The emergency department (ED) offers specific challenges and opportunities for palliative care–related programs and initiatives. ED providers serve an important role in both the initiation and the continuation of palliative care for the seriously ill as ED visits often increase within the last 6 months of life.¹ Palliative care is specialized care for the seriously ill that focuses on improving quality of life at any age and at any stage of disease. Palliative care can be provided along with curative treatment in the ED and often improves patient quality of life, symptom control, and transitions of care, without shortening survival or disrupting potential life-prolonging interventions.^{2, 3} Hospice care is applicable for a subset of seriously ill patients with less than 6 months of expected survival. ED referrals and care transitions from ED to hospice⁴ may similarly impact patient outcomes and quality of life. However, systematic quality measurements of the impact of ED-palliative care interventions are rare.

National organizations such as Center to Advance Palliative Care (CAPC), American Academy of Hospice and Palliative Medicine (AAHPM), and the Hospice and Palliative Nurses Association (HPNA) provide guidance to programs by identifying quality metrics for palliative care.^5-7 For example, CAPC categorizes metrics into outcome measures, process measures, and transition plans.^{5, 6} Measuring What Matters (AAHPM and HPNA) is a consensus recommendation for a portfolio of ten performance measures to guide hospice and palliative medicine programs for assessment and improvement.^{5, 6} In addition, AAHPM developed an implementation guide for patient-reported outcome performance measures for quality improvement and regulatory reporting efforts.⁷ These quality measures were designed for hospitalized (>24 h) or hospice patients and are not specific to the ED setting. Therefore, there is little guidance on how to measure quality improvements specifically related to ED palliative care interventions. This gap was explored by a committee on convened by the Palliative Medicine Section of the American College of Emergency Physicians, in 2017, to develop a consensus on best practices for ED palliative care.⁸ We present the work of this committee to articulate a set of relevant ED palliative care quality measures using an expert consensus approach (Table 1).

The committee included academic (MR, RG, SL, EI) and community (TL, RP) EM and HPM physicians (DW, KA) and an EM nurse (GC), with representation from EM administrative leadership and those with dual EM and HPM board certification. The committee retained its structure with no attrition or addition of members throughout the modified nominal group expert consensus process. The group convened via a 60-minute monthly conference call that occurred for approximately 2 years (October 2017–July 2019).

The quality measures were defined via five consensus process phases: (1) identifying preassessments and personnel needs for ED palliative care quality measurement; (2) identifying specific ED palliative care quality measures via literature review and expert consensus; (3) categorizing ED-palliative care quality measures into the three domains of clinical outcomes, operational sustainability, and patient satisfaction; (4) within each domain, grouping the measures for ED palliative care initiatives along the patient care continuum—from arrival in ED to identification of eligible patient to final disposition; and (5) conference calls and face-to-face meetings to finalize the document (Table 1).

We derived the three main domains of clinical outcomes, operational sustainability, patient satisfaction from the domains of quality care set forth by the Centers for Medicare & Medicaid Services (e.g., clinical outcomes, operational sustainability, patient satisfaction, financial impact, and adherence to the joint commission standards).⁹ Clinical outcome measures focus on assessing the quality of clinical care services provided in the ED for patients with palliative care–related needs, for example, assessment and management of pain and distressing symptoms in a timely manner. Operational sustainability measures focus on processes such as patient flow, disposition, readmissions, and resource utilization. For example, use of palliative care order set or the ED length of stay in those with ED palliative care consultations. Patient or customer satisfaction measures assess the patient and/or their family member/caregiver's perceptions of quality of care provided in the ED; for example, through Press Ganey scores or other surveys. We also reviewed and modified some of the previously defined quality measures^6-8 that had ED relevance. For example, screening for distressing symptoms, psychosocial needs, spiritual/religious concerns, and documentation of health proxy or advance directives.

