Emergency Department–Embedded Palliative Care Consultations: A Feasibility Pilot Study

Key Message : Embedding palliative care providers within the emergency department is feasible and effective in an urban, safety-net hospital setting. This model facilitated earlier goals-of-care discussions, assisted with disposition decisions, and enhanced outpatient follow-up. ED clinicians reported high acceptance, demonstrating that integrated palliative care can strengthen patient-centered care in time-pressured environments.

Abstract:

Background:
For many—particularly the uninsured or underinsured—the emergency department (ED) serves as the primary point of healthcare contact and a key opportunity for early palliative care (PC) intervention. Prior studies have shown that ED-based PC interventions improve patient and family satisfaction, reduce intensive care utilization and hospital length of stay, increase hospice referrals, and lower costs.(1) While standardized trigger-based consultation systems have demonstrated mixed results and limited generalizability, embedding PC providers directly in the ED may better align interventions with local needs and workflows.(2,3)

Objectives:
To pilot and evaluate the feasibility and workflow of an ED-embedded PC provider model designed to improve goal-concordant care, facilitate early interventions, strengthen outpatient continuity, and enhance primary PC skills among emergency clinicians at a large safety-net hospital.

Methods:
From June 1–14, 2024, an ED-embedded PC consultation service was piloted in a 55-bed urban ED in Northern California (annual census ~60,000 visits). Two emergency physicians with additional PC training (non-fellowship) staffed the service. Providers were stationed in the main ED area from 11:00 AM to 1:00 PM, three weekdays per week. Consults were initiated by either ED staff or the embedded provider. Patients managed primarily by trauma surgery, those requiring emergent transfer, or those with Kaiser insurance were excluded. Consultations focused on goals-of-care discussions, disposition planning, and outpatient PC referrals through e-consults.

Results:
The pilot established a feasible workflow and increased referral to outpatient clinics. Clinical outcomes included 31% changing code status, 15% admitted to a lower level of care, 8% avoiding hospitalization, and 21% newly referred to outpatient PC. ED staff strongly agreed the service was valuable and unobtrusive.

Conclusions:
An ED-embedded palliative care consultation model is feasible, clinically meaningful, and well accepted in a safety-net hospital setting.

References: 1) George N, Phillips E, Zaurova M, Song C, Lamba S, Grudzen C. Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review. J Pain Symptom Manage. 2016 Jan;51(1):108-19.e2. doi: 10.1016/j.jpainsymman.2015.07.017. Epub 2015 Aug 31. PMID: 26335763.

2) Kistler EA, Stevens E, Scott E, Philpotts LL, Greer JA, Greenwald JL. Triggered Palliative Care Consults: A Systematic Review of Interventions for Hospitalized and Emergency Department Patients. J Pain Symptom Manage. 2020 Aug;60(2):460-475. doi: 10.1016/j.jpainsymman.2020.02.001. Epub 2020 Feb 12. PMID: 32061721.

3) Wang DH, Heidt R. Emergency Department Embedded Palliative Care Service Creates Value for Health Systems. J Palliat Med. 2023 May;26(5):646-652. doi: 10.1089/jpm.2022.0245. Epub 2022 Nov 11. PMID: 36367980.