Evaluation of a clinical decision support tool to promote early palliative care for seriously ill emergency department patients (PRIM-ER): a mixed-methods RE-AIM study

Early initiation of palliative care improves care for patients with serious, life-limiting illness in the emergency department (ED). The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize early initiation of palliative care through the use of an electronic health record -based clinician decision support (CDS) tool (Support-ED) to identify high risk patients most likely to benefit from primary palliative care and provide clinician training and “nudges” within the emergency department setting. Best Practice Alerts (BPAs), automated notifications either interruptive or non-interruptive to help guide clinicians, were one component of the Support-ED suite. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated the Support-ED tool at the delivery-site level through mixed-methods analysis of implementation audit feedback, post-implementation surveys, and in-depth interviews with site Principal Investigators (PIs) and physician champions. 33 sites completed audit feedback and post-implementation surveys, and 7 sites participated in interviews. REACH: Providers (Physicians, Physician Assistants and Nurse Practitioners) were considered the primary stakeholder for the intervention, followed by nurses and trainees. EFFECTIVENESS: A majority (23/33, 70%) of site PIs said they would recommend the tool to other EDs. BPAs identifying hospice patients were most favorable. ADOPTION: Half of the sites ( n = 17) implemented more than one BPA, with 36% of sites ( n = 12) implementing three BPAs. One-third of sites implemented a non-interruptive banner instead of a BPA (11/33, 33%). IMPLEMENTATION: Overall, 82% ( n = 27) of sites reported making changes to the intervention during implementation. Common barriers included providers perceived relevance, competing department priorities, and provider’s alert fatigue. The COVID-19 pandemic was a facilitator in creating role relevance and a barrier due to staff turnover. MAINTENANCE: One-year post-intervention, almost all sites ( n = 31) were still using a component of the intervention and a majority ( n = 26, 79%) had plans for continued use. Health systems can effectively integrate and maintain ED-based palliative care electronic CDS tools, provided the EHR components are thoughtfully tailored and adaptable to unique workflows and environments, and are considered clinically relevant to the contexts of care and clinical end-users. Opportunities exist to optimize CDS maintenance and explore considerations. Clinicaltrials.gov, NCT03424109 Registered 6 February 2018, https://classic.clinicaltrials.gov/ct2/show/NCT03424109 .