In each of the three main domains, we further subcategorized the quality measures to reflect the fact that ED palliative care initiatives may often be implemented along the continuum of a patient's course in the ED. Therefore, the subcategories range from ED arrival to final disposition, including: (1) patient screening and identification, (2) assessment and management of palliative care needs, (3) referrals for palliative care services, (4) appropriate transitions of care, and (5) other categories such as order set/protocol-related measures.

We prioritized the inclusion of ED palliative care quality measures that were time based, patient specific, and actionable. ED performance management is often centered around improving patient flow and reducing crowding; thus, throughout-based, “nonclinical” metrics are highly relevant for ED palliative care interventions.

One example is ED arrival time to palliative care screening or time from palliative care consultation to final disposition. “Clinical” time-based measures such as time from pain assessment to delivery of pain management are important considerations. To assess the full impact of ED palliative care interventions, the time period for assessing quality may need to extend to 24 to 72 h after admission. For example, when assessing whether an ED palliative care consultation leads to a higher rate of having an early family meeting in those patients who died, a program may need to gather data 24 to 72 h after admission from ED.

Patient-specific measures are valuable to an ED for: (1) identifying the patient population of interest for screening/implementation of ED palliative care initiatives—for example, an ED serving multiple long-term care facilities should focus their palliative care screening efforts on the elderly patients arriving from those facilities and identify a suitable tool (e.g., frailty); (2) identifying an individual ED patient's palliative care needs, for example, the number of patients who screen positive for the “surprise” question—“would you be surprised if the patient died within this year?”; (3) identifying and allocating appropriate institutional resources based on patient load, for example, number of ED palliative care consultations or ED hospice referrals requested; and (4) measuring financial impact and outcomes, for example, number of interventions such as ventilator or dialysis after an ED palliative care consultation.

Actionable ED palliative care quality measures help standardize ED best practices and transitions of care. Examples include documentation of advance directives (e.g., in those admitted to the intensive care unit), use of palliative care order sets, or number of ED deaths where spiritual/chaplain support was offered. Also, reviewing patient suggestions via satisfaction surveys and implementing changes based on data has the potential to impact overall patient care in the ED.

We recognize that there exists a wide variability in ED access to resources related to palliative and hospice care. Reviewing ED palliative care quality measures before implementation may help guide an ED in defining how and where to focus an ED palliative care initiative. Measuring the impact of initiatives can provide meaningful feedback for an organization and help make the case for strategic institutional investment. ED data collection has unique challenges, often related to time constraints and limited personnel support. Therefore, measures that are easy to collect/document and fit within preexisting ED processes and roles of staff are most likely to be successful. One example is having a triage nurse to identify patients (using set criteria) to be screened for palliative care needs. Similarly automatic triggers and alerts in the electronic record may assist data entry and collection, such as use of palliative care order sets or smart phrases for documenting goals of care conversations or advance directives. What measures to report (ED readmissions vs. cost savings) and to whom will be based on alignment with departmental and institutional goals.^{8, 10}

Partnerships of ED palliative care champions with the palliative care team members are valuable. This is helpful for assessing impact and effectiveness of ED initiatives during the hospital stay in addition to defining the roles and responsibilities of interdisciplinary team members outside and within the ED such as case managers, chaplains, or social workers in screening, needs assessment, management, and data gathering for ED palliative care initiatives. Staff education is a very important aspect of any quality improvement initiative; however, the scope of this paper does not list ED palliative quality measures related to educational initiatives such as increased knowledge or impact provider attitudes related to ED palliative care.

In conclusion, these ED palliative care quality measures seek to provide guidance for EDs seeking to define a problem, assess the department's palliative care needs, and/or measure the progress/impact/effectiveness of an implemented ED palliative care initiative across the patient care continuum. Ideally, these ED palliative care quality measures would be used for a continuous cycle of quality improvement.

