RCT of PC in ED: Corita Grudzen, Fernanda Bellolio, & Tammie Quest

Eric 00:11

Welcome to the GeriPal Podcast.This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have with us today?

Alex 00:15

We are delighted to welcome back Corita Grudzen, who is an emergency medicine physician, researcher and head of the Division of Supportive and Acute Care Services at Memorial Sloan Kettering Cancer Center. Corita, welcome back to the GeriPal Podcast.

Corita 00:30

Thank you.

Alex 00:31

And we’re delighted to welcome Fernanda Bellolio, who is an emergency medicine physician and professor of emergency medicine at the Mayo Clinic. Fernanda, welcome to the GeriPal Podcast.

Fernanda 00:42

Thank you for having me.

Alex 00:44

And we’re delighted to welcome Tammie Quest. Long overdue. So delighted to have you. Emergency medicine physician and palliative medicine physician and professor and director of the Emory Palliative Care Center. Tammie, welcome to GeriPal.

Tammie 00:57

Thanks, friends.

Eric 00:59

So we’ve got a lot to talk about. We’re going to jump into a trial of a primary palliative care in the ED that, interestingly enough, did not show a difference in the outcomes that they were looking at. But before we jump into that, I think somebody has a song request for Alex.

Fernanda 01:16

I do have a song request. It’s Another One Bites the Dust by Queen.

Eric 01:20

Why did you pick this song?

Fernanda 01:23

I like that the tempo that it has is around 110 beats per minute. And this is the range of recommended chest compressions to record your pulmonary resuscitation or CPR. So that’s why we asked for this song.

Eric 01:35

Okay. So it was not the fact that this was another primary palliative care that bit the dust.

Alex 01:41

Another primary palliative care intervention.

Corita 01:44

No reflection on the trial. [laughter]

Eric 01:48

Oh, we’ll get to the trial.

Tammie 01:50

Alex, you can tell where the emergency physicians minds were exactly with Fernanda and we see where. [laughter]

Alex 01:59

All right. For the pre-recorded version, I set a metronome to 110. I’m pretty sure I did okay there. We’ll see how I do live here. Let’s hear, let’s see.

Alex 02:16

(singing)

Eric 02:51

That was great.

Alex 02:53

Did the patient survive the CPR? [laughter]

Eric 02:55

Is it too slow?

Tammie 02:56

It usually doesn’t work no matter what.

Corita 02:58

You do, especially in this population with a gagny of greater than 6.

Tammie 03:04

Depends on how long they were pre-hospital.

Eric 03:09

Okay, I’m going to start off with you, Corita. I think back in what, May 2016, you published a randomized controlled trial, first author, palliative care and the ED randomized study, cancer patients. Primary outcome was quality of life. And you improved quality of life. Why did you do another study of palliative care in the ed?

Corita 03:33

Yeah, great question. So that study was focused on patients admitted to the hospital. And as we know, palliative care for the most part is available Monday through Friday 9 to 5. Luckily, at MSK, we have palliative care 24 7, which is very unique. But so if someone got admitted, palliative care could see them the next day. I think that study was really important, especially I think the message that I give people is you can do something as simple as calling a consultation and improve quality of life months later. So that’s great.

But what do we do about the majority of our patients who get discharged home? You know, most, most ERs admit, you know, far fewer than 50% of their patients. And so how do we think about palliative care in those patients? They go to observation and go home or just get discharged straight from the ER?

Eric 04:26

So that 2016 study was in the ED, but it was getting specialty palliative care to see them when they were hospitalized, is that right?

Corita 04:32

Yep. They could have seen them in the ED or the next day upstairs. Yeah.

Eric 04:36

Okay, but that was a specialty palliative care study. Tammie, you’ve been doing emergency department work, palliative care work, for a long time. Why do you think this was important? Like, what are the needs?

Tammie 04:51

Yeah, so I would say that 30 years we’ve been in the palliative care space, not in emergency medicine, but we’ve been advancing the science in general palliative care for over 30 years and just plugging away with it, study after study after study to build the field. And every study that we do in emergency medicine builds the field.

I like to believe that we’ve come a long way since the support study in 1995. It was actually April 24th of 1995, it was published and had quite negative results. And that seemed to not stop us. It simply motivated us to keep going.

Eric 05:35

And so, and for our listeners, because we’ve talked about support in the past, can you describe real quick, like in one sentence, can you do a one sentence support? Like, what did they do?

Tammie 05:45

So the One sentence of the support study was the largest randomized control clinical trial ever done at that time, funded by the Robert Wood Johnson foundation, trying to have a. Essentially a primary palliative care intervention of sorts. But a nurse led intervention of trying to support palliative care course. And it turned out that actually it didn’t work. They put all this time and effort into it and the outcomes that they had hoped for, better dying, less pain, didn’t really happen.

