximately 1.4 million in urban, suburban, and rural areas, PEOL care is provided within the community in diverse residential homes and facilities.  Although 75-85 % of Albertans prefer home as the place of care at end of life, 65-75 % of patients die in hospital (Alberta Service Alberta, 2012).  Palliative patients in the community are at risk for visits to the ED and acute care admissions when their symptoms and other palliative needs cannot be met in a timely manner.  However, the ED environment is usually not best suited to manage acute symptom issues of this patient population: ED visits may result in long wait times, EDs often lack privacy to have sensitive conversations, and the ED treatment focus may be incongruent with the patient’s goals of care.
Prior to the start of the initiative, chart reviews and a literature review were conducted. PEOL patients in the Edmonton Zone between 2009 and 2012 had an average of 2-4 ED visits and 1.6 acute care admissions in the last six months of life.  A detailed chart review of patients admitted to two community hospitals within a six week period demonstrated the primary reason for admission was shortness of breath, followed by weakness and/or falls.
There is scant information on collaboration or initiatives with paramedicine in the community. Mercandante et al (2012) reported characteristics of emergency calls to a palliative care team over 6 months for 689 patients in three home care programs: of the 118 first emergency calls, the three primary reasons were dyspnea, pain, and delirium. A collaboration amongst EMS and a community palliative network in France demonstrated respect of the care plan in 83% of emergency situations, compared to 40% without collaboration (Burnod et al., 2012).
Patients in the community are at risk of needing urgent care in the last six months of life.  An Australian study found that in the last 108 days of life, 96% of patients with a palliative diagnosis required a hospital visit and two thirds required hospital admission (Rosenwax et al, 2011).  In Ontario, Canada, 33% of the 91,561 patients who died of cancer between 2002 and 2005 visited the ED during the final two weeks of life (Barbera, Taylor, & Dudgeon, 2010).  However, as many authors have discovered, not all emergency visits are necessary, and there is interest in understanding both reasons for visits and potential for avoidance (Barbera et al., 2010; Burnod et al., 2012; Delgado-Guay et al., 2015; Mercedante et al., 2012; Rosenwax et al., 2011; Smith et al., 2012).
There are physical, emotional, spiritual, and social benefits of enabling patients and families to participate in the choice to remain in the home or to be transported to an ED.  To address present challenges and enhance capacity to meet future needs of the PEOL population, innovative strategies to support patients in the community are needed.
Innovation
In a report by the Health Quality Council of Alberta (2012), recommendations were made that “AHS continue with innovative solutions to support palliative care patients in their community setting” and provide “options for immediate care at home that can obviate the need to go to an emergency department, and support the patient and family’s decision to remain at home” (p. 11).  A protocol was developed by AHS Calgary Zone in which EMS assisted with management of unexpected pain crises in identified palliative patients in the community.  Based on the chart review and existing programs, a collaborative initiative was undertaken by AHS Edmonton Zone Continuing Care and EMS to manage PEOL patients at home when they experienced a symptom event that was urgent but not emergent.  The primary goals of this quality improvement initiative were to provide the right care at the right location and to meet the patient and family’s wishes. In addition, the initiative was expected to reduce unnecessary ED and hospital admissions; facilitate staff and physician engagement and collaboration; and identify frequent causes and outcomes of palliative patients’ needs for urgent care.
The PEOL Care and Treat in Place initiative was implemented in February of 2013. A pilot was launched in a limited geographic area with activation by either registered nurses (RN), nurse practitioners (NP) or registered respiratory therapists (RRT). Three months later, the initiative was expanded to include all PEOL patients receiving care in the community across the Edmonton Zone, with activation by Continuing Care regulated healthcare professionals for identified palliative patients who either received home care or were in assisted living homes.
The Continuing Care healthcare professional assessed the need for urgent care and called the EMS deployment manager, who dispatched an ambulance without lights or sirens. The paramedic arrived at the patient’s home and collaborated with the healthcare professional in providing care and treatment within their respective scopes of practice. If indicated, the paramedic obtained direction from an emergency consult physician who also had access to a palliative care physician on call.  When it was possible, the patient remained at home and ongoing care was managed by the healthcare professional.  Communication with the primary care provider (family physician or nurse practitioner) was ongoing and reactivation was possible until the necessary longer term resources were arranged (e.g. home oxygen or repeat medication administration). It is important to note that if the situation became emergent, transport to hospital was an option.
