Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients

Norton, Sally A.; Hogan, Laura; Holloway, Robert G.; Temkin‐Greener, Helena; Buckley, Marcia J.; Quill, Timothy E.

doi:10.1097/01.ccm.0000266533.06543.0c

Cited by 379 publications

(326 citation statements)

References 35 publications

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“…900 patients were removed from the sample because they died. This is common practice in the medical community because various factors, such as Do-not-resuscitate orders, can skew LOS estimates for patients who die (Norton et al 2007, Rapoport et al 1996. We note that we verified the robustness of our empirical analysis by also including patients who died and find our results are quite similar.…”

Section: Datasupporting

confidence: 74%

The Impact of Delays on Service Times in the Intensive Care Unit

Chan¹,

Farias

Escobar

2017

Management Science

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Mainstream queueing models are frequently employed in modeling healthcare delivery in a number of settings, and further used in making operational decisions for the same. The vast majority of these queueing models assume that the service requirements of a job are independent of the state of the queue upon its arrival. In a healthcare setting, this assumption is equivalent to ignoring the effects of delay experienced by a patient awaiting care. However, it is only natural to conjecture that long delays may have adverse effects on patient outcomes and can potentially lead to longer lengths of stay (LOS) when the patient ultimately does receive care. At a very coarse level, prior research confirms these natural conjectures. This work sets out to understand these delay issues from an operational perspective. In particular, using data of nearly 6,000 Emergency Department (ED) visits, we use an instrumental variable approach to empirically measure how congestion in the Intensive Care Unit (ICU) can lead to delays in boarding from the ED to the ICU and measure the impact on the patient's ICU LOS.Capturing these empirically observed effects in a queueing model is challenging as the effect introduces potentially long range correlations in service and inter-arrival times. As such, we consider the problem of how to incorporate these measured delay effects into a queueing model and characterize approximations to various quantities of interest when the service time of a job is adversely impacted by the delay experienced by that job. Our findings suggest that this delay effect can be substantial and ignoring it when using queueing models to model healthcare delivery systems may result in significant under-provisioning.

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Section: Datasupporting

confidence: 74%

The Impact of Delays on Service Times in the Intensive Care Unit

Chan¹,

Farias

Escobar

2017

Management Science

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“…Despite longer ICU and hospital lengths of stay that suggest more time to implement advance care planning and end-of-life discussions for both of these patient populations, these patients are more likely to receive CPR shortly before death, less likely to have a DNR order in place at the time of death, and less likely to have documentation of prognostic discussions. In addition, longer ICU lengths of stay for patients who die in the ICU have been used as a marker of poorquality palliative care in the ICU and may suggest a prolongation of dying associated with inadequate preparation of patients and surrogate decision makers for decisions regarding end-of-life care (19,20).…”

Section: Discussionmentioning

confidence: 99%

Palliative Care for Patients Dying in the Intensive Care Unit with Chronic Lung Disease Compared with Metastatic Cancer

et al. 2016

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Rationale: Palliative care has been focused largely on patients with cancer, and yet patients with chronic lung diseases also have high morbidity and mortality. The majority of deaths in intensive care units (ICUs) follow decisions to withhold or withdraw life-sustaining treatments, suggesting that palliative care is critically important in this setting.Objectives: We explored differences in receipt of elements of palliative care among patients with interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) who die in ICUs compared with patients with cancer.Methods: We identified patients with COPD, ILD, or metastatic cancer who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. We used robust multivariable logistic and linear regression to compare differences in receipt of elements of palliative care and length of stay. Measurements and Main Results:Compared with patients with cancer, patients with COPD were more likely to receive cardiopulmonary resuscitation before death and patients with ILD were less likely to have documentation of pain assessment in the last day of life. Patients with ILD and COPD were less likely to have a do-not-resuscitate order in place at the time of death and less likely to have documentation of discussions about prognosis than patients with cancer. Patients with COPD had longer hospital lengths of stay, and patients with COPD and ILD had longer ICU lengths of stay. Conclusions:Among patients who die in the ICU, patients with ILD and COPD receive fewer elements of palliative care and have longer lengths of stay than patients with cancer. These findings identify areas for improvement in caring for patients with chronic lung diseases.Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

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“…Evidence suggests that utilization of palliative care resources improves end-of-life care in the ICU. [17][18][19] We found that more than half of patients who died with comfort care in the hospital did so after being transferred to the ICU for a trial of aggressive care, suggesting that this population may have benefited from more involvement of our palliative care service. In summary, our data on end-of-life care following MET activation suggest that the METs are able to take advantage of an opportunity to identify patients who would not want resuscitation efforts because of personal preferences or futility of treatments.…”

Section: Discussionmentioning

confidence: 86%

Resource utilization and end‐of‐life care in a US hospital following medical emergency team‐implemented do not resuscitate orders

Dargin

Mackey

et al. 2014

Journal of Hospital Medicine

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BACKGROUND: Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE:To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN: Retrospective review.SETTING: Single, tertiary care center. PATIENTS:Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS:Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care.

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Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients

Abstract: Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.

Cited by 379 publications

References 35 publications

The Impact of Delays on Service Times in the Intensive Care Unit

The Impact of Delays on Service Times in the Intensive Care Unit

Palliative Care for Patients Dying in the Intensive Care Unit with Chronic Lung Disease Compared with Metastatic Cancer

Resource utilization and end‐of‐life care in a US hospital following medical emergency team‐implemented do not resuscitate orders

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