And so at the time, and I remember starting in this field early, very early on, that it was widely quoted and that it just led people to have in their gut that we knew there was something there, even though that study didn’t show, and in their gut said, we need to keep going. And so many things were born after that. So it’s probably not one sentence, but it’s worth a good read for anybody in this field.

Eric 06:50

And Fernanda. So this was a primary palliative care study that we’re gonna be talking about. Why is that important in the emergency room?

Fernanda 06:59

It’s really important because we are the front door or the entry door, if you want to, from so many patients that come every day. Actually, our training as emergency physicians is mostly to resuscitate to acute care. We talk about CPR rather than communication skills or end of life discussion. This was actually something novel and new for so many of us, probably not the five that we are in this room, but for I would say 90% of my colleagues, this was something new and novel and important and came at such a good time also, that I guess we’re going to talk about that later.

Eric 07:34

Yeah, well, let’s dive into that. So this was a primary palliative care study. Corita, what did you do in this study?

Corita 07:45

So we were really building off the work that’s been done for decades. So Tammie developed something called EPIC for Emergency medicine, which is a curriculum that was one of the first ways that I think palliative care got spread in our community. And so we use that. We use Vital Talk. We adapted a small group of us, Vital Talk for emergency medicine, which is communication skills training using simulation. I think most people who listen probably know. And then we had clinical decision support. And so we took all of those key pieces and audit and feedback and delivered them at the level of the ed. So it was a cluster randomized trial.

We weren’t randomizing providers or patients. It was really at the level of the ED across 33 EDs in random order, and then tried to see if we could make a difference in healthcare utilization, primarily the primary outcome was admission to the hospital, acute care admission.

Eric 08:45

Why did you choose that as a primary outcome?

Corita 08:48

Well, in retrospect it probably wasn’t the best primary outcome, but it’s a pragmatic trial. So in the end we had almost 100,000 patients that were included in our analysis. So you have to have something that we could look at in claims. We weren’t going to collect patient reported outcomes from 100,000 people. It just, you know, wasn’t in the budget or the thoughts. And I think yeah, we wanted something feasible and we thought we could make a difference because that is the one decision we are responsible for. Right. As emergency physicians, we either admit or we don’t admit. That’s completely up to us for the most part. And so I thought it was something within our control.

Alex 09:30

Can I ask just unpack a little bit about the intervention itself. What is a clinical decision support? What does that mean? Like in sort of practice?

Corita 09:39

Yeah, so we used the electronic health record, I think, in support. Just going back to that trial. It really was kind of clinical decision support, but using paper. And so we did a similar intervention but using electronic means. And so I think, you know, there’s been tons of clinical decision support trials that are negative and positive all over the place. But we felt like we want to give like the primary thing about clinical decision support is to give the provider information they don’t already have. So we know these patients are really, really sick. That’s not news to us. Right.

But what we don’t know is are they already on hospice? Do they have documents in the record like medical orders for life sustaining treatment or a healthcare proxy? So we wanted to give emergency physicians that information, especially the hospice information, or if there were electronic or other orders, and let them know about that right when the patient comes in. Cause what we see is that some of the worst outcomes we have are when someone gets resuscitated because no one was there to explain. And it’s very traumatic obviously for the family and all of that and the team really.

Alex 10:52

And did you have algorithms you’d present to them, like given this patient’s circumstance, these are recommendations?

Corita 10:59

No, it was rather simple. No, no, no. It was like this patient is on hospice and call the case manager to figure out how the patient ended up here. It was very simple. Now it was a pragmatic trial. So we let sites have some flexibility. So we did have a clinical decision support pop up that said, hey, this patient has serious illness, why don’t you go have a goals of care discussion? Everyone Hated that, as you can imagine, because one, they already know the patient’s really, really sick.

Right. The emergency physician knows it’s not new information. Number two, you’re asking them to do something that maybe they don’t have time, maybe it’s interrupting their work at the wrong time. Like, I think I would actually ask Fernanda what. I know you guys had a particular clinical decision support alerts that popped up and to talk about what? Yeah, what you guys found the most useful because you actually were part of the team and developed them at your sites.

Fernanda 12:00

We have different response depending on the site because also we have different resources in each one of the hospitals. We have two hospitals that were community hospitals without palliative care or social work support. Was the clinician working frontline in those community hospitals? And they found that they had no time. Even the alert will come. They found they have no time to go talk to the patients because they had to make many decisions with limited time. So they say, I’m, I think this is the best and I will go. A more paternalistic approach will go this way.

They actually hate the decision support coming. And they say, after the trial is done, we’re done with this, we will stop and not have it anymore. Versus in our academic side that we’re very well supported. We have palliative care, we have also social work, et cetera. We still have the decision support. But it’s true what Corita was saying. When the alert comes, you’re like, oh, yeah, I’m not surprised about the surprise question. Yes, this is true. This is a patient that might not not be here in a year. So I think we had different responses depending who was the user. So I don’t think it’s across the board that works for them.

