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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2019-036598 on 28 April 2020. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-036598 on 28 April 2020. Downloaded from End-of-life Management Protocol Offered Within Emergency Room (EMPOWER) – study protocol for a multicentre study Journal: BMJ Open ManuscriptFor ID peerbmjopen-2019-036598 review only Article Type: Protocol Date Submitted by the 20-Dec-2019 Author: Complete List of Authors: Yash Pal, Rakhee; National University Hospital Kuan, Win Sen; National University Hospital , Singapore, Emergency Medicine; National University Hospital Tiah, Ling; Changi General Hospital Kumar, Ranjeev; Khoo Teck Puat Hospital Wong, Yoko; Singapore Clinical Research Institute Shi, Luming; Singapore Clinical Research Institute Zheng, Charles; Singapore Clinical Research Institute Lin, Jingping; National University Hospital Liang, Sufang; National University Hospital Segara, Uma; National University Hospital Yong, Woon Chai; National University Hospital; NUS Yong Loo Lin School of Medicine http://bmjopen.bmj.com/ Chan, Noreen; National University Hospital; NUS Yong Loo Lin School of Medicine Chua, Mui Teng; National University Hospital; NUS Yong Loo Lin School of Medicine Ibrahim, Irwani; National University Hospital; NUS Yong Loo Lin School of Medicine PALLIATIVE CARE, ACCIDENT & EMERGENCY MEDICINE, Quality in Keywords: health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT on September 29, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 17 BMJ Open 1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-036598 on 28 April 2020. 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Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 17 BMJ Open: first published as 10.1136/bmjopen-2019-036598 on 28 April 2020. Downloaded from 1 2 3 TITLE PAGE 4 5 6 End-of-life Management Protocol Offered Within Emergency Room 7 8 (EMPOWER) – study protocol for a multicentre study 9 10 Rakhee Yash Pal1, Win Sen Kuan1,2, Ling Tiah3, Ranjeev Kumar4, Yoko Kin Yoke Wong5, 11 Luming Shi5, Charles Qishi Zheng5, Jingping Lin1, Sufang Liang1, Uma Chandra Segara1, Woon 12 Chai Yong6,7, Noreen Guek Cheng Chan6,7, Mui Teng Chua1,2*, Irwani Ibrahim1,2 13 14 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore 15 2 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 16 3 Accident & EmergencyFor Medicine, peer Changi General review Hospital, Singapore only 17 4 Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore 18 5 Singapore Clinical Research Institute, Singapore 19 6 Division of Palliative Care, National University Cancer Institute, Singapore 20 7 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 21 22 *Corresponding author: 23 Dr Mui Teng Chua 24 Address: Emergency Medicine Department, National University Hospital, 9 Lower Kent Ridge Road, Level 25 4, Singapore 119085 26 Email: [email protected] 27 Telephone number: +65 67723024 28 29 Addresses of all authors: 30 1 Emergency Medicine Department, National University Hospital, National University Health System, 31 Singapore. 9 Lower Kent Ridge Road, Level 4, Singapore 119085 32 http://bmjopen.bmj.com/ 33 2,7 Departments of Surgery and Medicine, Yong Loo Lin School of Medicine, National University of 34 Singapore, Singapore. 10 Medical Dr, Singapore 117597 35 36 3 37 Accident & Emergency Medicine, Changi General Hospital, Singapore. 2 Simei Street 3, Singapore 38 529889 39 4 Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore. 90 Yishun Central, Singapore 40 on September 29, 2021 by guest. Protected copyright. 41 768828 42 43 5 Singapore Clinical Research Institute, Singapore. 31 Biopolis Way, Singapore 138669 44 45 6 Division of Palliative Care, National University Cancer Institute, Singapore. 5 Lower Kent Ridge Road, 46 Singapore 119074 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-036598 on 28 April 2020. Downloaded from 1 2 3 End-of-life Management Protocol Offered Within Emergency Room 4 5 (EMPOWER) – study protocol for a multicentre study 6 7 Rakhee Yash Pal1, Win Sen Kuan1,2, Ling Tiah3, Ranjeev Kumar4, Yoko Kin Yoke Wong5, 8 Luming Shi5, Charles Qishi Zheng5, Jingping Lin1, Sufang Liang1, Uma Chandra Segara1, Woon 9 Chai Yong6,7, Noreen Guek Cheng Chan6,7, Mui Teng Chua1,2*, Irwani Ibrahim1,2 10 11 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore 12 2 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 13 3 Accident & Emergency Medicine, Changi General Hospital, Singapore 14 4 Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore 15 5 Singapore Clinical Research Institute, Singapore 16 6 Division of Palliative Care,For National peer University Cancerreview Institute, Singapore only 17 7 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 18 19 ABSTRACT 20 21 Background 22 23 Patients at their end-of-life (EOL) phase frequently visit the emergency department (ED) due to their symptoms, yet 24 the environment and physicians in ED are not traditionally equipped or trained to provide palliative care. This 25 multicentre study aims to measure the current quality of EOL care in ED to identify gaps, formulate improvements 26 and implement the improved EOL care protocol. We shall also evaluate healthcare resource utilisation and its 27 associated costs. 28 29 Methods and analysis 30 31 This study employs a quasi-experimental interrupted time series design using both qualitative and quantitative methods, involving the EDs of 3 tertiary hospitals in Singapore, over a period of 3 years. There are 5 phases in this 32 http://bmjopen.bmj.com/ study: (1) retrospective chart reviews of patients who died within 5 days of ED attendance; (2) pilot phase to 33 validate the CODETM questionnaire in the local context; (3) pre-implementation phase; (4) focused group 34 discussions (FGDs); and (5) post-implementation phase. In the prospective cohort, patients who are actively dying 35 or have high likelihood of mortality this admission, and whose goal of care is palliation, will be eligible for 36 inclusion. At least 140 patients will be recruited for each pre- and post-implementation phase.
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