A multifaceted and collaborative approach to education was delivered to the Continuing Care and EMS staff and physicians.  A combination of written materials and face to face presentations were utilized. Tracking of events was done both manually and electronically, however, not all activations were captured in the data collection because reporting of the calls was dependent on front-line staff and appropriate coding by EMS.
Between June 2013 and December 2014, there were 110 known activations. The median time between these calls and patients’ death was 9 days, which demonstrates these patients were in the last stage of life. The majority of activations were by the RN in the patient’s home during a palliative symptom crisis, with an EMS response time of approximately 15 minutes. There were various reasons for calling EMS, such as nausea, delirium, and lift assistance. The most common reason was for pain (31%), followed by dyspnea (24%).  Treatments were consistent with a palliative approach to symptom management: opioids and oxygen were used for dyspnea; opioids for pain; intravenous or subcutaneous fluids and anti-emetics were used for dehydration and nausea. In accordance with patients’ preferences and symptom management, the majority of calls (60%) resulted in patients staying at home.  The calls which resulted in transport (40%) were a result of the healthcare professionals’ assessment and recognition of the need for emergency care and acute care resources; the paramedics collaborated to provide patient-centered care to ensure comfort prior to transport. Patients and family members who were treated and remained at home rated high satisfaction with the initiative by survey.
Discussion
As anticipated, the majority of symptoms and conditions did not require a visit to the ED. The requirement of a healthcare professional in the home limited the number of calls, however also facilitated clinical judgement and collaboration. Some RNs modified the approach by activating the initiative for treatment and transfer to the ED when they recognized that a patient required emergency care but not a “911” lights and sirens approach, which affected the percentage of those transferred. One of the most valuable outcomes of the initiative was due consideration and discussion of the patient’s wishes to have symptom treatment at home or be transported to hospital.
In summary, this initiative enabled collaboration and innovation among and across sectors, including community care programs, EMS, and primary care. As of April 2015, this initiative expanded across the province of Alberta and continues to evolve. Opportunities were created to enable palliative patients to remain at home or be transported to ED as appropriate.
References
Alberta Service Alberta (2012).  Alberta vital statistics: Annual review. Retrieved from https://open.alberta.ca/dataset/691ec9c3-35b6-4068-86b7-c04d85b073e2/resource/075a7313-ab27-4e05-94d9-0384bd1276f4/download/2664467-2012-AB-Vital-Statistics-Annual-review.pdf
Barbera, L., Taylor, C., & Dudgeon, D. (2010). Why do patients with cancer visit the emergency department near the end of life? Canadian Medical Association Journal, 182(6), 563-568.
Burnod, A., Lenclud, G., Ricard-Hibon, A., Juvin, P., Mantz, J., & Duchateau, F. X. (2012). Collaboration between prehospital emergency medical teams and palliative care networks allows a better respect of a patient’s will. European Journal of Emergency Medicine, 19(1), 46-47.
Delgado-Guay, M. O., Kim, Y. J., Shin, S. H., Chisholm, G., Williams, J., Allo, J., & Bruera, E. (2015). Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care. Journal of Pain and Symptom Management, 49(3), 497-504.
Health Quality Council of Alberta (2012).  Review of the quality of care and safety of patients requiring access to emergency department care and cancer surgery and the role and process of physician advocacy. Calgary, Alberta: Author.
Mercadante, S., Porzio, G., Valle, A., Aielli, F., Costanzo, V., Adile, C., … & Group, H. C. I (2012). Emergencies in patients with advanced cancer followed at home. Journal of Pain and Symptom Management, 44(2), 295-300.
Rosenwax, L. K., McNamara, B. A., Murray, K., McCabe, R. J., Aoun, S. M., & Currow, D. C. (2011). Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care. Medical Journal of Australia, 194(11), 570-573.
Smith, A. K., McCarthy, E., Weber, E., Cenzer, I. S., Boscardin, J., Fisher, J., & Covinsky, K. (2012). Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Affairs, 31(6), 1277-1285.

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