Eric 13:09

And in addition to the clinical support, you did teaching, both didactics and communication teaching, is that right?

Corita 13:17

Yeah. So the EPIC for emergency medicine was asynchronous, so they could do that on their own. Read all of that and then Vital Talk. It was in the middle of the pandemic, so we started out face to face and then quickly moved to Zoom, which I know a lot of it’s delivered that way now, but we had all of the apps and docs do VitalTalk 4 hours the course. They did the EPIC, EM and some other reviews. They did that as a pre read. And then we gave them audit and feedback on their performance after they started.

Eric 13:56

And what was the fidelity to the intervention at these sites? Like, how many people actually did that?

Corita 14:01

Sorry. We also did LNAC. I think all nurses did LNAC. So our benchmark was 75% of all nurses and 75% of the independent practitioners. And we reached that. There was one site we didn’t that was in the midst of the terrible pandemic and there were a lot of traveling nurses. And so we just missed the nursing mark on one. And then we had a leadership transition. There was one ED where the docs didn’t reach that, but I would say for the Fernanda was a perfect site PI and did very well at Mayo. But for the most part, we reached it across the board and everyone got their clinical decision support.

Eric 14:40

So basically everybody got the dose of the intervention pretty much. And it was like 29eds. Is that right?

Corita 14:49

Yes, we had. Yeah, that’s a more complicated story. We had two pilots and then there was a few bit the dust, so to speak.

Eric 14:58

I’m going to do really quick wonky because these confuse me all the time. This is a cluster randomized control trial and it’s stepped wedge.

Fernanda 15:05

Yep.

Eric 15:06

What the heck does that mean again?

Corita 15:08

So stepped wedge means it’s like a staircase, really literally. And you roll out the intervention one step or one wedge at a time. You could do a cluster randomized trial. That’s you simultaneously run the intervention. Right. You just flip a coin. Each site gets the intervention or doesn’t. We decided to do step wedge because the intervention was so human resource intensive. And that’s the vital talk part. There were not at that time enough trainers to run train 29EDs worth of physicians and apps at the same time, as you can imagine.

Eric 15:45

So ultimately, all 29EDs got the intervention. It was started at randomized. Started at different time points in that ladder and the cluster randomization, am I right that you’re not randomizing the people? Because there were like a hundred thousand people. You’re randomizing the ed?

Fernanda 16:05

Yes.

Eric 16:06

When they’re going to start the intervention.

Corita 16:08

Yeah. And step wedge, I’ll just say, has really fallen out of favor.

Alex 16:12

Oh, it has, yeah.

Corita 16:14

So at the collab collaboratory, if you talk to the biostatisticians there, you should do everything at all costs. Did you just submit a grant using.

Tammie 16:26

Stepped wedge? Not too long ago. I thought it was okay.

Corita 16:28

Yeah. So it is. At this point, it is really a design of last resort only. And they tried to the collaboratory, which is like the core pragmatic, they tried at all costs to be like, don’t do it, don’t do it.

Eric 16:44

Is that because, like, hypothetically, if there was a, let’s say a global outbreak of Some new virus that a pre. Kind of post stepped wedge design may be influenced by that outcome.

Corita 16:57

Exactly, exactly. Yeah, yeah. I mean, you can control for time, which we did. But yeah, it’s complicated. And the pandemic hit at exactly the same time as our intervention started, so it’s not ideal.

Eric 17:12

So if you’re looking at a site like, you know, they get randomized pre. You see their hospitalization rates and you randomized post. And that happens coincide with randomizing that post intervention. Happen. Coincide. Covid. It may be the COVID that’s increasing hospitalization rate.

Corita 17:29

Exactly. Yeah, exactly. Yes. And each site serves as its own control, so there is that. But most of our visit. Our post intervention visits occurred post pandemic or during the pandemic. And most of our pre intervention occurred. The vast majority occurred pre pandemic. So as we know, like, everything changed. The patients coming in changed, admission rate changed, the resources in the community changed.

Eric 17:57

Like, oh, for a while. Hospices were very hard to get people.

Corita 18:01

Into nursing homes, you know. Yeah, whole host of things.

Eric 18:04

So let’s just jump into the findings. Did this primary palliative care intervention in the emergency room involving a. Wait. A hundred thousand patients. Wait, I don’t. Who were the patients again, who were included? They were. Had to be.

Corita 18:18

So they were. Yeah, so we use something called the GAGNY score, which predicts short term mortality. So they were at high risk of dying in the next six months.

Eric 18:28

Okay, so older adults high risk of dying using the GAGNY score, which includes.

Alex 18:33

And I think the GAGNY score is like a comorbidity type score.

