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Boston Medical Center (BMC), a safety-net hospital, treated a substantial portion of the Boston cohort that was sick with COVID-19. Unfortunately, these patients experienced high rates of morbidity and mortality given the significant health disparities that many of BMC's patients face. Boston Medical Center launched a palliative care extender program to help address the needs of critically ill ED patients under crisis conditions. In this program evaluation our goal was to assess outcomes between those who received palliative care in the emergency department (ED) vs those who received palliative care as an inpatient or were admitted to an intensive care unit (ICU). We used a matched retrospective cohort study design to assess the difference in outcomes between the two groups. A total of 82 patients received palliative care services in the ED, and 317 patients received palliative care services as an inpatient. After controlling for demographics, patients who received palliative care services in the ED were less likely to have a change in level of care (P<0.001) or be admitted to an ICU (P<0.001). Cases had an average length of stay of 5.2 days compared to controls who stayed 9.9 days (P<0.001). Within a busy ED environment, initiating palliative care discussions by ED staff can be challenging. This study demonstrates that consulting palliative care specialists early in the course of the patient's ED stay can benefit patients and families and improve resource utilization.

IntroductionDespite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer’s disease and related Dementias, regardless of age.Methods and analysisThe Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included.Ethics and disseminationThe Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov.Trial registration numberNCT04857060; ClinicalTrials.gov

Purpose Goals of care conversations are essential for physicians treating critically ill patients in the surgical intensive care unit (SICU). However, many providers feel uncomfortable having these conversations. This study aimed to assess the feasibility, acceptability, and effectiveness of implementing training in the Serious Illness Conversation Guide (SICG) for residents in our institution’s SICU. Methods All residents rotating through our institution’s SICU during the 2021–2022 academic year completed SICG training. Training consisted of a 1.5-h pre-recorded lecture, pre-course reading, and quiz followed by a 1-h group session for participants to practice the SICG with standardized patients. Validated surveys were administered before, after, and at 1, 3, 6, and 12 months post-training to evaluate the acceptability and effectiveness of the training. Results Training significantly increased residents’ mean confidence levels in conducting serious illness conversations (4.3 ± 0.4 vs. 5.4 ± 0.1, p  < 0.001). Post-training, 92% of residents agreed or strongly agreed that the teaching methods were effective, 88% agreed or strongly agreed that the training positively impacted their attitude towards communicating with seriously ill patients, 88% agreed or strongly agreed that they could apply what they learned to their clinical practice, and 92% agreed or strongly agreed that they would recommend this training to others. Conclusions Training in the use of the SICG is feasible, acceptable, and effective for SICU residents at our institution. Residents reported an overall increase in confidence levels in conducting serious illness conversations and found the training applicable to their clinical practice.

Importance Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians. Objective To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation. Design, Setting, and Participants This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022. Intervention The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care. Main Outcome and Measures The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing. Results A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool. Trial Registration ClinicalTrials.gov Identifier:NCT04857060

Optical transient surveys continue to generate increasingly large datasets, prompting the introduction of machine-learning algorithms to search for quality transient candidates efficiently. Existing machine-learning infrastructure can be leveraged in novel ways to search these datasets for new classes of transients. We present a machine-learning accelerated search pipeline for the Deeper, Wider, Faster (DWF) programme designed to identify high-quality astrophysical transient candidates that contain a single detection. Given the rapid observing cadence of the DWF programme, these single-detection transient candidates have durations on sub-minute timescales. This work marks the first time optical transients have been systematically explored on these timescales, to a depth of m\\(\\)23. We report the discovery of two high-quality sub-minute transient candidates from a pilot study of 671,761 light curves and investigate their potential origins with multiwavelength data. We discuss, in detail, possible non-astrophysical false positives, confidently reject electronic artefacts and asteroids, ruling out glints from satellites below 800 km and strongly disfavouring those at higher altitudes. We calculate a rate on the sky of \\(4.72^+6.39_-3.2810^5\\) per day for these sub-minute transient candidates.