Emergency Planning and Management
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Emergency Planning and Management

Key Messages

  • A palliative care emergency is a sudden and life-threatening change in a person’s condition. [1]
  • General practitioners (GPs), nurses, aged care services, emergency medical services and emergency departments (EDs) play a central role in providing acute medical care in these situations. [1,2]
  • If implemented appropriately in aged care facilities, advance care planning can reduce emergency hospitalisations for older people towards the end of their life and improve their management in case of hospital admission. [3-7]
  • Strategies to improve discharge planning and community support for individuals and their carers may reduce readmission of older adults into acute care. [2,5,8-11]
  • Early initiation of palliative care or referral to specialist services in the emergency department (ED) may contribute to less hospitalisation and help people remain at home at end-of-life. [3,4,6,7,12,13]

 


Background

Older people especially those living in residential aged care (residents) are particularly vulnerable group with complex care needs. [2] A high number of emergency transfers from residential aged care (RAC) to hospital/ED occur in the last months of life and this trend is likely to increase in Australia and other countries. [1,2,5,14]

Handovers of care are particularly important to reduce risk of receiving inappropriate treatment. [15] Planning ahead for emergencies (emergency planning) is good practice and can improve the quality and safety of care. [4,15,16]

Evidence Summary

Emergencies may be completely unexpected but some may be anticipated during assessment. [16] Advance care planning documentation can reduce the risk of poor communication and unnecessary or unwanted invasive treatments in the event of an unplanned medical event. However, advance care plan completion rates remain low even for chronically ill older adults. For more information see Advance Care Planning.

Out-of-hours palliative care emergencies may require a transfer to a hospital, however, with an increasing focus on out-of-hospital palliative care, ambulance services around Australia have developed specialised roles. Extended Care Paramedics (ECPs) or Community Care Paramedics, with additional training and equipment for responding to palliative care needs. [17-19]

Many older adults with serious and life-threatening illness present to emergency departments (EDs) with an acute deterioration in health. [12,13] One review notes that each year up to 75% of residents in aged care facilities are transferred to a hospital emergency department for acute changes in health. [3] Despite the intensive use of these services, older adults transferring to acute care from a residential aged care facility (RACF) often have adverse clinical outcomes or die. [3] Strategies to address poor transition between services or engagement in palliative emergency and discharge planning are evaluated in the literature. They include early referral from ED to a palliative specialist appointment, early discharge planning, telehealth community support, electronic health records and education for caregivers on symptom management. The evidence is not strongly in support of any one intervention, all seem to show promising outcomes for quality of life for the individual and their family. [6,8-13]

The decision for a transfer to ED is often complex and influenced by many factors [1,2,5] including 

  • access to a complete and current advance directive or similar documentation
  • whether discussions for end-of-life care had been held and any plans made
  • the perception of the quality of acute medical care in residential aged and in ED/hospital
  • expectations of relatives and communication between relatives and residential aged care staff
  • the availability of a GP particularly after hours
  • the capacity (skills, confidence and staff numbers) of nursing staff to manage chronic conditions, acute conditions, end-of-life planning, and fall prevention
  • adequate training of aged care staff particularly those working nights and on weekends. 

Although early initiation of palliative care in the ED may contribute to less hospitalisation and help people remain at home at end-of-life, it requires adequate community support to be effective. Currently there is insufficient evidence on which to base strategies to improve palliative care in the ED or to reduce hospital admissions. Advance care planning can identify preferred responses in an emergency. [3,4,6,7,12,13] To reduce the likelihood of readmission to acute care, several strategies that empower individuals and their carers in symptom management seem to be effective: education to improve knowledge of care and monitoring of change, and telephone support to help with symptom management. [8,9,11]

Quality Statement

Overall the quality of the reviews included in this synthesis was good, with most reviews considered acceptable or of high quality.

