Palliative Care Initiated in the Emergency Department
Authors: Grudzen Corita R. , Siman Nina , Cuthel Allison M. , Adeyemi Oluwaseun , Yamarik Rebecca Liddicoat , Goldfeld Keith S. ,   PRIM-ER Investigators, Abella Benjamin S. , Bellolio Fernanda , Bourenane Sorayah , Brody Abraham A. , Cameron-Comasco Lauren , Chodosh Joshua , Cooper Julie J. , Deutsch Ashley L. , Elie Marie Carmelle , Elsayem Ahmed , Fernandez Rosemarie , Fleischer-Black Jessica , Gang Mauren , Genes Nicholas , Goett Rebecca , Heaton Heather , Hill Jacob , Horwitz Leora , Isaacs Eric , Jubanyik Karen , Lamba Sangeeta , Lawrence Katharine , Lin Michelle , Loprinzi-Brauer Caitlin , Madsen Troy , Miller Joseph , Modrek Ada , Otero Ronny , Ouchi Kei , Richardson Christopher , Richardson Lynne D. , Ryan Matthew , Schoenfeld Elizabeth , Shaw Matthew , Shreves Ashley , Southerland Lauren T. , Tan Audrey , Uspal Julie , Venkat Arvind , Walker Laura , Wittman Ian , Zimny Erin 
Published: January 2025

ImportanceThe emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness.ObjectiveTo assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness.Design, Setting, and ParticipantsCluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.InterventionA multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff.Main Outcome and MeasuresThe primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months.ResultsThere were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, −3.1% [95% CI, −3.7% to −2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]).Conclusions and RelevanceThis multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.Trial RegistrationClinicalTrials.gov Identifier: NCT03424109