Palliative care and prehospital emergency medicine: analysis of a case series

Ambulance transport to hospital in patients with a palliative ambulance management plan

The palliative ambulance management plan (AMP) is a document that assists paramedics in the acute care of patients with life-limiting illness. We retrospectively examined ambulance attendances for 111 patients with an AMP in the Hutt Valley, New Zealand. Ambulances attended 46 patients on 67 occasions with 40% transported to an acute hospital. Transport preferences were followed in 70% of attendances and 48% of transports to the hospital. Although uncontrolled symptoms were the most common indications for ambulance attendance, most of these attendances did not result in transport to hospital. AMPs provide paramedics with the ability to recognise a patient's wishes to remain at home and provide care that can enable this.

South African palliative care provider perspectives on emergency medical services in palliative situations

Introduction

Due to the frequent intersection of Emergency Medical Services (EMS) with palliative situations and the increasing global need for palliative care, there has been increased recognition of the need for palliative care integration with EMS. However, EMS and palliative care systems remain segregated in many Low-to-Middle Income Country contexts, as in South Africa (SA). The aim of this study was to gather perspectives of palliative care providers in SA concerning EMS in palliative situations.

Methods

A qualitative design employing individual semi-structured interviews was implemented. Ten interviews with experienced doctors and nurses holding post-graduate palliative medicine qualifications were conducted. Verbatim transcriptions of interviews were subjected to content analysis with an inductive-dominant approach to develop codes and categories.

Results

Four categories were developed: (1) Disposition towards EMS, (2) Perceived EMS challenges, (3) Positive EMS impact across patients' palliative care journeys and (4) Methods of EMS and palliative care system integration. Participants maintained an overall positive view of EMS and palliative care integration, noting the beneficial impact of EMS and suggesting various methods of integration, while also highlighting challenges and concerns.

Conclusion

EMS and palliative care integration would be mutually beneficial to both systems while benefiting patient well-being and the broader healthcare system. Potentially low-cost, high-impact interventions suggested by participants, such as palliative care cards for patients and enhancing EMS and palliative care system communication, represent efficacious and judicious use of limited resources within the SA context. Pilot studies investigating these suggestions should be conducted.

Comparison of Palliative Knowledge and Self-Efficacy Expectation of German Paramedics Between a Rural and an Urban Structured Emergency Medical Service Area

OBJECTIVE(S)

Differences in the German emergency medical service (EMS) can be seen in the countryside in contrast to the city with regard to travel distances to hospitals and in the access routes of EMS-physicians. In order to investigate the success of establishment of palliative crisis cards associated with training and the rural and urban EMS structures, two urban and two rural EMS areas were compared using the Paramedic Palliative Care Test (PARPACT). Methods: The PARPACT includes test items on palliative knowledge (PK, maximum score: 15 points) and palliative self-efficacy expectations (PSE, maximum score: 18 points), as well as items on palliative attitudes in dealing with palliative care patients. We used a 4-point Likert-type scale. For data analysis, nonparametric tests (χ-test and Mann-Whitney U test) were used in addition to descriptive analysis (frequencies, means, medians, standard deviations, and ranges). Results: In total, 291 out of 750 ambulance or EMS personnel participated in the voluntary survey. Rural ambulance or EMS personnel answered the PK-questions correctly more often on average (mean: 11.19, SD: 1.85) than urban ambulance or EMS personnel (mean: 9.18, SD: 2.39; Mann-Whitney U test: U=5040.000, P=.001). In addition, ambulance or EMS personnel with the highest level of training (3-year-trained paramedics) performed better in PK (mean: 10.38, SD: 2.31) than less intensively training ambulance or EMS personnel (mean: 9.58, SD: 2.43; Mann-Whitney U-test: U=8446.500, P=.004). In terms of PSE, rural ambulance or EMS personnel also achieved higher mean PSE-scores (mean: 12.55, SD: 2.60) than urban ambulance or EMS personnel (mean: 9.77, SD: 3.41; Mann-Whitney U-test: U=5148.500, P=.001). Conclusions: Better training in the EMS is associated with improved PK compared to less qualified nonphysician EMS staff. The establishment of palliative crisis cards and the structures in the city alone do not lead to improved knowledge and PSE.

Assessing the Acceptability and Feasibility of Leveraging Emergency Department Social Workers' Advanced Communication Skills to Assess Elderly Patients' Goals and Values

Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients' goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.

Emergency medical services and palliative care: a scoping review

OBJECTIVES

The aim of this study was to map existing emergency medical services (EMS) and palliative care literature by answering the question, what literature exists concerning EMS and palliative care? The sub-questions regarding this literature were, (1) what types of literature exist?, (2) what are the key findings? and (3) what knowledge gaps are present?