 

Page updated 17 September 2021
 

  • References

  • About PubMed Search

  1. Lemoyne SE, Herbots HH, De Blick D, Remmen R, Monsieurs KG, Van Bogaert P. Appropriateness of transferring nursing home residents to emergency departments: a systematic review. BMC Geriatr. 2019 Jan 21;19(1):17. doi: 10.1186/s12877-019-1028-z.
  2. Pulst A, Fassmer AM, Schmiemann G. Experiences and involvement of family members in transfer decisions from nursing home to hospital: a systematic review of qualitative research. BMC Geriatr. 2019 Jun 4;19(1):155. doi: 10.1186/s12877-019-1170-7.
  3. Dwyer R, Gabbe B, Stoelwinder J, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing. 2014 Nov;43(6):759-66.
  4. Dwyer R, Stoelwinder J, Gabbe B, Lowthian J. Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: A review of patient and organizational factors. J Am Med Dir Assoc. 2015 Jul 1;16(7):551-62.
  5. Bone AE, Evans CJ, Etkind SN, Sleeman KE, Gomes B, Aldridge M, et al. Factors associated with older people's emergency department attendance towards the end of life: a systematic review. Eur J Public Health. 2019 Feb 1;29(1):67-74. doi: 10.1093/eurpub/cky241.
  6. Buswell M, Lumbard P, Prothero L, Lee C, Martin S, Fleming J, et al. Unplanned, urgent and emergency care: what are the roles that EMS plays in providing for older people with dementia? An integrative review of policy, professional recommendations and evidence. Emerg Med J. 2016 Jan;33(1):61-70.
  7. Oulton J, Rhodes SM, Howe C, Fain MJ, Mohler MJ. Advance directives for older adults in the emergency department: a systematic review. J Palliat Med. 2015 Jun;18(6):500-5.
  8. Bull MJ, Boaz L, Jerme M. Educating family caregivers for older adults about delirium: A systematic review. Worldviews Evid Based Nurs. 2016 Jun;13(3):232-40.
  9. Clegg A, Siddiqi N, Heaven A, Young J, Holt R. Interventions for preventing delirium in older people in institutional long-term care. Cochrane Database Syst Rev. 2014 Jan 31;(1):CD009537.
  10. Conroy S, Stevens T, Parker S, Gladman J. A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'. Age Ageing. 2011 Jul;40(4):436-43.
  11. Slack C. Best practice for after-hours hospice symptom management: A literature review. Home Healthc Now. 2015 Oct;33(9):482-6.
  12. da Silva Soares D, Nunes CM, Gomes B. Effectiveness of emergency department based palliative care for adults with advanced disease: A systematic review. J Palliat Med. 2016 Jun;19(6):601-9.
  13. DiMartino LD, Weiner BJ, Mayer DK, Jackson GL, Biddle AK. Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review. J Palliat Med. 2014 Dec;17(12):1384-99.
  14. Wilson JG, English DP, Owyang CG, Chimelski EA, Grudzen CR, Wong HN, et al. End-of-Life Care, Palliative Care Consultation, and Palliative Care Referral in the Emergency Department: A Systematic Review. J Pain Symptom Manage. 2020 Feb;59(2):372-383.e1. doi: 10.1016/j.jpainsymman.2019.09.020. Epub 2019 Oct 3.
  15. CareSearch. Sharing Care [Internet]. Adelaide: CareSearch, Flinders University; 2021 [updated 2021 Aug 24; cited 2021 Sep 17].
  16. CareSearch. Emergencies [Internet]. Adelaide: CareSearch, Flinders University; 2017 [updated 21 February 2017; cited 2021 Jun 25].
  17. Gravier S, Noble AH. The role of paramedics in palliative care (1.19MB pdf). Response. 2019 Jan.
  18. SA Ambulance Service. Extended Care Paramedics [Internet]. Adelaide: SA Ambulance Service; 2021 [cited 2021 Jun 25].
  19. Agency for Clinical Innovation. Extended Care Paramedic [Internet]. Sydney: NSW Government; 2020 [cited 2021 Jun 25].

Definition

Palliative medical emergencies include: airway obstruction, bowel obstruction, delirium, major bleeding, spinal cord compression and seizures. (CareSearch).

Searches

Final search

(airway obstruction[majr] OR superior vena cava syndrome[majr] OR airway obstruction[ti] OR superior vena cava syndrome[ti] OR intestinal obstruction[ti] OR bowel obstruction[ti] OR Intestinal Obstruction[majr] OR confusion[majr] OR confusion[ti] OR delirium[ti] OR Hemorrhage[majr] OR haemorrhage[ti] OR hemorrhage[ti] OR Seizures[majr] OR seizure*[ti] OR Hypercalcemia[Majr] OR Hypercalcemia[ti] OR acute pain[majr] OR breakthrough pain[majr] OR acute pain[ti] OR breakthrough pain[ti] OR emergenc*[ti] OR emergent[ti] OR urgent[ti] OR emergency treatment[majr] OR emergencies[majr] OR emergency medicine[majr] OR emergency medical services[majr])