Corita 18:36

Yeah, exactly. Yeah. It counts how many conditions you have. You know, I think dementia has the most points and etc.

Eric 18:43

We’ll have a link to it too, because it happens to be on a prognosis.

Corita 18:47

I know.

Eric 18:48

If you want to play around with that. And you excluded nursing home patients. Why did you exclude nursing home patients?

Corita 18:53

We felt like we couldn’t make such of an impact. It wasn’t like the intervention. It would have been a different intervention. Let’s just put it that way. Like we would have devised a different intervention.

Alex 19:03

Wait, wait, before we get to the. What did you find? Tammie, what do you think of this intervention? Like, is this like what you would have designed? I mean, is this ideal palliative care? Is it like the best you can do, given that it has to be feasible for. I don’t know.

Tammie 19:18

Yeah, so. So I have. So first of all, we keep saying 100,000 without like a celebratory. Just really, you know, cord or something here. So, like, I don’t.

Eric 19:30

Should we add that to special effects as our producer?

Tammie 19:34

Every time we say 100,000, we need to, like, really go, woo, Right? Because I think that being able to have large cohorts that are prospectively collected in anything in emergency medicine, I would say that the thing that the only other thing that we have consistently that much data on is cardiac arrest or maybe cardiac conditions like acute MI or stroke. But like, that, it rises to a really high level. So I just want to start by saying anything that you can get almost 100,000 people in an emergency department study in is, like, incredibly remarkable.

So let’s just start there. The second piece I would say is that one of the tricky pieces. Would I have done this a little bit differently? The one thing that we know is that education alone will not actually deliver behavior change. So if our behavior change is that we actually want an emergency clinician to do something, one of the really kind of key steps is really adding an operational component to the study. So ensuring that. And that’s really hard to do, by the way, with 29 emergency departments and figuring out what that is.

So, for instance, would it have made a difference if, as a requirement in this study, every single emergency department who was eligible to be in the intervention had to have a relationship with an inpatient hospice for which discharge was immediately available to an emergency department? Let’s just say that that is one of the criteria and that that was part of what you had. That may be something that we could try in the future, for instance. Right. But I think that, you know, hindsight is 20 20, but at the time, and I remember, you know, kind of just when you’re looking at scaling something, it can be. It can be really tough. So I think if there was only. If there was only one thing in the design phase that I might have added to this or for a future study is to add an operational component to the intervention.

Eric 21:49

All right, we’re dancing around the results. We got to save the results because we’re kind of alluding to them. What did you find?

Corita 21:56

So there was no difference across every single outcome. Primary outcome, all of our secondary outcomes, they were remarkably the same.

Eric 22:06

So what were that? The primary outcome was hospitalization. No difference.

Corita 22:10

No difference? No. Statistically, admissions went down, but it was not significant. Revisits were the same. Home health was the same. Hospice was the same. Mortality was the same. Hospitalization, rehospitalization. All the same at six months.

Eric 22:27

Huh? So no difference. Go ahead, Alex.

Alex 22:30

Well, so, Corita, maybe we can Just go around. Corita, what did you think when you saw this?

Corita 22:36

I was not surprised at all.

Eric 22:38

Oh, no?

Corita 22:39

Why? Yeah, it was funny because our biostatistician was like, so nervous to tell me. He thought I would be really upset. And I’m like, no, it’s totally okay. We trained thousands of people. We train literally thousands of nurses in lnac. Thousands. Well, hundreds. Almost a thousand physicians in vital talk. I mean, and I am certain. And we, like, set up this clinical decision support which at every health system is still up and running and identifying those patients. So, like, do I think we improved care and improved communication? 100%. And that’s what I care most about. So I don’t.

Eric 23:19

Are you looking at any data on that? Can you look at any data since this is a pragmatic study?

Corita 23:24

We do? Yeah. Well, we. I mean, part of it is we looked at implementation outcomes, like, you know, fidelity to the function, not just the form, but like the. The. We looked at reach. We did some qualitative. I mean, those articles didn’t get published in jama, so in journals, but we had qualitative. We had things on the reach effectiveness, all of that kind of those implementation outcomes that were all very positive. And I guess I’ll hand it off to Fernanda, who can really speak to, I think, the fact that her clinical decision support is still up and running.

Eric 24:02

Well, before you jump into that answer, Fernanda, did it surprise you go into Alex’s question, or did you think same thing? I kind of expected that.

Fernanda 24:11

No. I don’t know. I was hoping we will make a difference, but I was okay, not like seeing the data and, you know, I’m a data person, but I was hoping, you know, that we can make a difference. I 100% agree with Corita that we felt our people were trained in communication, in goals of care, even delivering bad news, that is things we were not trained before. So this actually was amazing how I could see my colleagues also going and say, hey, I never thought this was so important, but it was so timely. Remember, this was March 2020, around that time when we got all this training and we were having now these conversations really often.

