Attitudes and knowledge of emergency doctors towards end-of-life care in the emergency department: a national survey.

BACKGROUND: Emergency departments (EDs) are seeing an increase in patients requiring end-of-life (EOL) care. There is paucity of data of attitudes and knowledge of physicians providing EOL care in the ED both internationally and in Ireland. OBJECTIVE: The aim of this project was to assess the attitudes and knowledge of ED physicians towards EOL care. METHODS: This was a cross-sectional electronic survey of ED physicians working in Irish EDs and was facilitated through the Irish Trainee Emergency Research Network over a 6-week period. The questionnaire covered the following domains: demographic data, awareness of EOL Care, views and attitudes towards EOL care. RESULTS: Of a potential 679 respondents, 441 responses were received, of which 311 (response rate of 44.8%) had fully completed the survey across 23 participant sites. Majority of the respondents were under the age of 35 (62%), were male (58%) and at Senior House Officer level (36%). In terms of awareness, 32% (98) of respondents were not aware of palliative care services in their hospitals while only 29% (91) were aware of national EOL guidance. Fifty-five percent (172) reported commencing EOL care in the ED, however 75.5% (234) respondents reported their knowledge of EOL care to be limited or non-existent. Only 30.2% respondents felt comfortable commencing EOL care in the ED without speciality team input. There appears to be a lack of clarity on the roles and responsibilities of emergency medicine nurses and doctors in the care of the dying patient in ED with only 31.2% (95) being clear on this role. Significant differences were observed associated with clinical experience and physician grade. CONCLUSION: This study has highlighted a lack of awareness and knowledge of EOL care particularly amongst less experienced emergency medicine doctors. Formalized training and education programs in the provision of EOL care in the ED will improve comfort levels and knowledge amongst the emergency medicine doctors and improve the quality of care provided.

The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine.

BACKGROUND: Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team's service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. METHODS: The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team's first 12 months of operation using the prospectively maintained service database. RESULTS: Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. CONCLUSION: Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.