Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions

Clinical Outcomes After Early Palliative Care Evaluations in Geriatric Trauma Intensive Care

INTRODUCTION

Older trauma patients are at risk for worse outcomes compared to younger patients. We hypothesized that early initiation of palliative care (EPC) evaluations, within 72 h of trauma intensive care unit (ICU) admission, would be associated with reduced invasive procedures without a change in hospital mortality.

METHODS

A retrospective cohort review was performed of all trauma patients aged ≥65 y admitted to the trauma (ICU) from January 1, 2016, to December 31, 2021. Patients who received formal palliative care assessments were included. Patient demographics and injury characteristics were evaluated. The primary outcome was ICU length of stay (LOS). Secondary outcomes included code status change, tracheostomy or percutaneous endoscopic gastrostomy placement, use and length of mechanical ventilation, in-hospital mortality, and withdrawal of life-sustaining care.

RESULTS

Two hundred twenty-five patients met inclusion. One hundred and six had EPC while 119 had late palliative care. EPC was associated with decreased ICU LOS (3 versus 9 d, P < 0.001), hospital LOS (3 versus 11 d, P < 0.001), and days on mechanical ventilation (P < 0.001), and fewer tracheostomy (P = 0.007) and percutaneous endoscopic gastrostomy tubes (P = 0.049). There was no difference in withdrawal of life-sustaining care (P = 0.581) or in-hospital mortality (P = 0.172). Pre-existing code status or code status clarification early in admission was associated with EPC (P = 0.003) and decreased interventions.

CONCLUSIONS

EPC is associated with decreased LOS and fewer invasive procedures without a change in hospital mortality. Early discussions regarding code status are helpful in decreasing hospital costs and futile interventions. Further investigation is required to standardize palliative care in this population.

Comparison of factors influencing the decision to withdraw life-sustaining treatment in intensive care unit patients after implementation of the Life-Sustaining Treatment Act in Korea

BACKGROUND

The decision to discontinue intensive care unit (ICU) treatment during the end-oflife stage has recently become a significant concern in Korea, with an observed increase in life-sustaining treatment (LST) withdrawal. There is a growing demand for evidence-based support for patients, families, and clinicians in making LST decisions. This study aimed to identify factors influencing LST decisions in ICU inpatients and to analyze their impact on healthcare utilization.

METHODS

We retrospectively reviewed medical records of ICU patients with neurological disorders, infectious disorders, or cancer who were treated at a single university hospital between January 1, 2019 and July 7, 2021. Factors influencing the decision to withdraw LST were compared between those who withdrew LST and those who did not.

RESULTS

Among 54,699 hospital admissions, LST was withdrawn in 550 cases (1%). Cancer was the most common diagnosis, followed by pneumonia and cerebral infarction. Among ICU inpatients, LST was withdrawn from 215 (withdrawal group). The withdrawal group was older (78 vs. 75 years, P=0.002), had longer total hospital stays (16 vs. 11 days, P<0.001), and higher ICU readmission rates than the control group. There were no significant differences in the healthcare costs of ICU stay between the two groups. Most LST decisions (86%) were made by family.

CONCLUSIONS

The decisions to withdraw LST of ICU inpatients were influenced by age, readmission, and disease category. ICU costs were similar between the withdrawal and control groups. Further research is needed to tailor LST decisions in the ICU.

Integrating Palliative Care Screening in the Intensive Care Unit: A Quality Improvement Project

BACKGROUND

Patients admitted to the intensive care unit have complex medical problems and increased rates of mortality and recurrent hospitalization for the following 10 years compared with patients without a history of critical illness. Delayed access to palliative care can result in untreated symptoms, lack of understanding of care preferences, and preventable admissions. Despite studies supporting palliative care screening, there is no standardized method to assess palliative care needs of patients admitted to critical care units.

LOCAL PROBLEM

A community hospital critical care team identified a need for an improved palliative care process for patients admitted to the intensive care unit.

METHODS

The aim of this quality improvement project was to improve patient access to timely palliative care consultation while increasing the reach of the palliative care team. Guided by the Institute for Healthcare Improvement model of plan-do-study-act cycles, the team created a palliative care screening tool with clinical indicators for nurses to use upon patient admission. Patients with numeric scores indicating positive screening tool results could be automatically referred for palliative care consultation.

RESULTS

Of 267 patients, 59 (22%) had positive screening tool results, compared with 31 (11.6%) identified with the traditional consultative method. Descriptive analysis revealed that patients identified for referral without use of the screening tool were hospitalized a mean of 6 days until consultation was requested.