Remember that at the beginning of COVID pandemic, there was no treatment. The outcomes were really bad, like really high mortality. So we were actually having these conversations. It was again, a perfect time. I remember my vice chair coming and saying, thank you so much for doing this training. It’s amazing. And I’m like, well, don’t thank me, but like, I’m glad this is the you know, the reception of the training, it was really great and timely.

Eric 25:11

And in those other studies that were published, do we have data that it improved some outcomes, ability to have these discussions or.

Corita 25:23

Yeah, I mean, that’s what the qualitative data showed. The interviews with people like the impact on of the course, especially the vital talk, was really changed. Change practice, you know, for many. I think we know that, you know, from everyone who’s taken the course or has participated. Yeah. I mean, quality of, you know, sometimes I think, okay, well, should we have looked at quality of communication? But I think everyone knows from Randy Curtis, who, you know, was always a true believer, that, like, don’t use that as an outcome because it’s always really high and you can’t move it because it’s already patients rate qualifications, specifically Randy.

Eric 26:01

Curtis’s, he had a 2014 JAMA article on simulation. Basically vital talk. Right. For residents and nurse practitioners, primary outcome was the quality of communication. No difference.

Corita 26:15

Yeah. And he warned me. So I was like, what should we do? He’s like, don’t use that as your primary outcome. But here I am. Another negative trial. But yeah.

Eric 26:24

Yeah. So I guess the bigger question I’m going to turn to you, Tammie, on this is that we actually had Yale Shanker and Bob Arnold on to talk about primary palliative care intervention and oncology in infusion clinics. No difference in their primary outcome. The primary care intervention did not work well. I think we had some debate about whether it worked or not, but the primary outcome was negative. I can’t think of another primary palliative care intervention off the top of my head that worked. We’ve done a nursing home palliative care and a primary parent intervention study. On our podcast, we’ll have a link to it with Leive Van den Block.

Eric 27:15

That primary palliative care doesn’t work. We’ve had a lot of focus on advanced care planning. People saying advanced care planning doesn’t work. Doesn’t work. Doesn’t work because the outcomes are the same. Maybe a qualitative data, we can see some differences. Should we be focused on primary palliative care too, saying we have no evidence that it works?

Tammie 27:32

I’m not ready to give up yet. I’m not ready to give up yet. So I will just. You haven’t experienced why?

Eric 27:40

Tell me why. What motivates you?

Alex 27:43

Well, yeah, you can answer the surprise first by way of moving in.

Tammie 27:46

Yeah, so I’m not surprised. I mean, so I think disappoint. We should have disappointment and surpr. Separated. Right. So disappointment, yes, of course. Right. And I know that you know, but surprise, no. And again, I’m really focused on the operational aspects of things and part of if you take an outcome like hospitalization. So we have good data that shows that for emergency clinicians, something like respiratory distress in a patient is the absolute most difficult thing that you will manage, gives you the most anxiety, and is most likely to lead to an admission. So unless you have.

There are just certain things that people are going to complain of that you have to have. I have to have an overwhelming sense of safety and care and knowing things are going to be okay. To actually discharge a sick person who meets the score that you’re talking about. I mean, I don’t even want to discharge, well, people who have shortness of breath, let alone people who have uncontrolled pain or other things or things that are bringing them into an emergency department and could have fragile caregivers and all sorts of things. So the nuance of trying to prevent hospitalization is so hard that for an emergency clinician, I think that that’s really a really hard one. I’ll just go straight up from an emergency department now. If you looked at.

Corita 29:27

I would just have one caveat to that though, which is observations. So we did allow observation counted as remaining outpatient. Right. So not every site had obs, but I think obs is a great counter to that where you can have 24 to 48 hours of like, you know, helping someone and let me jump in.

Tammie 29:51

On, let me jump in on obs. Can I jump in on obs?

Eric 29:54

You got to describe it though.

Tammie 29:56

Yeah. So let me, let me do observation. So observation is often in an emergency department. It’s a, it’s a place where typically you’re shooting for a 23 hour stay, but you can have up to two midnights or less than that. And it’s highly protocolized. So most observation units, not all, but many in emergency departments, are protocolized for common conditions seen in an emergency department that have an algorithmic workup. Right. So GI bleed, TIA, chest pain, undifferentiated abdominal pain, things that you might need to observe for longer.

What I will say, and that differs greatly depending on the hospital or the emergency department. And so many emergency departments, actually you have to be low risk. Like the criteria to go into the obs unit is that you are relatively low Risk. And if there is a chance that you would be admitted that you’re encouraged, actually just go ahead and admit that patient. So part of it is in the 29 emergency departments. Knowing that the observation criteria would allow for a patient likely as sick as the one in this trial is not a slam dunk that you.