DESIGN

A scoping review of literature was performed with an a priori search strategy.

DATA SOURCES

MEDLINE via Pubmed, Web of Science, CINAHL, Embase via Scopus, PsycINFO, the University of Cape Town Thesis Repository and Google Scholar were searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Empirical, English studies involving human populations published between 1 January 2000 and 24 November 2022 concerning EMS and palliative care were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and full texts for inclusion. Extracted data underwent descriptive content analysis and were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines.

RESULTS

In total, 10 725 articles were identified. Following title and abstract screening, 10 634 studies were excluded. A further 35 studies were excluded on full-text screening. The remaining 56 articles were included for review. Four predominant domains arose from included studies: (1) EMS' palliative care role, (2) challenges faced by EMS in palliative situations, (3) EMS and palliative care integration benefits and (4) proposed recommendations for EMS and palliative care integration.

CONCLUSION

EMS have a role to play in out-of-hospital palliative care, however, many challenges must be overcome. EMS provider education, collaboration between EMS and palliative systems, creation of EMS palliative care guidelines/protocols, creation of specialised out-of-hospital palliative care teams and further research have been recommended as solutions. Future research should focus on the prioritisation, implementation and effectiveness of these solutions in various contexts.

Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study

Background

Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting.

Objective

The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP.

Methods

This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected.

Results

PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions.

Conclusions

This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.

Co-designing Community Out-of-hours Palliative Care Services: A systematic literature search and review

BACKGROUND

In order to provide responsive, individualised and personalised care, there is now greater engagement with patients, families and carers in designing health services. Out-of-hours care is an essential component of community palliative care. However, little is known about how patients, families and carers have been involved in the planning and design of these services.

AIM

To systematically search and review the research literature that reports on how out-of-hours palliative care services are provided in the community and to identify the extent to which the principles of co-design have been used to inform the planning and design of these services.

DESIGN

Systematic literature search and review.

DATA SOURCES

A systematic search for published research papers from seven databases was conducted in MEDLINE, PsycINFO, Embase, Emcare, PubMed, CINAHL and Web of Science, from January 2010 and December 2021. Reference list searches of included papers were undertaken to source additional relevant literature. A manifest content analysis was used to analyse the data.

RESULTS

A total of 77 papers were included. The majority of out-of-hours services in the community were provided by primary care services. The review found little evidence that patients, families or carers were involved in the planning or development of out-of-hours services.

CONCLUSION

Incorporating patients, families and carers priorities and preferences in the planning and designing of out-of-hours palliative care service is needed for service providers to deliver care that is more patient-centred. Adopting the principles of co-design may improve how out-of-hours care scan be delivered.

Emergency medical services and palliative care: protocol for a scoping review

INTRODUCTION

The purpose of emergency medical services (EMS) is to preserve life and limb in emergency situations. Palliative care, however, is not concerned with 'life-saving' measures, but the prevention and relief of suffering. While these care goals appear to conflict, EMS and palliative care may be complementary if integrated. The aim of this scoping review is to map existing literature concerning EMS and palliative care by identifying literature types, extracting key findings and noting limitations using descriptive analysis.

METHODS AND ANALYSIS

The framework of Arksey and O'Malley will direct this review. The following databases will be searched: MEDLINE via PubMed, Web of Science, CINAHL, Embase and PsycINFO. In addition, the University of Cape Town Thesis Repository and Google Scholar will be searched for relevant grey literature. Empirical studies concerning EMS and palliative care published between January 2000 and September 2021 will be included. Article selection will be performed and presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist. Extracted data from included articles will undergo descriptive analysis with findings being reported in a discussion format.

ETHICS AND DISSEMINATION

This review will identify and describe existing literature concerning EMS and palliative care, highlighting key findings and knowledge gaps in the subject area. Findings will be disseminated to relevant stakeholders through peer-reviewed, open-access journal publication. As no participants will be involved and selected literature is publicly available, no ethical approval will be required.

Mapping the future for research in emergency medicine palliative care: A research roadmap

BACKGROUND

The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation.

OBJECTIVE

The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research.

METHODS

Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics.

RESULTS

Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC.

CONCLUSIONS

There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

Decision-Making by Emergency Medicine Personnel in Prehospital Treatment of Patients Receiving Palliative Care: A Questionnaire, Comparative Cohort Study

OBJECTIVE

Palliative care is an approach to improve quality of life in patients with life-limiting diseases. The sudden nature of such conditions involves emergency providers as the first responders, who have roles in delivering appropriate care to meet patients' needs. In this study, we evaluated whether previous experience in palliative care among paramedic students could affect their decision-making skills in prehospital work.

