Screening Tool for Identifying Patients in Need of Palliative Care: Enhancing Emergency Department Practices

Introduction

The emergency department (ED) is increasingly becoming a critical point of care for individuals grappling with life-limiting illnesses. These patients often experience frequent hospital admissions, enduring poorly managed symptoms and undergoing treatments that offer minimal benefit. Palliative care (PC) has emerged as a specialized field dedicated to enhancing the quality of life for patients and families facing advanced illness. Studies have consistently demonstrated that palliative care interventions lead to improved symptom management, enhanced quality of life, and more efficient healthcare resource utilization. However, a significant challenge remains: identifying patients within the ED setting who would most benefit from palliative care services. Currently, there is a lack of validated and readily applicable screening tools for who needs palliative care within the emergency department environment. This gap in identification often results in missed opportunities to provide timely and effective palliative care, potentially leading to unnecessary suffering and increased healthcare costs.

The Need for a Palliative Care Screening Tool in the Emergency Department

The necessity for effective screening tools for who needs palliative care in the ED stems from several critical factors. Emergency departments are designed for acute care, often focusing on immediate stabilization and diagnosis. This acute-care focus can sometimes overshadow the needs of patients with chronic, life-limiting illnesses who present to the ED. These patients may be experiencing exacerbations of their underlying conditions, uncontrolled pain, or other distressing symptoms that could be significantly alleviated through palliative care interventions.

Without a systematic approach to identify these individuals, opportunities to offer palliative care consultation and support are frequently missed. This can lead to:

Suboptimal Symptom Management: Patients may endure unnecessary pain, shortness of breath, anxiety, and other distressing symptoms that palliative care is specifically designed to address.
Increased Hospital Admissions and Readmissions: Lack of palliative care in the ED can result in hospital admissions that might be avoidable with better outpatient symptom management and support. Furthermore, without addressing the underlying palliative care needs, readmission rates may also increase.
Potentially Aggressive and Non-Beneficial Treatments: In some cases, patients may be subjected to interventions that are unlikely to improve their prognosis or quality of life and may even cause further distress. Palliative care can help guide care decisions to align with patient goals and values.
Increased Healthcare Costs: Unnecessary hospitalizations, repeated ED visits, and aggressive treatments contribute to escalating healthcare costs. Early palliative care integration can optimize resource utilization by focusing on patient-centered care and symptom management.

Developing a Content-Valid Screening Tool: The Delphi Method Approach

Recognizing the critical need for a practical solution, a research initiative was undertaken to develop a simple and content-valid Screening Tool For Who Needs Palliative Care in the ED setting. The primary objective was to create a tool that could be easily used by ED providers to identify patients with significant unmet palliative care needs, triggering a timely inpatient palliative care consultation.

The development process employed a rigorous methodology, utilizing a modified Delphi technique. This method is well-suited for achieving consensus among experts on complex topics, particularly when developing clinical tools or guidelines. The Delphi technique involves a structured communication process with a panel of experts, conducted in multiple rounds, to refine and validate the tool.

The Delphi Technique: A Step-by-Step Overview

Initial Tool Development: The process began with the creation of an initial screening tool based on a comprehensive review of existing literature related to palliative care needs and identification in the emergency department and similar settings. This ensured the tool was grounded in current evidence and best practices.
Expert Panel Selection: A panel of fifteen palliative care experts was carefully selected to participate in the Delphi process. These experts brought diverse perspectives and extensive experience in palliative care, ensuring a robust evaluation of the screening tool.
Round One Survey: The initial screening tool was presented to the expert panel in the form of a survey. Experts were asked to review each item in the tool for accuracy and necessity. They used a Likert scale to rate their agreement and provided detailed narrative feedback on each item. This qualitative feedback was crucial for understanding the experts’ rationale and identifying areas for improvement.
Data Aggregation and Analysis: The responses from the first round were collected, aggregated, and analyzed. Quantitative data (Likert scale ratings) were summarized, and qualitative feedback was thematically analyzed to identify recurring suggestions and concerns.
Tool Revision: Based on the analysis of the first-round feedback, the screening tool was revised. Items that did not achieve consensus or were identified as unclear or redundant were modified, reworded, or removed.
Round Two Survey: The revised screening tool was then presented to the same expert panel for a second round of review. This iterative process allowed experts to reconsider their initial responses in light of the group feedback and the revisions made to the tool.
Consensus Determination: For each item in the screening tool, consensus was defined as greater than 80% agreement among the expert panel, along with meeting Lawshe’s critical values, a statistical measure of content validity. This rigorous threshold ensured that the final tool was strongly supported by expert opinion.
Final Tool Development: Items that achieved consensus were incorporated into the final screening tool. Items that did not reach consensus after two rounds were either further revised or eliminated.

Key Findings: A Content-Validated Screening Tool for Palliative Care Needs

The Delphi process, involving two rounds of surveys with fifteen palliative care experts, successfully led to consensus on the content validity of a screening tool for who needs palliative care in the emergency department. The iterative review and revision process resulted in a refined and practical tool.

Key Outcomes of the Delphi Process:

Item Refinement: While three screening items were accepted with minimal changes, the remaining items underwent significant revision, condensation, or elimination based on expert feedback. This demonstrates the value of the Delphi method in ensuring the relevance and clarity of each component of the tool.
Final 13-Item Tool: The resulting screening tool for who needs palliative care comprises 13 items, organized into a three-step process. This structured approach enhances the tool’s usability in the fast-paced ED environment. The three steps are:
1. Presence of a Life-Limiting Illness: This step focuses on identifying patients with conditions that are likely to progress and shorten lifespan, signaling potential palliative care needs.
2. Unmet Palliative Care Needs: This section delves into specific indicators of unmet needs, such as uncontrolled symptoms, psychosocial distress, and spiritual concerns.
3. Hospital Admission: This step considers the patient’s disposition, as hospital admission often presents an opportune time for palliative care consultation and initiation of services.
Expert Endorsement: A strong majority of the expert panel (86%) endorsed the adoption of the final screening tool for who needs palliative care. This high level of endorsement underscores the tool’s perceived value and potential for real-world application in emergency departments.

Conclusion and Future Directions

The successful development of a content-validated screening tool for who needs palliative care in the ED represents a significant step forward in improving the identification of patients who could benefit from these vital services. The use of a modified Delphi technique ensured a rigorous and expert-driven approach to tool development, resulting in a practical and well-supported instrument.

While content validation is a crucial initial step, further research is essential to fully evaluate the tool’s effectiveness in clinical practice. Future validation testing should focus on:

Usability and Feasibility: Assessing how easily and effectively the tool can be integrated into routine ED workflows.
Sensitivity and Specificity: Determining the tool’s accuracy in correctly identifying patients with palliative care needs (sensitivity) and excluding those who do not (specificity).
Impact on Patient Outcomes: Evaluating whether the use of the screening tool leads to improved symptom management, quality of life, and patient satisfaction, as well as potential reductions in hospital readmissions and healthcare costs.

By addressing these future research directions, we can further refine and validate this screening tool for who needs palliative care, ultimately enhancing the delivery of timely and effective palliative care to patients in the emergency department and beyond. This will contribute to a healthcare system that is more responsive to the holistic needs of individuals facing life-limiting illnesses.