Corita 31:14

And almost every ED has many for many reasons, US News Vizient. Almost every ed, and there’s some published literature and we also saw this has a pathway for hospice as part of obs. Almost. I mean, we have one like every patient that comes in with hospice goes to obs and NYU has one. Almost all of the health systems did have that.

Tammie 31:40

It wasn’t noted. But it’s something to remember, right. If you take general emergency departments or say you generalize this to community, that may or may not work. So in any case, I’m not surprised. It’s a hard outcome in sick people. Let’s just put it that way. It’s a hard outcome. Now, some of the other secondary things, you know, you may have have seen if it was trigger of specialty palliative care consultations. I mean, basically the things that we saw in 2016, you know, leveraged. I mean, you know, maybe I might have expected more, but I think a primary outcome of hospitalization is just a very hard primary outcome.

Eric 32:28

So let me ask you this, is that. I mean, I’m trying to imagine another study like primary cardiology intervention in the emergency room. You do teaching, you do some didactics.

Corita 32:38

We’re doing that right now, Eric. We’re doing an 80 site trial right now.

Eric 32:43

Right. You do this primary cardiology to improve ST elevation MI outcomes. But it’s okay if you don’t have any interventional cardiologists or cardiologists in the group. Right.

Tammie 32:57

So we’ve done that. And I mean, well, I hear there’s more. But the observation unit actually was the solution early on in palliative in. In emergency medicine, the observation unit was essentially built for patients with chest pain. Like, but in fact we used to call them chest pain.

Eric 33:17

But I’m trying to do. The analogy here is like this study did not require or did not push for specialty level palliative care involved.

Corita 33:25

That was not, that was absolutely not the recommendation and in fact should attach a lot of people.

Eric 33:32

Like in a cardiology ST elevation MI study, you probably have specialty cardiology involved, right?

Corita 33:40

No, it was an option. So part of the clinical decision support for complex patients, one of the recommendations was, you know, contacts order, palliative care consult. Absolutely.

Eric 33:49

Did they Use it more often in the.

Corita 33:51

We didn’t look because I wasn’t in. I mean, I’m sure they did, but it wasn’t the focus and it wasn’t an outcome of interest just because, you know, there was clear feedback from the sites. You know, we met as obviously with all the palliative care teams as well at all these health systems, and there’s no way they could have handled the increase in volume that if we had consulted them on every patient and that would not have changed the outcome because we’re trying to get people home, not waiting for palliative care. You know, I mean, at msk, we can get palliative care.

Eric 34:24

So it may not change the primary outcome of hospitalization because they would have been hospitalized but may have changed. Fernando, what do you think? Would it have changed potentially utilization rates like hospice utilization?

Fernanda 34:36

So it’s interesting question and I know you’re challenging a bit here as Eric, we do have now our primary, I mean, our palliative specialist to try at some point. We did like a pilot trying to go and come to the EV when needed. Initially they were worried what’s going to be the volume? Because also they’re really busy in the hospital. So I’m going to be called every 20 minutes to go to the ER. Are the basic conversations something that the emergency physician should be able to happen? At what point do we come in? What’s going from their perspective?

So we try a pilot. Although there was some concern about what numbers we will get, I’ll tell you, we don’t have it anymore. It wasn’t because we didn’t try. It just felt like the patient that had a palliative need for a specialist in the ED was not the same one that we wanted to include. We had to talk to a lot more patients than the ones that needed really that specialist care. Even if we had 1,000 palliative specialists that could come to the ED, it might not be the best resource at this point.

Alex 35:38

It’s such a difficult nut to crack. Like on the one hand, we have. Taking a step back, as Eric was saying, there are many primary palliative care interventions that have not been. They’ve been sort of negative trials or however you want to characterize it. They have not had.

Eric 35:55

They’ve been negative, they’ve been negative outcomes.

Corita 35:58

Yeah, but are you surprised, though, especially palliative care? You’re having people that they are. They believe in the mission. They have chosen this field, they’re doing an extra year of training versus like, you know, you have A captive audience versus, like, people that didn’t sign up for this, were not paying them to do this, they didn’t want to do a fellowship. You know, it’s like a completely different. And there is some evidence also, which is because obviously I looked up and I’ve talked to Yael about primary palliative care, and I think we need to have like an R13 or some like, conference on primary palliative care to figure out can we move this field forward.

Most of the interventions have been with nursing. It’s very interesting, as opposed to independent practitioners. So it’s comparing very different things, if that makes sense. In ours, we did train physicians, but most of the primary palliative care literature is in nursing.

Alex 36:56

Right. So that was an important advance. And as Erica said many times on this podcast, we learn as much from studies that are negative about what doesn’t work as we do from studies that are positive about what does work. And so it’s equally valuable. This was our first, you know, one of the first glimpses into training clinicians in palliative care. Principles also was negative for just about everything we look at. You looked at Tammie. I see you want to jump in, Jump in.