METHODS

This questionnaire-based prospective cross-sectional study was conducted from October 2019 to November 2020. We compared two groups of paramedic students in a tertiary hospital in Bangkok, Thailand. The class of 2019 did not attend palliative care courses and the class of 2020 completed a 2-week course regarding in-hospital palliative care services. Questionnaires including rating scales and checklists and involving cases with and without malignancy were completed via a web-based data collection form. The reliability of the questionnaire was tested. Decision-making skills were categorized into seven domains comprising life-sustaining treatment, withholding or withdrawing life-sustaining treatment, advance care planning, self-autonomy, decision-making capacity and surrogate decision-makers, prehospital dyspnea management, and communication skills.

RESULTS

Among 57 paramedics, 52 (91%) completed the questionnaire. There was no significant difference in decision-making between the two groups in all seven domains (p>0.050). Overall, participants more often recognized patients who were eligible for palliative care and made more decisions to withhold or withdraw life-sustaining treatment when patients had advanced malignancy than in cases of non-malignancy (100% and 84.6% respectively, p=0.006).

CONCLUSION

Our findings showed that the decision-making process for patients regarding prehospital palliative care was not significantly different between two groups of emergency personnel with and without in-hospital palliative care experience.

Hospice and Comfort Care Patient Utilization of Emergency Medical Services

Introduction: Emergency medical services (EMS) were designed to prevent death and disability. When hospice patients call 9-1-1, it can create challenging scenarios for EMS providers, patients, and families. The objective of this investigation is to understand the characteristics of hospice and comfort care patient EMS utilization in Alameda County, California. Methods: This is a 15-month (7/1/2019-10/1/2020) retrospective observational study in Alameda County using electronic patient care reports (PCRs). The search terms "hospice" and "comfort measures only" were applied to PCR narratives. Results: Of the 237,493 EMS provider response calls, 534 (0.2%) were for hospice and comfort care patients. One hundred seventy-four (32.6%) calls were from skilled nursing facilities versus 343 (64.2%) from private residences. Among the most common primary impressions were respiratory complaints (96; 18.0%), altered mental status (96; 18.0%), weakness (58; 10.9%), and cardiac arrest (45; 8.4%). The most common interventions included blood glucose (244; 45.7%), electrocardiogram (181; 33.9%), and intravenous placement (170; 31.8%). Of note, eight (1.5%) patients received cardiopulmonary resuscitation, and an additional eight (1.5%) patients were intubated endotracheally or received a supraglottic airway device for intubation. Sixty-eight (12.7%) patients received medications, the most common of which were fentanyl (17; 3.2%) and albuterol (16; 3.0%). Of note, five (0.9%) patients received naloxone. Ultimately, 468 (87.6%) patients were transported by EMS. Of the 33 (6.1%) patients who died on the scene, three received resuscitation attempts. Conclusion: Although EMS providers encounter hospice and comfort care patients infrequently, awareness of hospice services and comprehensive end-of-life care communication skills with patients and family should be an important part of EMS.

Effect of a Mobile Integrated Hospice Healthcare Program on Emergency Medical Services Transport to the Emergency Department

Objective: To evaluate the effect of a Mobile Integrated Hospice Healthcare (MIHH) program including hospice education and expansion of paramedic scope of practice to use hospice medication kits. Primary outcome was the effect on hospice patient transport to the Emergency Department. Secondary outcomes included reasons for patient transport and review of MIHH kit utilization. Methods: In 2015, the project was implemented in Ventura County, California in collaboration with county emergency medical services (EMS) agency, first response/transport organizations, and hospice programs. Paramedic supervisors received 30 hours of hospice training focusing on palliative care, grief and crisis counseling. When 9-1-1 was called for a patient, EMS first responders arrived on scene, determined a patient was enrolled in hospice and then contacted trained MIHH. Results: Six months (2/2015-7/2015) prior to project implementation the percentage of hospice patients transported to the ED averaged 80.3% (98/122). During the first (8/2015-7/2016), second (8/2016-7/2017) and third year (8/2017-7/2018) after project implementation, the percentage of hospice patients transported to the ED was 36.2% (68/188), 33.2% (63/190) and 24.8% (36/145) respectively. A total of 523 hospice patients were cared for by MIHH during this three-year interval. Of those hospice patients transported, the most common reason for transport was fall/trauma. The MIHH hospice kit was only used once in the field. Odds ratio for hospice transportation to the ED before and after project implementation was 0.125 (95% Confidence Interval: 0.077 to 0.201; p < 0.0001). This represents an absolute reduction risk of 46.6% (95% Confidence Interval: 38.53% to 54.72%). Conclusion: MIHH decreased the transportation of hospice patients to the ED. MIHH provided hospice education, provided family grief support and developed treatment plans with hospice nurses. An expanded scope of practice, including a paramedic hospice kit, was not contributory to this decrease.