急诊科 (ED) 为姑息治疗相关计划和举措提供了具体的挑战和机遇。ED 提供者在开始和继续对重病患者进行姑息治疗方面发挥着重要作用，因为 ED 就诊次数通常在生命的最后 6 个月内增加。¹姑息治疗是针对重病患者的专门治疗，其重点是改善任何年龄和疾病任何阶段的生活质量。姑息治疗可以与急诊室的治愈性治疗一起提供，通常可以改善患者的生活质量、症状控制和护理过渡，而不会缩短生存期或破坏潜在的延长生命的干预措施。^{2, 3}临终关怀适用于预期生存期少于 6 个月的部分重病患者。ED 转诊和从 ED 到临终关怀的护理过渡⁴可能同样影响患者的结果和生活质量。然而，对 ED 姑息治疗干预措施影响的系统质量测量很少。

姑息治疗推进中心 (CAPC)、美国临终关怀和姑息医学学会 (AAHPM) 以及临终关怀和姑息治疗护士协会 (HPNA) 等国家组织通过确定姑息治疗的质量指标为项目提供指导。^5-7例如，CAPC 将度量标准分为结果度量、过程度量和过渡计划。^{5, 6} Measuring What Matters（AAHPM 和 HPNA）是对十项绩效衡量组合的共识建议，用于指导临终关怀和姑息医学计划的评估和改进。^{5, 6}此外，AAHPM 还制定了患者报告结果绩效衡量实施指南，以提高质量和监管报告工作。⁷这些质量措施是为住院（> 24 小时）或临终关怀患者设计的，并不特定于 ED 环境。因此，关于如何衡量与 ED 姑息治疗干预相关的质量改进的指导很少。美国急诊医师学会姑息医学科于 2017 年召集的一个委员会探讨了这一差距，以就 ED 姑息治疗的最佳实践达成共识。⁸我们介绍了该委员会的工作，使用专家共识方法阐明了一套相关的 ED 姑息治疗质量措施（表 1）。

该委员会包括学术（MR、RG、SL、EI）和社区（TL、RP）EM 和 HPM 医生（DW、KA）和一名 EM 护士（GC），以及来自 EM 行政领导和具有双重 EM 和 HPM 的代表板认证。在整个修改后的名义小组专家共识过程中，委员会保留了其结构，没有减少或增加成员。该小组通过大约 2 年（2017 年 10 月至 2019 年 7 月）举行的每月 60 分钟的电话会议召开会议。

质量措施是通过五个共识过程阶段定义的：(1) 确定 ED 姑息治疗质量测量的预评估和人员需求；(2) 通过文献回顾和专家共识确定具体的 ED 姑息治疗质量措施；(3) 将 ED 姑息治疗质量措施分为临床结果、运营可持续性和患者满意度三个领域；(4) 在每个领域内，将 ED 姑息治疗举措的措施按照患者护理的连续性进行分组——从到达 ED 到识别符合条件的患者再到最终处置；(5) 电话会议和面对面会议以最终确定文件（表 1）。

我们从医疗保险和医疗补助服务中心提出的优质护理领域（例如，临床结果、运营可持续性、患者满意度、财务影响和遵守联合委员会标准）。⁹临床结果测量的重点是评估急诊室为有姑息治疗相关需求的患者提供的临床护理服务的质量，例如，及时评估和管理疼痛和痛苦症状。运营可持续性措施侧重于患者流动、处置、再入院和资源利用等过程。例如，使用姑息治疗顺序集或接受急诊姑息治疗咨询的患者的急诊住院时间。患者或客户满意度测量评估患者和/或其家庭成员/护理人员对急诊室提供的护理质量的看法；例如，通过 Press Ganey 分数或其他调查。我们还审查并修改了一些先前定义的质量措施^6-8具有 ED 相关性。例如，筛查令人痛苦的症状、社会心理需求、精神/宗教问题以及健康委托书或预先指示的文件。