CONCLUSION

The screening process can maximize the benefit of palliative care services with early patient identification, improved consultation efficiency, decreased critical care resource use, and reduced readmission rates.

Trends in utilisation of palliative care services in COVID-19 patients and their impact on hospital resources in the USA: insights from the national inpatient sample

OBJECTIVES

Poor prognosis and lack of effective therapeutic options have made palliative care an integral part of the management of severe COVID-19. However, clinical studies on the role of palliative care in severe COVID-19 patients are lacking. The objective of our study was to evaluate the utility of palliative care in intubated COVID-19 patients and its impact on in-hospital outcomes.

METHODS

Rate of palliative care consult, patient-level variables (age, sex, race, income, insurance type), hospital-level variables (region, type, size) and in-hospital outcome variables (mortality, cost, disposition, complications) were recorded.

RESULTS

We retrospectively analysed 263 855 intubated COVID-19 patients using National Inpatient Sample database from 1 January 2020 to 31 December 2020. 65 325 (24.8%) patients received palliative care consult. Factors associated with an increased rate of palliative care consults included: female gender (p<0.001), older age (p<0.001), Caucasian race (p<0.001), high household income (p<0.001), Medicare insurance (p<0.001), admission to large-teaching hospitals (p<0.001), patients with underlying comorbidities, development of in-hospital complications and the need for intensive care procedures. Patients receiving palliative consults had shorter hospital length of stay (LOS) (p<0.001) and no difference in hospitalisation cost (p=0.15).

CONCLUSIONS

Palliative care utilisation rate in intubated COVID-19 patients was reflective of disease severity and disparities in healthcare access. Palliative care may help reduce hospital LOS. Our findings also highlight importance of improving access to palliative care services and its integration into the multidisciplinary management of severe COVID-19 patients.

Use of the 3 Wishes Project to Help Individualize End-of-Life Care in a Medical Intensive Care Unit

BACKGROUND

Multiple organizations recommend that individualized end-of-life (EOL) care should be standard practice. However, a standardized approach does not exist because EOL care should be individually tailored. The 3 Wishes Project is an EOL intervention that provides direction for individualized care with 3 goals: dignify death, celebrate the patient's life, and support family members and the intensive care unit clinicians caring for the patient. Patients and families are given the opportunity to choose 3 wishes during the dying process.

OBJECTIVE

To ascertain if the implementation of the 3 Wishes Project allowed the medical team to provide individualized EOL care.

METHODS

The Iowa Model was used for this evidence-based project. The project was implemented in the medical intensive care unit at an academic medical center. Outcomes were evaluated by the collection and analysis of qualitative and quantitative data.

RESULTS

From the 57 patients who died during the 2-month implementation period, 32 wish forms were collected; 31 patients participated and 1 declined. Overall participation among patients was 56%. The top 5 wishes were cloth hearts, blankets, heartbeat printouts, fingerprints and handprints, and music. The total cost was $992, and the average cost per wish was $6.98. Eighty-five percent (33 of 39) of the respondents to the medical team survey indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care.

CONCLUSIONS

The survey data support the 3 Wishes Project as a method that allowed the medical team to individualize EOL care and as a valuable tool for incorporation at the bedside.

Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis

BACKGROUND

There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness of comparing EVT with IVT versus EVT alone.

METHODS

We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio.

RESULTS

The average costs per patient were estimated to be $47,304, $49,510, $59,770, and $76,561 for EVT-only strategy and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90 days, 1 year, 5 years, and 20 years, respectively. The cost saving of EVT-only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011 and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only being cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons.

CONCLUSION

Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.

Cardiac intensive care unit: where we are in 2023

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023.

Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs

Introduction

Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence.

Aim of the study

To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU.

Material and Methods

We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions.

Results

NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).

Conclusions

Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

Considering Patient, Family, and Provider Goals and Expectations in a Rapidly Changing Clinical Context: A Framework for Antimicrobial Stewardship at the End of Life

Antibiotic administration is often a part of end-of-life (EOL) care, including among patients who are not critically ill. Guideline-issuing bodies recommend that antimicrobial stewardship providers (ASPs) provide support to prescribers making decisions about whether or not to treat infections in this population. Relatively little is known about the rationale for antimicrobial prescribing during the EOL period in noncritical care settings, although patient and family preferences are often an influencing factor. The effectiveness of antimicrobials in improving quantity or quality of life in this population is unclear and likely context-specific.

