Paul DeSandre

Impact of Physician and Patient Gender on Pain Management in the Emergency Department—A Multicenter Study

OBJECTIVE Pain is a complex experience influenced by factors such as age, race, and ethnicity. We conducted a multicenter study to better understand emergency department (ED) pain management practices and examined the influence of patient and provider gender on analgesic administration. DESIGN Prospective, multicenter, observational study. SETTING Consecutive patients, >or=8-years-old, presenting with complaints of moderate to severe pain (pain numerical rating scale [NRS] > 3) at 16 U.S. and three Canadian hospitals. OUTCOMES MEASURES Receipt of any ED analgesic, receipt of opioids, and adequate pain relief in the ED. RESULTS Eight hundred forty-two patients participated including 56% women. Baseline pain scores were similar in both genders. Analgesic administration rates were not significantly different for female and male patients (63% vs 57%, P = 0.08), although females presenting with severe pain (NRS >or=8) were more likely to receive analgesics (74% vs 64%, P = 0.02). Female physicians were more likely to administer analgesics than male physicians (66% vs 57%, P = 0.009). In logistic regression models, predictors of ED analgesic administration were male physician (odds ratio [OR] = 0.7), arrival pain (OR = 1.3), number of pain assessments (OR = 1.83), and charted follow-up plans (OR = 2.16). With regard to opioid administration, female physicians were more likely to prescribe opioids to females (P = 0.006) while male physicians were more likely to prescribe to males (P = 0.05). In logistic regression models, predictors of opioids administration included male patient gender (OR = 0.58), male patient-physician interaction (OR = 2.58), arrival pain score (OR = 1.28), average pain score (OR = 1.10), and number of pain assessments (OR = 1.5). Pain relief was not impacted by gender. CONCLUSION Provider gender as opposed to patient gender appears to influence pain management decisions in the ED.

Integration of palliative care into emergency medicine: The Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration

BACKGROUND Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. CASE REPORT We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. DISCUSSION We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. CONCLUSION The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.

A Rapid Two-Stage Screening Protocol for Palliative Care in the Emergency Department: A Quality Improvement Initiative

BACKGROUND A rapid two-stage screening protocol was developed to improve referral for palliative care needs among frail elderly in the emergency department (ED). MEASURES A new triage tool was administered, with assessment tools for activities of daily living, performance, functional staging, symptom burden, and caregiver distress. INTERVENTION Stage One identified elderly patients meeting criteria for life-limiting conditions. Stage Two referred patients with crescendo losses in activities of daily living, high symptom burden, and caregiver distress to palliative care or hospice. OUTCOMES Over eight months, 1587 patients were screened, representing 22% of ED visits made by patients older than 65 years during this time period. Of these, 140 met functional decline criteria, and 51 of these needed palliative care consultation. Five patients were referred to hospice, 20 received palliative care, and 26 received no further service. CONCLUSIONS/LESSONS LEARNED The project shows unmet needs among elderly ED patients, and the feasibility of rapid screening and referral using a quality improvement approach. At its peak, the project accounted for half the referrals to the palliative care consultation service.

Management of Cancer-Related Pain

Patients and families struggling with cancer fear pain more than any other physical symptom. There are also significant barriers to optimal pain management in the emergency setting, including lack of knowledge, inexperienced clinicians, myths about addiction, and fears of complications after discharge. In this article, we review the assessment and management options for cancer-related pain based on the World Health Organization (WHO) 3-step approach.

Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine

BACKGROUND The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. DISCUSSION We use excerpts from conversations with emergency physicians to highlight the challenges in hospice and palliative medicine training and practice that are commonly being identified by these physicians, at varying phases of their careers. The lessons learned from this initial dual-certified physician cohort in real practice fills a current literature gap. Practical guidance is offered for the increasing number of trainees and mid-career emergency physicians who may have an interest in the subspecialty pathway but are seeking answers to what a future integrated practice will look like in order to make informed career decisions. CONCLUSION The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.

Prescription Drug Monitoring Programs: Ethical Issues in the Emergency Department

Prescription drug monitoring programs are statewide databases available to clinicians to track prescriptions of controlled medications. These programs may provide valuable information to assess the history and use of controlled substances and contribute to clinical decisionmaking in the emergency department (ED). The widespread availability of the programs raises important ethical issues about beneficence, nonmaleficence, respect for persons, justice, confidentiality, veracity, and physician autonomy. In this article, we review the ethical issues surrounding prescription drug monitoring programs and how those issues might be addressed to ensure the proper application of this tool in the ED. Clinical decisionmaking in regard to the appropriate use of opioids and other controlled substances is complex and should take into account all relevant clinical factors, including age, sex, clinical condition, medical history, medication history and potential drug-drug interactions, history of addiction or diversion, and disease state.

Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework

Emergency medicine (EM) physicians commonly care for patients with serious life‐limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary‐level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary‐level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM.

Derivation and validation of a risk model for emergency department palliative care needs assessment using the Screen for Palliative and End-of-Life Care Needs in the Emergency Department (SPEED).

22 Background: A key setting for the provision of palliative care is the emergency department (ED) where important decisions regarding treatment and next site of care are determined; however identifying patients who would benefit from a palliative care consult is an ongoing challenge. The (SPEED) is a 5-question tool that assesses unmet palliative care needs. METHODS We performed a retrospective derivation and temporal validation of a risk model for a palliative care event (PCE) among cancer patients with an ED visit and subsequent hospital admission using data available upon arrival, including data from the SPEED tool. A PCE was defined as a palliative care consult, discharge to hospice, or in-hospital death. We developed a multivariate logistic regression model to predict PCEs. We assessed model performance using a receiver operating characteristic curve and visual inspection of quintile plots. RESULTS Eleven factors were identified as predictive of a PCE, including SPEED score, proxy SPEED informer, age, EMS arrival, emergent or immediate ED acuity, the number of ED visits within the last 90 days, metastatic cancer, cardiac arrhythmias, coagulopathy, depression and weight loss. In validation, the risk model had an area under the curve of 0.72 and calibration showed an underestimation of risk in the second and third quintiles. CONCLUSIONS A risk model based on SPEED score has been successfully derived, but needs a larger dataset for proper validation. If the predictive ability of the model is confirmed, a risk model can efficiently identify cancer patients arriving to the ED who may benefit from early initiation of a palliative care consult.