Chapter 8 206 performance (SQ plus ECOG 3-4), can be used to differentiate in the urgency of their needs. Research should be aimed at the question whether the use of SQ plus ECOG, as described in Table 3 in Chapter 5, improves patient outcomes such as quality of life and symptom burden. This could be studied in an ED using SQ plus ECOG to identify patients with palliative care needs in a prospective follow-up study design including questionnaires distributed to patients after 1, 3 and 6 months, and after 1 year. After identification in the ED, a multidimensional screening of problems should take place, for example by referring to the palliative care consultation team, or by screening by ED-clinicians using the 5-SPEED (see 8.5.2.2). As part of a cluster randomised trial, these outcomes can be compared with an ED in which standard care is provided. Also, SQ plus ECOG could be used to provide insight into the outcomes of ED-triggered palliative care as a care model. The outcomes of such a study can be a multidimensional approach to symptoms and the quality of palliative or end-of-life care including goal concordance. The study in Chapter 5 was conducted in patients who were already admitted to the ED. SQ plus ECOG could also provide insight if asked to the admitting clinician before admission to the ED. It could trigger goals-of-care discussions before ED-admission, which can contribute to appropriate care, with or without admission. This could be studied using a prospective cohort study design, in which the SQ plus ECOG could be asked to the ordering clinician during the triage process if it concerns a patient with advanced cancer. The primary outcome can be goal concordance of care, measured from data collected from patient records, for example by using the cues for documentation of proactive palliative care from 8.3.3.1. It is known that conducting palliative care implementation research in the ED can be challenging. George et al. found that their screening tool was considered feasible in clinical practice by 70% of the ED-clinicians; however, although the 78% of patients who were found by screening as having unmet palliative care needs, only 26% was referred to palliative care.97, 98 Successful implementation of a multidimensional screening intervention in the ED therefore depends on the quality of the implementation process. In Leiden University Medical Center’s ED, the acutely presenting older patient (APOP) screener was carefully introduced in the workflow of this ED. The implementation strategy, which was part of a plan-do-study-act study, included acquiring information from clinicians and patients, adaptation of the screener where appropriate, development of standard operation procedures, integration into electronic patient records and an educational intervention, which all occurred pre-implementation. Already two months after implementation, 31% vs 21% (p=0.0002) received a comprehensive geriatric assessment.99 This demonstrates that a plan-do-study-act strategy, which is part of participatory action research, can be an effective way to implement and study palliative care interventions in the ED.
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