Comparative costs for critically ill patients with limited English proficiency versus English proficiency

OBJECTIVES

To conduct comparative cost analysis of hospital care for critically ill patients with Limited English Proficiency (LEP) versus patients with English proficiency (controls).

PATIENTS AND METHODS

We conducted a historical cohort study using propensity matching at Mayo Clinic Rochester, a quaternary care academic center. We included hospitalized patients who had at least one admission to ICU during a 10-year period between 1/1/2008-12/31/2017.

RESULTS

Due to substantial differences in baseline characteristics of the groups, propensity matching for the covariates age, sex, race, ethnicity, APACHE 3 score, and Charlson Comorbidity score was used, and we achieved the intended balance. The final cohort included 80,404 patients, 4,246 with LEP and 76,158 controls. Patients with LEP had higher costs during hospital admission to discharge, with a mean cost difference of $3861 (95% CI $822 to $6900, p = 0.013) and also higher costs during index ICU admission to hospital discharge, with a mean cost difference of $3166 (95% CI $231 to $6101, p = 0.035). A propensity matched cohort including only those that survived showed those with LEP had significantly greater mean costs for all outcomes. Sensitivity analysis revealed that international patients with LEP had significantly greater overall hospital costs of $9,240 than patients with LEP who resided in the US (95% CI $3341 to $15,140, p = 0.002).

CONCLUSION

This is the first study to demonstrate significantly higher costs for patients with LEP experiencing a critical illness. The causes for this may be increased healthcare utilization secondary to communication deficiencies that impede timely decision making about care.

Impact of admitting department on the management of acute coronary syndrome after an out of hospital cardiac arrest

AIM

This study aimed to analyze the influence of the hospital admitting department on adherence to the Guidelines of European Society of Cardiology for management of acute coronary syndromes in patients after out-of-hospital cardiac arrest (OHCA) of coronary etiology.

METHODS

We studied retrospective-prospective register of 102 consecutive patients with OHCA as a manifestation of acute coronary syndrome (ACS). Patients were admitted to the coronary care unit (CCU) 52, general intensive care unit (GICU) 21, or GICU after initial Cath lab treatment (CAG-GICU) 29. This study compared the differences in the management of ACS in patients with OHCA of coronary etiology based on the admitting department in a tertiary care institution.

RESULTS

Twelve of the 21 (57.1%) patients admitted to the GICU were evaluated as having ACS on-site where they experienced OHCA. In the CCU group, 50 out of 52 (96.2%) and 28 of 29 (100%) patients in the CAG-GICU group (P<0.001). Coronary angiography was performed in 10 of 21 patients (48%) admitted to the GICU. It was performed in 49 out of 52 (94%) CCU patients and, in the CAG-GICU group, 28 out of 29 patients. The mean time to CAG differed significantly across groups (that is, GICU 200.7 min., CCU 71.2 min., and CAG-GICU 7.5 min. (P<0.001)). Aspirin was used in 48% of GICU, 96% of CCU, and 79% of CAG-GICU patients (P<0.001), while in the pre-hospital phase, aspirin was used in 9.5% of GICU, 71.2% of CCU, and 50% of CAG-GICU patients (P<0.001). P2Y12 inhibitor prescriptions were lower in patients admitted to the GICU (33% vs. 89% CCU and 57% CAG-GICU, P<0.001). The department's choice significantly affected the time to initiation of antithrombotics, which was the longest in the GICU.

CONCLUSION

The choice of admission department for patients with OHCA caused by ACS was found to affect the extent to which the recommended treatments were used. An examination of OHCA patients by a cardiologist upon admission to the hospital increased the likelihood of an early diagnosis of ACS as the cause of OHCA.

ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study

BACKGROUND

End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending.

OBJECTIVE

To examine whether practices that became ACOs altered spending and utilization at the EOL.

DESIGN

Retrospective analysis of Medicare claims.

PATIENTS

We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients.

MAIN MEASURES

Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation.

KEY RESULTS

The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death.

CONCLUSIONS

With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.

Effects of Medicare advantage on patterns of end-of-life care among Medicare decedents

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on patterns of end-of-life care.

DATA SOURCES

We used data from the Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims, the Minimum Data Set, the Outcome and Assessment Information Set, the Area Health Resources File, and Geographic Variation Public Use File for 2012-2014.

STUDY DESIGN

To address selective enrollment into MA, we exploited a discontinuity in payment rates by county population (urban floor payments) as an instrument.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries continuously enrolled in MA or TM during their last year of life between 2012 and 2014 using Medicare administrative data.