Tammie 37:23

So one thing that. So if you look at the very earliest interventions in palliative care in the emergency department, so one of the reasons that Corita’s work is so valuable, no matter, no matter what the outcome, is that she assigned more rigorous methodology. But actually, if you look at the ED literature was built on very small one site studies where you would have this small thing happen in this one ed, you’d have one nurse or one training or one something or another. And early on in the field, we actually, and those were what I would consider to be primary palliative care interventions.

They are not at the level, they’ve not all been scaled and replicated at the level of this particular intervention. Though I will say the whole field was founded on small primary palliative care interventions because there wasn’t anybody else and nobody was in the emergency department. And so some of the earliest embedding were not people that were really subspecialty trained. They were people who had an interest and an engagement and an operational focus to make this happen. And so because you remember, board certification didn’t come around until 2007. And at that time we had maybe 10, 25 people. So if you look at anything pre 2009, seven or nine in emergency medicine, anything that was published as an intervention was essentially a primary palliative care intervention.

So I will Say that if you dig back into the literature and history telling us going back and digging through some of those things and trying to amplify that into randomized control clinical trials, apparently not stepped wedge per Korea, because we’re never doing that again. But if we never do that again, but we go back and dig and look at all the nuggets of things. I’m just not ready to give up yet. Now what I will say, because here’s.

Eric 39:37

And you’re not ready to give up on primary palliative care.

Alex 39:40

Primary palliative care, that’s right.

Tammie 39:42

I’m not ready to give up on.

Corita 39:43

For the record, no way. I’m not ready either.

Tammie 39:45

Because here’s the other deal. What we didn’t do when we improved cardiac outcomes in an emergency department and stroke outcomes, we did not make emergency physicians necessarily go do neuro fellowships. They can’t do them. Nor did we make them do cardiology fellowships. They can’t do them. What we did was we trained systematically. Every emergency physician in this country that becomes board eligible has core competencies back to residency. And we married that to clear operations and handoffs and algorithms and time limits.

Corita 40:24

Right, and time limits within X minutes.

Tammie 40:27

Exactly. We put a time limit. So we have seen common serious problems be managed in an emergency department effect effectively with better outcomes when we put all of those things around it.

Eric 40:44

Let me ask you this, then, moving forward, if you had to design the next study about primary palliative care in the ed, what would that look like based on what you’ve learned from this study?

Alex 40:55

Let’s go to Tammie first because she has to leave in three minutes.

Corita 40:58

Okay.

Tammie 41:00

I’d add an operational component.

Eric 41:03

Can you give me an idea what that looked like?

Tammie 41:05

So I would. I think that, you know, hard discharge outcomes, maybe not even obs. I mean, because that’s a little bit, you know, sneaky because they still have to go someplace. But I would have a hard community operational component which is a place for them to go or be. That is safe. And so that is. Hospice is one of those things. And the second thing that I would do is trying to. You’d have to tailor it to each individual emergency department because you couldn’t. This is what gets to be complicated for standardization.

But the case management model, the social work model that exists in an emergency department that makes disposition happen in some places, trying to add that in. So I think those are kind of operational components as to. Because the emergency physician’s core stress always is. I don’t have to do that. But now what do you want me to do. And there’s gotta be something else.

Eric 42:10

Fernanda, what would you do?

Fernanda 42:12

Well, maybe creating TV shows that despite realistic expectations of what’s happening after eight days.

Eric 42:20

That’s great. So outcomes of CPR are not. Most people survive.

Alex 42:26

Yeah. The James Tulsky paper, miracles and misinformation on TV in New England Journal. Yeah.

Eric 42:32

Okay. Karina, what would you do? What’s the next for you?

Corita 42:36

I agree with Tammie. I think, you know, it’s all about the resources and the place you can. And that was something we couldn’t control. You know, it was. It’s like outside of our control. Other than observation, we, you know, we can’t force a hospice. You know, getting Gipsy approved for most of our patients is almost impossible. So even if you have home hospice coming, it’s like, still doesn’t feel safe enough. And so then you need caregivers to.

Tammie 43:03

Consent, which is tricky.

Eric 43:05

Well, let me ask you this. Let me ask you this. Karina and Fernanda, too. Like, what if your intervention worked really well? There were amazing goals of care discussions. And it turns out people wanted to be hospitalized, people didn’t want to go back home. They weren’t ready for hospice. They wanted to be have more interventions. What if it worked? And the outcome.

Corita 43:34

That would contradict decades of literature about what people want when time is short. But that would be interesting. Yeah. That would be a complete reversal of everything we know about what most people want. I mean, we know, like in this.

Tammie 43:49

Study that the people that died, you know, on. I think it was, on average was like 17 days. Right. Was that. Is that. So these were people very close to the end.

