The emergency department (ED) serves as a crucial point of care for individuals facing serious, life-limiting illnesses. Identifying patients within this setting who could benefit from palliative care is often challenging, relying heavily on individual provider recognition. To address this, the implementation of a clinical decision support (CDS) tool offers an automated solution to improve the identification process, ensuring that more patients receive timely and appropriate palliative care. This approach not only streamlines adherence to best practice guidelines but also significantly enhances the quality of care delivered in the fast-paced environment of the ED.
The Primary Palliative Care for Emergency Medicine (PRIM-ER) study was initiated to explore and optimize the use of electronic health records in this context. The core objective was to develop a CDS tool capable of pinpointing high-risk patients who are most likely to benefit from primary palliative care. This tool is designed to provide immediate, point-of-care clinical recommendations, directly within the existing electronic health record system, to support clinicians in making informed decisions about palliative care integration.
The development of the Emergency Department Supportive Care Clinical Decision Support (Support-ED) tool was a key component of a value-based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health. This project adopted a multidisciplinary strategy, beginning with a comprehensive scoping review of existing ED palliative care screening tools. A dedicated workgroup was then formed, bringing together diverse expertise to define patient screening criteria and identify suitable referral services. The initial design of Support-ED underwent rigorous usability testing, evaluated through the System Usability Scale questionnaire. Crucially, the ED workforce received thorough education on the rationale, objectives, and practical application of Support-ED. Finally, a monitoring dashboard was established to continuously track the tool’s performance and facilitate ongoing feedback and refinement.
The scoping review phase highlighted the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a robust, validated instrument that could be effectively adapted for the CDS tool. Multidisciplinary workshops further clarified the primary goals of the CDS: first, to accurately identify patients exhibiting indicators of serious life-limiting illnesses, and second, to facilitate seamless referrals to essential support services, including palliative care and social work. The iterative design process refined the CDS tool to trigger clinical alerts based on three specific patient scenarios. These include: 1) the presence of an advance care planning document, signaling pre-existing patient preferences; 2) a prior hospice disposition, indicating previous engagement with end-of-life care; and 3) the presence of historical and/or current clinical data indicative of a serious life-limiting illness, particularly when no advance care planning document is on record. Ongoing monitoring and feedback mechanisms have been essential in identifying areas for improvement, leading to several modifications aimed at enhancing the CDS tool’s overall functionality and user experience within the ED workflow.
In conclusion, clinical decision support tools represent a valuable asset in the effective implementation of primary palliative care best practices within the emergency department setting. Healthcare systems aiming to integrate such tools should carefully consider the importance of tailoring their CDS solutions to align with their specific workflows and operational environments. The experiences and findings from the Support-ED development and implementation offer valuable insights for other health systems seeking to seamlessly integrate a primary palliative care CDS system into their existing care processes, ultimately improving patient outcomes and experiences.
Trial registration: ClinicalTrials.gov Identifier: NCT03424109.