PRINCIPAL FINDINGS

We did not find evidence that MA enrollment led to a change in hospital admissions in the last 30 days of life, but MA enrollment decreased hospital as the site of death by 11.0 (95% CI: -13.9 to -8.1) percentage points. Once hospitalized, however, MA enrollment increased use of intensive care by 6.7 (95% CI: 0.3 to 13.1) percentage points and non-invasive mechanical ventilation by 9.2 (95% CI: 5.5 to 12.9) percentage points. MA enrollment increased hospice use by 6.2 (95% CI: 2.3 to 10.1) percentage points at time of death and 7.7 (95% CI: 3.8 to 11.6) percentage points in the last 30 days of life. Particularly, MA enrollment increased hospice admissions among those who were admitted to the hospital within 30 days prior to hospice admission by 18.8 (95% CI: 13.8 to 23.8) percentage points. However, MA enrollment decreased hospice admissions among those who were admitted to home health within 30 days prior to hospice admission by 18.6 (95% CI: -21.9 to -15.2) percentage points.

CONCLUSIONS

MA plans may improve end-of-life care by reducing hospital death while also improving access to hospice, especially among recently hospitalized persons.

Improving Outcomes Measurement in Palliative Care: The Lasting Impact of Randy Curtis and his Collaborators

Palliative care research is deeply challenging for many reasons, not the least of which is the conceptual and operational difficulty of measuring outcomes within a seriously ill population such as critically ill patients and their family members. This manuscript describes how Randy Curtis and his network of collaborators successfully confronted some of the most vexing outcomes measurement problems in the field, and by so doing, have enhanced clinical care and research alike. Beginning with a discussion of the clinical challenges of measurement in palliative care, we then discuss a selection of the novel measures developed by Randy and his collaborators and conclude with a look toward the future evolution of these concepts. Randy and his foundational work, including both successes as well as the occasional near miss, have enriched and advanced the field as well as (immeasurably) impacted the work of so many others-including this manuscript's authors.

Hysterectomy with a General Gynecologist vs. Gynecologic Oncologist in the Setting of Endometrial Intraepithelial Neoplasia: A Cost-Effectiveness Analysis

BACKGROUND

Standard treatment for patients with endometrial intraepithelial neoplasia (EIN) is a hysterectomy, which has a 43% risk of concomitant endometrial cancer on final pathology. General gynecologists and gynecologic oncologists perform hysterectomies; however, patients who have a hysterectomy for EIN with a general gynecologist and are found to have cancer may require a second surgery by a gynecologic oncologist to complete staging. There is current ongoing discussion regarding whether patients with EIN should be provided the option to receive the initial hysterectomy with a gynecologic oncologist.

OBJECTIVE

To better understand if patients with EIN should be initially referred to a gynecologic oncologist for treatment, we examined the cost-effectiveness of hysterectomy by general gynecologists versus gynecologic oncologists for patients with EIN.

STUDY DESIGN

We created a decision-analytic model using TreeAge Pro software to compare outcomes between patients with EIN undergoing hysterectomy by a general gynecologist versus a gynecologic oncologist. Our theoretical cohort contained 200,000 patients, an estimate of the number of individuals diagnosed with EIN each year in the United States. Outcomes included costs, quality-adjusted life years (QALYs), primary lymph node dissection (LND), secondary LND, surgical site infection, and perioperative mortality. We assumed that surgical morbidity and mortality were the same under generalist and specialist care and applied costs of travel and lost work for those seeing a gynecologic oncologist. We performed univariable sensitivity analyses as well as multivariable probabilistic sensitivity analysis to assess the model's robustness given the uncertainty of model inputs.

RESULTS

In our theoretical cohort of 200,000 patients with EIN, hysterectomy with a gynecologic oncologist was associated with a decrease in 10,811 second surgeries for LND, 87 surgical site infections, and 9 perioperative mortalities. When hysterectomy was performed by a general gynecologist, 9 fewer patients had a LND due to perioperative mortalities that occurred prior to LND with a gynecologic oncologist. Hysterectomy with a gynecologic oncologist was the dominant, cost-effective strategy as it saved $116 million and increased QALYs by 180. In our univariable analyses, hysterectomy with a gynecologic oncologist was cost-saving and increased QALYs over a wide range of probabilities and costs for LND, surgical site infection, and perioperative mortality. However, hysterectomy with a gynecologic oncologist is only a cost-effective and cost-saving saving strategy in just over 50% of multivariable simulations, demonstrating that that there is significant uncertainty in the model's cost-effectiveness.