Alex 43:58

These are pretty sick.

Eric 44:00

This would be consistent with past literature that. Tammie, I know you gotta go. Thank you for joining us.

Alex 44:05

We’ll keep going.

Tammie 44:06

Awesome.

Eric 44:06

This would be consistent with past literature, is if you bring up goals of care conversations, you’re not forcing people. But turns out most people don’t want default of medicine, which is very aggressive care at the end of life.

Corita 44:18

Yeah. When time is short. Let’s just.

Eric 44:19

When time is short.

Corita 44:20

Yeah.

Alex 44:21

Yeah. But the prognosis piece is key.

Eric 44:23

Go ahead, Fernanda.

Fernanda 44:24

To answer your question, really, just having that small conversation initiated in the ed, even if they’re not ready to make that decision yet, gets them thinking. Okay. They talk about goals of care. What do I mean? What are my goals of care for? Amazing. How many patients come to the ED have never even thought about this, despite being on palliative chemotherapies, et cetera. So it really, you Put that seed on them. I agree. They might want to be admitted. They might want.

They’re not ready to have a more, I don’t know, like an outpatient treatment at that point. But you are putting that seed, and that really makes a big difference for the admitting team, too. And I think passing on that baton to the team upstairs, if they’re going to come in, is so important, too. And it’s part of why we’re still having the BPAs or like the clinical decision support tools that Corita mentioned in the hospital, because it helps even if they are not dismissed. So I agree with you. Not because, I mean, it’s a. Like a non.

Eric 45:17

Fernanda, let me ask both of you. I’m going to start with you, Fernanda. So we’re going to end with another one bites the dust.

Alex 45:23

Wait, wait, wait.

Eric 45:25

Before you introduce that.

Alex 45:26

Hold on. I want to just say one thing, which is also I want to say I think there has been culture change in the emergency department. One of my first studies was called Am I doing the Right Thing?

Corita 45:36

I know I quote you. I say that all the time.

Alex 45:40

Thank you. Like emergency medicine providers, they want to do the right thing, and yet they often don’t have the skills, the training, the knowledge to do the right thing or to know what the right thing to do is. And so I think that that is changing over time. And Fernandez talked about how that’s maybe changed more in academic centers than community settings, but I think it will continue to change. And in our palliative medicine program, like majority of fellows who match next year are emergency medicine trained. It’s like, whoa, what’s happening? We’ve had at least one emergency medicine trainee, like, every year in our fellowship for several years now. There’s movement here, so I just want to note that as well. Okay, Eric, go ahead.

Eric 46:25

Is this another study that bites the dust? Would you consider this a negative study, Fernanda? Negative study of primary palliative care.

Fernanda 46:34

I think we learned a lot from this study, and we’re better because of it.

Eric 46:38

Great. Corita, how would you answer that question?

Corita 46:43

I think. I don’t know. It was a negative trial. Absolutely. But I think the wonderful thing, and I always tell people about pragmatic trials, is you’re implementing interventions that have already been shown to work. So you are changing care for the better the first day you start the study, because we know these things in isolation work fantastically, maybe not in the outcome we looked at. So I think, to me, that’s a win from the beginning, before you even look at the results. So it’s a negative trial.

Eric 47:16

I’m going to push you on that. Do we know these individual things really work in big randomized control? I don’t know. Does just communication education, has that been shown to work? I won’t apply the same principles that we’re having discussion around advanced care planning. Does it work or not? To some of these things. Doing didactics for four hours, does that really work? I love this study because I think it does give us information. Maybe we need more. Just like Tammie said, you can teach people all you want, but if you don’t change the system, you’re going to get the exact same results.

Corita 47:54

I don’t think it changes disposition in the emergency department. I think it has profound impact on moral distress for the emergency. And we have a lot of qualitative data. It decreases moral distress, it increases satisfaction with your work. I’m certain it improves communication in certain scenarios. And there’s lots of literature on Lnec and Epic. EM like smaller. They’re not RCTs, but we know vital talk. Otherwise we wouldn’t have people flocking to the courses. You know, I think they’re really impactful. So not in disposition from the ed, but in other ways.

Eric 48:30

Wonderful. Well, Corita Fernanda, thanks you for joining us. And thank you, Tammie, who’s no longer with us. She had to run off to another meeting. But before we end, Alex, a little bit more of Another One Bites the Dust.

Alex 48:50

(singing)

Eric 49:25

Wonderful. Corita, Fernanda and Tammie, thank you for joining us on this GeriPal podcast.

Corita 49:30

Thank you so much for having us.

Fernanda 49:33

Thank you for having us.

Eric 49:34

And thank you to all of our listeners for your continued support.

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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guests Corita Grudzen, Fernanda Bellolio, and Tammie Quest have no relationships to disclose.

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