Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

Zalenski, Robert J.; Jones, Spencer S.; Courage, Cheryl; Waselewsky, Denise; Kostaroff, Anna S.; Kaufman, David; Beemath, Afzal; Brofman, John; Castillo, James W.; Krayem, Hicham; Marinelli, Anthony; Milner, Bradley; Palleschi, Maria Teresa; Tareen, Mona; Testani, Sheri; Soubani, Ayman O.; Walch, Julie; Wheeler, Judy C.; Wilborn, Sonali; Granovsky, Hanna; Welch, Robert D.

doi:10.1016/j.jpainsymman.2016.08.003

Cited by 76 publications

(85 citation statements)

References 35 publications

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“…However, this apparent discrepancy could be explained by the fact that this was merely an observational study, with a high incidence and variability in the application of palliative care strategies: when comparing patients with "correct" or "inadequate" ELM-PC, there was a significant reduction in ICU time (and progression to death) in the group with the "correct" application. This corroborates the findings of interventional studies, in which the screening and application of palliative management reduced ICU hospitalisation time, particularly when applied early [22,23].…”

Section: Discussionsupporting

confidence: 87%

End-of-life management in intensive care units: a multicentre observational prospective cohort study

Alliprandini¹,

Ferrandin²,

Fernandes³

et al. 2019

ait

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With the impressive improvements in medical care in recent years, it is to be expected that intensive care unit (ICU) care would result (as well as reducing mortality from serious critical illnesses) in increased comfort and dignity for patients and their families, thus reducing their suffering. However, the latter objective is still far from a reality, and the practice of applying futile support therapies is still common in the ICU setting, particularly among patients who eventually die in the hospital [1]. It has been estimated that beds intended for intensive care account for 13.4% of all hospital beds in the USA, representing a cost of 0.56% of the country's gross domestic product (GDP). Despite the greater use of hospices and end-of-life palliative care, approximately one in five Americans die in an ICU [2]. In low-and medium-income countries, there are a lack of data about the rate of hospitalisation and death in

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Section: Discussionsupporting

confidence: 87%

End-of-life management in intensive care units: a multicentre observational prospective cohort study

Alliprandini¹,

Ferrandin²,

Fernandes³

et al. 2019

ait

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“…Further, many of these patients are likely at high risk of poor short- and long-term health outcomes as well [ 36 ]. These adverse events may potentially be mitigated by introducing high quality, early palliative and community-based care, which – in the context of overly aggressive treatments – has shown positive results including reduced inpatient and ICU visits, reduced length-of-stay and direct costs, and improved quality of communication [ 37 – 40 ].…”

Section: Discussionmentioning

confidence: 99%

Describing the characteristics and healthcare use of high-cost acute care users at the end of life: a pan-Canadian population-based study

Qureshi

Isenberg

Tanuseputro

et al. 2020

BMC Health Serv Res

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Background A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada. Methods We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC). Results We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs. Conclusions High users – persistent and non-persistent – are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

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“…Even though our findings are consistent with prior studies and underscore the need to provide PCC earlier in the hospital stay, this study does not provide a definitive answer as to why the overall impact of palliative care is stronger within the first six days of hospital admission. 12,[27][28][29] Of note, we found a 12% increase in mortality for patients consulted during hospital days 7-30. This finding is consistent with at least one prior study.…”

Section: Discussionmentioning

confidence: 55%

“…Based on prior studies and our own internal data, the impact of PCC may be relative to timing of consultation during hospital stay. [27][28][29] Therefore, the treatment group was stratified into three subgroups based on hospital day of consult -0 to 2 days (early), 3 to 6 days (middle), and 7 to 30 days (late) and compared with the usual care group separately.…”

Section: Discussionmentioning

confidence: 99%

Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality

Barkley

McCall

Maslow

et al. 2019

Journal of Palliative Medicine

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Background: Inpatient palliative care consultation (PCC) may reduce 30-day readmissions and inpatient mortality among seriously ill patients. Objective: To evaluate the impact of timing of PCC on 30-day readmissions and inpatient mortality. Design: Retrospective, observational study comparing risk-adjusted, observed-to-expected (O/E) 30-day readmissions and inpatient mortality among patients receiving inpatient PCC to all other inpatients. Setting/Subjects: Adult patients with hospital length of stay (LOS) <30 days, primary diagnoses of circulatory, infectious, respiratory, neoplasms, injury/poisoning, and digestive system were included from eight hospitals in a single health care system. Results: Compared with non-PCC patients (n = 43,463), PCC patients (n = 6043) had a greater proportion of African Americans, Medicare, LOS ‡7 days, intensive care unit stays, discharges to skilled nursing facility and hospice, primary diagnoses of infections and neoplasms, comorbidities of congestive heart failure, cancer, and dementia, Charlson comorbidity score ‡8 (p < 0.001), and fewer males (p = 0.03). Adjusted readmission reduction attributed to PCC among 0-2-, 3-6-, and 7-30-day subgroups was 14.1%, 19.2%, and 16.4%, respectively (usual care O/E = 0.904 vs. subgroup O/Es = 0.764, 0.713, 0.741, respectively). Adjusted mortality reductions attributed to PCC among the 0-2-and 3-6-day subgroups were 19.4% and 19.1%, respectively. A 12% mortality increase was observed in the 7-30-day subgroup (usual care O/E = 0.738 vs. subgroup O/Es = 0.544, 0.547, 0.858, respectively). Conclusions: Inpatient PCC reduces 30-day readmissions and inpatient mortality with the greatest impact demonstrated within six days of hospital admission. Early PCC should be encouraged for eligible patients.

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Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

Cited by 76 publications

References 35 publications

End-of-life management in intensive care units: a multicentre observational prospective cohort study

End-of-life management in intensive care units: a multicentre observational prospective cohort study

Describing the characteristics and healthcare use of high-cost acute care users at the end of life: a pan-Canadian population-based study

Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality

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