在三个主要领域中的每一个领域中，我们进一步对质量措施进行了细分，以反映这样一个事实，即 ED 姑息治疗举措通常可能沿着 ED 患者疗程的连续体实施。因此，子类别的范围从 ED 到达到最终处置，包括：(1) 患者筛查和识别，(2) 姑息治疗需求的评估和管理，(3) 姑息治疗服务转介，(4) 适当的护理过渡， (5) 其他类别，例如与命令集/协议相关的措施。

我们优先考虑纳入基于时间、针对特定患者且可操作的 ED 姑息治疗质量措施。急诊绩效管理通常以改善患者流量和减少拥挤为中心；因此，基于整体的“非临床”指标与 ED 姑息治疗干预措施高度相关。

一个例子是 ED 到达时间到姑息治疗筛查或从姑息治疗咨询到最终处置的时间。“临床”基于时间的措施，例如从疼痛评估到实施疼痛管理的时间是重要的考虑因素。为了评估 ED 姑息治疗干预的全部影响，评估质量的时间可能需要延长到入院后 24 至 72 小时。例如，在评估 ED 姑息治疗咨询是否会导致死亡患者的早期家庭会议率更高时，程序可能需要在 ED 入院后 24 至 72 小时收集数据。

患者特定的措施对于 ED 来说是有价值的：(1) 确定感兴趣的患者人群以筛查/实施 ED 姑息治疗计划——例如，为多个长期护理机构提供服务的 ED 应该将他们的姑息治疗筛查工作重点放在从这些设施到达的老年患者并确定合适的工具（例如，虚弱）；(2) 确定个体 ED 患者的姑息治疗需求，例如，对“惊喜”问题筛查呈阳性的患者数量——“如果患者在今年内死亡，你会感到惊讶吗？”；(3) 根据患者负荷确定和分配适当的机构资源，例如，请求的 ED 姑息治疗咨询或 ED 临终关怀转诊的数量；(4) 衡量财务影响和成果，例如，

可操作的 ED 姑息治疗质量措施有助于标准化 ED 最佳实践和护理过渡。示例包括预先指示的文件（例如，在重症监护病房的患者）、姑息治疗医嘱集的使用，或提供精神/牧师支持的急诊科死亡人数。此外，通过满意度调查审查患者建议并根据数据实施变更有可能影响急诊室的整体患者护理。

我们认识到，在 ED 获取与姑息治疗和临终关怀相关的资源方面存在很大差异。在实施之前审查 ED 姑息治疗质量措施可能有助于指导 ED 确定如何以及在何处关注 ED 姑息治疗计划。衡量举措的影响可以为组织提供有意义的反馈，并有助于为战略机构投资提供理由。ED 数据收集具有独特的挑战，通常与时间限制和人员支持有限有关。因此，易于收集/记录并适合现有 ED 流程和员工角色的措施最有可能成功。一个例子是让一名分诊护士（使用既定标准）识别需要接受姑息治疗需求筛查的患者。类似地，电子记录中的自动触发和警报可以帮助数据输入和收集，例如使用姑息治疗指令集或智能短语来记录护理对话或预先指示的目标。报告哪些措施（ED 再入院与成本节省）以及向谁报告将基于与部门和机构目标的一致性。^{8, 10}

ED 姑息治疗倡导者与姑息治疗团队成员的合作非常宝贵。这有助于评估住院期间急诊计划的影响和有效性，此外还可以定义急诊内外跨学科团队成员的角色和责任，例如个案经理、牧师或社会工作者在筛查、需求评估、管理、 ED 姑息治疗计划的数据收集。员工教育是任何质量改进计划的一个非常重要的方面；然而，本文的范围并未列出与教育举措相关的 ED 姑息治疗质量措施，例如增加与 ED 姑息治疗相关的知识或影响提供者的态度。

总之，这些 ED 姑息治疗质量措施旨在为 ED 寻求定义问题、评估部门的姑息治疗需求和/或衡量在整个患者护理连续体中实施的 ED 姑息治疗计划的进展/影响/有效性提供指导. 理想情况下，这些 ED 姑息治疗质量措施将用于质量改进的连续循环。