Four Things We've Learnt from Delivering Palliative Care Services from A Virtual Emergency Department
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Dr Paul Tait, Dr Jane Conway, Darren Daff, Tanya Rowett – South Australian Virtual Care Service.
In 2021, the South Australian Government funded the South Australian Virtual Care Service (SAVCS) to provide virtual emergency nursing, medical and paramedic support across South Australia.
Virtual care is "any interaction between patients and members of their circle of care that occurs remotely, using any form of communication or information technology, to facilitate or maximise the quality and effectiveness of patient care".[1]
SAVCS's model is to support local care teams - for instance, paramedics, nurses, and medical officers - so that care delivery occurs in the most appropriate space, including care of people with palliative care needs.
We are based on the emergency care model and consider ourselves to be a safety net for care teams in the community rather than a substitution service. Indeed, being a virtual emergency department (ED) means we have identified four opportunities that bricks-and-mortar EDs cannot offer, particularly relating to those with palliative care needs living in their own home or a residential age care home.
1. Conflict
Potential conflicts can arise between local policy and the person’s preferences, particularly through the lens of palliative care. For instance, an advance care directive might advocate for comfort measures, while local aged care or ambulance policy necessitates a medical review following a particular clinical event. Without immediate access to the person's usual GP or locum services, these clinical events have resulted in after-hours hospital transfers. Indeed, people with palliative care needs may return to their home environment after an extended stay in the ED. To address this, our medical officers, in close collaboration with the local care team, thoroughly review the person's situation and work with the care team towards a plan that meets the person's goals of care.
2. Connection
In today's world, families can be spread far and wide. This means the people the person wants to keep informed are sometimes absent during consultations in a traditional in-person ED setting. Using virtual technology, we can connect critical family members in consultation with the care team regardless of location, ensuring clear and consistent messaging. At the end of the consultation, we can leave the family members online to debrief and catch up.
3. Convenient
National guidelines promote the idea of anticipatory prescribing for people where death is imminent, as the changes associated with the terminal phase can necessitate the switch from the oral to the subcutaneous route. Anticipatory prescribing ensures appropriate subcutaneous medicines are ordered in advance so the registered nurse has legal orders to switch symptom management to the subcutaneous route. Yet, a sudden deterioration in someone's condition when the usual prescriber is not around can sometimes catch the care team without valid prescriptions for appropriate symptom relief. Contact with the SAVCS can ensure that legal and ongoing medication orders are in place quickly.
4. Coach
The handover process is a crucial part of communication between healthcare teams. Yet, in the rush to contact SAVCS, some care team members do not have all the relevant details of the person in front of them that could support the SAVCS clinicians. While our staff have prompted this information from the local care team, we've noticed that repeat callers are better equipped with information about the person's situation when making the call. Feedback loops are developing, allowing the local care team to learn from the SAVCS interactions.
The use of virtual emergency care provides an additional tool for care teams across SA to meet the palliative care needs of their patients. By conducting medical reviews, connecting with family members, prescribing medications, and establishing feedback loops, we believe that SAVCS can complement the work of the local care teams in delivering palliative care services. This is a significant advancement in care delivery, and we are proud to be at the forefront of this innovation.
Reference
- Wong A, Bhyat R, Srivastava S, Boissé Lomax L, Appireddy R. Patient Care During the COVID-19 Pandemic: Use of Virtual Care. J Med Internet Res. 2021 Jan 21;23(1):e20621. doi: 10.2196/20621. PMID: 33326410; PMCID: PMC7822645.