End-of-Life Management Protocol Offered Within Emergency Room: a Multicentre Study (EMPOWER)

NCT03906747 | Unknown

• 1 other identifier: HSRG-EoL17Jun001
• Study Type: observational
• Target: 900
• Locations: 1 country
• Sites: 3

Brief Summary

End-of-life (EOL) care has garnered increasing recognition and acceptance in the field of emergency medicine. Some emergency departments (EDs) in Singapore have instituted or plan to institute EOL care as part of the workflow. However, the EOL protocols are not standardised across all these EDs. The adherence to and quality of EOL care have not been formally measured in all institutions. Hence, gaps to improve the quality of care have yet to be determined. The aims are to systematically measure the current quality of EOL care in three Singapore hospital EDs and identify the quality gaps; formulate interventions to address these gaps and implement the improved EOL care; and measure the improvement post-implementation. The investigators hypothesise that the current quality of EOL care in three EDs is suboptimal and the interventions planned will improve the quality of care provided. The study team plans to conduct an interrupted time series study to detect whether the interventions have an effect significantly greater than any underlying trend over time. The quality of care indicators to be measured are timely identification of patients who require EOL care, adequacy of symptom control based on compliance to prescriptions, opportunities to discuss and develop an individualised care plan, perceived quality of care by healthcare providers and next-of-kin, and cost effectiveness. Planned interventions include refining the protocol with collaboration of content experts in palliative care, education and training of healthcare providers, and addressing specific gaps identified to improve cost effectiveness. The results of this study will form the standardisation and foundation for establishing the national benchmark for quality of EOL care in Singapore EDs.

Conditions

Palliative Care; Emergency Department; Cost Effectiveness

Outcome Measures

Primary Outcomes (3)

• Mortality rate within 48 hours of hospital admission

  Proportion of patients who fits criteria of EOL who died within 48 hours (patient centred)

  26 months

• Satisfaction assessed by Care of the Dying Evaluation (CODE) questionnaire

  Proportion of next-of-kin who perceived that they were adequately supported (family centred)

  26 months

• Satisfaction of healthcare workers with care rendered assessed by a staff survey

  Level of satisfaction of with the overall quality of end of life care provision by doctors at ED

  26 months

Secondary Outcomes (1)

• Proportion of patients in EOL pathway who have documentation of an individualised care plan, and symptoms who are prescribed with appropriate medicine

  26 months

Study Arms (3)

Patients

Patients at their end-of-life (EOL) phase attending the emergency department

Other: Review of medical records

Family members and next-of-kin of (EOL) patients

Family members and next-of-kin of EOL patients in the emergency department

Other: Interviews, questionnaire and focused group discussions

Healthcare workers

Comprised of doctors in the emergency department, nurses and general practitioners

Other: Interviews, questionnaire and focused group discussions

Interventions

Interviews, questionnaire and focused group discussions OTHER

To determine the effectiveness of the quality of care as perceived by relatives, we will perform a survey during the ED stay, with the next-of-kin to patients who was on the EOL pathway using a questionnaire developed for ED settings. The questionnaire will be administered by the research assistant face-to-face in the emergency department to assess the quality of care and the level of support provided to patients and their families in the last days of life. We will also determine the level of staff's knowledge and perception of the EOL care using a locally-designed self-administered anonymous survey. A focus group discussion (FGD) will be formed in each hospital to identify the gaps to the current EOL care by structured questionnaire. The group will also make recommendations to improve the quality of the EOL care. There will be separate FGD for: (i) healthcare professionals (ii) family members and (iii) general practitioners who will care for the patient if terminally discharged.

Family members and next-of-kin of (EOL) patients; Healthcare workers

Review of medical records OTHER

Electronic medical records will be reviewed to collect the following data: 1. Proportion of patients who fits criteria of EOL who died within 48 hours; 2. Proportion of patients on EOL pathway who have documentation that patient and/or family are given opportunities to discuss an individualised care plan; 3. Proportion of patients on EOL pathway who have documentation of an individualised care plan that is followed; 4. Proportion of patients on EOL pathway who have symptoms who are prescribed with medicines with individualised indications for use, dosage and route of administration

Patients

Eligibility Criteria

• Age: 21 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Probability Sample

Study Population

Patients attending the emergency department at their end-of-life phase, relatives of such patients and healthcare workers involved with care

You may qualify if:

• Actively dying patient or high likelihood of mortality within 48 hours
• Family accepts that the goals of care are provision of comfort, symptom relief and respect of dignity
• Patient is not a candidate for cardiopulmonary resuscitation, endotracheal intubation or transfer to the intensive care unit
• Family members want to stay by patient's bedside
• Any of the life-limiting conditions such as chronic frailty with poor functional state and limited reversibility (Karnofski Performance Scale \<40%), chronic severe illness with poor prognosis, or other deteriorating conditions and at risk of dying with complications that are not reversible, as subject to the treating clinician's judgment

You may not qualify if:

• Vulnerable population e.g. prisoners, pregnant women
• Patients, relatives or staff who refused to participate
• Patients who have been recruited, or had declined participation, in the previous ED attendance(s)

Sponsors & Collaborators

• National University Hospital, Singapore: lead
• Singapore Clinical Research Institute: collaborator

Study Sites (3)

National University Hospital

Singapore, 119074, Singapore

Location

Changi General Hospital

Singapore, 529889, Singapore

Location

Khoo Teck Puat Hospital

Singapore, 768828, Singapore

Location

Related Publications (2)

• Chua MT, Sen Kuan W, Zheng CQ, Tiah L, Kumar R, Wong YKY, Lin J, Liang S, Mayland CR, Shi L, Ibrahim I, Pal RY. Validation of "Care of the Dying Evaluation" in Emergency Medicine (CODE-EM): pilot phase of end-of-life management protocol offered within emergency room (EMPOWER) study. Ann Palliat Med. 2021 Jun;10(6):6145-6155. doi: 10.21037/apm-21-380. Epub 2021 May 25.

  PMID: 34118856 DERIVED

• Yash Pal R, Kuan WS, Tiah L, Kumar R, Wong YKY, Shi L, Zheng CQ, Lin J, Liang S, Segara UC, Yong WC, Chan NGC, Chua MT, Ibrahim I. End-of-life management protocol offered within emergency room (EMPOWER): study protocol for a multicentre study. BMJ Open. 2020 Apr 28;10(4):e036598. doi: 10.1136/bmjopen-2019-036598.

  PMID: 32350018 DERIVED

MeSH Terms

Conditions

Emergencies

Interventions

Interviews as Topic; Surveys and Questionnaires

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Data Collection; Epidemiologic Methods; Investigative Techniques; Health Care Evaluation Mechanisms; Quality of Health Care; Health Care Quality, Access, and Evaluation; Public Health; Environment and Public Health

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: February 25, 2019
• First Posted: April 8, 2019
• Study Start: January 18, 2019
• Primary Completion: December 31, 2021
• Study Completion: December 31, 2022
• Last Updated: April 13, 2022

Record last verified: 2022-03

Data Sharing

• IPD Sharing: Will not share

Locations

SG (3)