South African paramedic perspectives on prehospital palliative care

Background

Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice.

Methods

A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings.

Results

Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist.

Conclusion

Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Management of oncology-related emergencies at the emergency department: A long-term undertaking

Background:

The emergency department at the Singapore General Hospital is an emergency department with an annual census of 140,000 and oncology-related attendances of about 4000 (2.8%). These patients are often admitted for further care. Palliative care in the emergency department for these patients is often minimal. The aim of this study was to determine the state of current management of oncology-related emergencies at the Singapore General Hospital’s emergency department, hence identifying specific areas for intervention.

Methods:

We carried out a retrospective data review of all Singapore General Hospital’s emergency department patients who had either cancer-related diagnoses or were admitted to the Medical Oncology Department in October 2018. Simple statistical analysis was then performed using IBM SPSS version 21.

Results:

Of 308 identified patients, there was approximately equal distribution by sex. The women were generally younger than the men (61.33 ± 13.63 years vs 67.36 ± 12.02 years, p = 0.063, confidence interval −8.94 to −3.13). Seventy-two (23.4%) of the patients arrived at emergency department by ambulance. The mean emergency department length of stay was 4.25 h. About half of the patients had either lung, colorectal, or breast as their primary site of cancer. There was no correlation between clinical severity according to the National Early Warning Scores and triage complaint-type or emergency clinical diagnosis. More than 90% were admitted, with about 32.6% dying during their inpatient stay. High National Early Warning Scores were significantly associated with mortality.

Conclusion:

There is large potential for interventions to improve patient well-being in the pre-hospital setting and emergency department. Given the sizable number of patients with poor outcomes, palliative care is also of paramount importance.

Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases

Introduction

The aim of our study was to investigate challenges faced by emergency physicians (EPs) who provide prehospital emergency care to patients with advanced incurable diseases and family caregivers in their familiar home environment.

Methods

Qualitative study using semistructured interviews with open-ended questions to collect data from 24 EPs. Data were analyzed using qualitative content analysis.

Results

We identified nine categories of challenges: structural conditions of prehospital emergency care, medical documentation and orders, finding optimal patient-centered therapy, uncertainty about legal consequences, challenges at the individual (EP) level, challenges at the emergency team level, family caregiver's emotions, coping and understanding of patient's illness, patient's wishes, coping and understanding of patient's illness, and social, cultural, and religious background of patients and families. EPs strengthened that the integrations of specialized prehospital palliative care services improved emergency care by providing resources to patients and family caregivers, enhancing the quality and availability of medical documentation and accessibility of aftercare in emergencies. Areas of improvement that were identified were to promote emergency physicians' knowledge and skills in palliative care, communication, and family caregiver support by education and training. Furthermore, structures for better care on-site, thorough medical documentation, and specialized palliative care emergency facilities in hospital and prehospital care were requested.

Conclusion

Prehospital emergency care in patients with advanced incurable diseases in their familiar home environment may be improved by training EPs in palliative care, communication, and caregiver support competences. Results underline the importance of collaborative specialized palliative care and prehospital emergency care.

Paramedics providing palliative care at home: A mixed-methods exploration of patient and family satisfaction and paramedic comfort and confidence

OBJECTIVE

Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.

METHODS

In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.

RESULTS

In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = &lt; 0.001) as did confidence in palliative care without transport (p = &lt; 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.

CONCLUSIONS

After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.

Nursing home residents at the Emergency Department: a 6-year retrospective analysis in a Swiss academic hospital

The increasing number of elderly persons produces an increase in emergency department (ED) visits by these patients, including nursing home (NH) residents. This trend implies a major challenge for the ED. This study sought to investigate ED visits by NH residents in an academic hospital. A retrospective monocentric analysis of all ED visits by NH residents between 2005 and 2010 in a Swiss urban academic hospital. All NH residents aged 65 years and over were included. Socio-demographic data, mode of transfer to ED, triage severity rating, main reason for visit, ED and hospital length of stay, discharge dispositions, readmission at 30 and 90 day were collected. Annual ED visits by NH residents increased by 50 % (from 465 to 698) over the study period, accounting for 1.5 to 1.9 % of all ED visits from 2005 to 2010, respectively. Over the period, yearly rates of ED visits increased steadily from 18.8 to 27.5 per 100 NH residents. Main reasons for ED visits were trauma, respiratory, cardiovascular, digestive, and neurological problems. 52 % were for urgent situations. Less than 2 % of NH residents died during their ED stay and 60 % were admitted to hospital wards. ED use by NH residents disproportionately increased over the period, likely reflecting changes in residents and caregivers' expectations, NH staff care delivery, as well as possible correction of prior ED underuse. These results highlight the need to improve ED process of care for these patients and to identify interventions to prevent potentially unnecessary ED transfers.