Palliative care and hospitalists: a partnership for hope

Prevalence of specialised palliative care consultation for eligible children within a paediatric cardiac ICU

OBJECTIVE

Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one.

METHODS

Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period.

MEASUREMENTS AND RESULTS

A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult.

CONCLUSIONS

Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.

The sentinel hospitalization and the role of palliative care

With current healthcare reform and calls for improving care quality and safety, there is renewed emphasis on high-value care. Moreover, given the significant healthcare resource utilization for patients with chronically progressive illnesses or for patients at the end of life, innovative and efficient care delivery models are urgently needed. We propose here the concept of a sentinel hospitalization, defined as a transitional point in the patient's disease course that heralds a need to reassess prognosis, patient understanding, treatment options and intensities, and goals of care. Hospitalists are well positioned to recognize a patient's sentinel hospitalization and use it as an opportunity for active integration of palliative care that provides high-quality and cost-saving care through its patient- and family-oriented approach, its interdisciplinary nature, and its focus on symptom control and care coordination.

ACUTE center for eating disorders

BACKGROUND

While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.

METHODS

We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported.

RESULTS

From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero.

DISCUSSION

Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Investing in the future: building an academic hospitalist faculty development program

BACKGROUND

Academic hospital medicine (AHM) groups continue to grow rapidly, driven largely by clinical demands. While new hospitalist faculty usually have strong backgrounds in clinical medicine, they often lack the tools needed to achieve excellence in the other aspects of a faculty career, including teaching, research, quality improvement, and leadership skills.

OBJECTIVE

To develop and implement a Faculty Development (FD) Program that improves the knowledge, skills, attitudes, and scholarly output of first-year faculty.

INTERVENTION

We created a vision and framework for FD that targeted our new faculty but also engaged our entire Division of Hospital Medicine. New faculty participated in a dedicated coaching relationship with a more senior faculty member, a core curriculum, a teaching course, and activities to meet a set of stated scholarly expectations. All faculty participated in newly established divisional Grand Rounds, a lunch seminar series, and venues to share scholarship and works in progress.

RESULTS

Our FD programmatic offerings were rated highly overall on a scale of 1 to 5 (5 highest): Core Seminars 4.83 ± 0.41, Coaching Program 4.5 ± 0.84, Teaching Course 4.5 ± 0.55, Grand Rounds 4.83 ± 0.41, and Lunch Seminars 4.5 ± 0.84. Compared to faculty hired in the 2 years prior to our FD program implementation, new faculty reported greater degrees of work satisfaction, increased comfort with their skills in a variety of areas, and improved academic output.

CONCLUSION

Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission.

Role of hospitalists in an offsite alternate care center (ACC) for pandemic flu

Recent concerns about an influenza pandemic have highlighted the need to plan for offsite Alternate Care Centers (ACCs). The likelihood of a successful response to patient surges will depend on the local health systems' ability to prepare well in advance of an influenza pandemic. Our health system has worked closely with our state's medical biodefense network to plan the establishment of an ACC for an influenza pandemic. As hospitalists have expanded their roles in their local health systems, they are poised to play a major role in planning for the next influenza pandemic. Hospitalists should work with their health system's administration in developing an ACC plan.