CONCLUSIONS

In our model, hysterectomy with a gynecologic oncologist for patients with EIN was associated with cost savings and increased QALYs. Our study supports that patients undergoing hysterectomy for EIN at institutions using Mayo criteria to determine need for lymphadenectomy may benefit from surgery with a gynecologic oncologist rather than a general gynecologist to reduce costs and adverse events associated with a second surgery.

Bereavement in critical care: A narrative review and practice exploration of current provision of support services and future challenges

This special article outlines the background to bereavement in critical care and scopes the current provision and evidence for bereavement support following death in critical care. Co-authored by a family member and former critical care patient, we aim to draw out the current challenges and think about how and where support can be implemented along the bereavement pathway. We draw on the literature to examine different trajectories of dying in critical care and explore how these might impact bereavement, highlighting important points and risk factors for complicated grief. We present graphic representation of the critical junctures for bereavement in critical care. Adjustment disorders around grief are explored and the consequences for families, including the existing evidence base. Finally, we propose new areas for research in this field.

End-of-life use of antibiotics: a survey on how doctors decide

OBJECTIVES

Infections are the main complications in terminal diseases. Many patients die using antibiotics, which raises questions about their real usefulness and role in unnecessary prolongation of suffering. This survey evaluated how doctors use antibiotics in palliative care.

METHODS

From June to August of 2016, an online survey was conducted with 224 doctors who provide palliative care. They had to decide whether to initiate antibiotics in fictitious scenarios involving patients with suspected infections (urinary tract infection, pneumonia, sepsis) in end-of-life (from cancer, dementia, malignant stroke with sequelae, advanced COPD, multiple organ failure). Then, they had to decide whether to stop, maintain, or extend antibiotics after non-response in 72 hours.

RESULTS

88-100% of doctors decided to initiate antibiotics in all situations, except in advanced dementia (55%), and most of them decided to maintain/extend antibiotics inadequately. Factors associated with maintaining/extending antibiotics inadequately were: longer time since graduation (over 13 years; significant in all 7 clinical situations; OR range: 2.45-10.11), and not having formal specialization in palliative care (statistically significant in 3 of 7 situations).

CONCLUSIONS

Most palliative care physicians in this study decided to initiate and maintain/extend antibiotics at the end-of-life.

Which criteria is a better predictor of ICU admission in trauma patients? An artificial neural network approach

PURPOSE

One of the most critical concerns in the intensive care unit (ICU) section is identifying the best criteria for entering patients to this part. This study aimed to predict the best compatible criteria for entering trauma patients in the ICU section.

METHOD

The present study was a historical cohort study. The data were collected from 2448 trauma patients referring to Shahid Rajaee Hospital between January 2015 and January 2017 in Shiraz, Iran. The artificial neural network (ANN) models with cross-validation and logistic regression (LR) with a backward method was used for data analysis. The final analysis was performed on a total of 958 patients who were transferred to the ICU section.

RESULTS

Based on the present results, the motor component of the GCS score at each cutoff point had the highest importance. The results also showed better performance for the AUC and accuracy rate for ANN compared with LR.

CONCLUSION

The most critical indicators in predicting the optimal use of ICU services in this study were the Motor component of the GCS. Results revealed that the ANN had a better performance than the LR in predicting the main outcomes of the traumatic patients in both the accuracy and AUC index. Trauma section surgeons and ICU specialists will benefit from this study's results and can assist them in making decisions to predict the patient outcomes before entering the ICU.

Applying the Care and Communication Bundle to Promote Palliative Care in a Neuro-Intensive Care Unit: Why and How

Background: Delivery of palliative care in neurointensive care units (neuro-ICUs) can be inconsistent, often due to absence of formal care triggers. The Care and Communication Bundle (CCB) of Quality Indicators provides a standardized process to deliver effective palliative care services in ICUs, but application of these indicators in this setting has not yet been systemically assessed. Objectives: To evaluate the fit of a CCB in the neuro-ICU through a novel scoring system and identify barriers to adherence. Design: CCB standards for a neuro-ICU were delineated. Assessment of documented indicators and barriers was conducted through electronic medical record retrospective review. Setting/Subjects: A 30-bed neuro-ICU in a large Academic Medical Center in the Southeastern United States. Chart reviews were conducted for 133 critically ill neurology and neurosurgery patients who expired between November 2018 and January 2020. Results: Results demonstrate moderate adherence to CCB standards, including excellent consistency in establishment of patient-centered communication and referral to supportive services (e.g., social work, spiritual support). Identified areas for improvement include documentation of patient and family involvement in care process (i.e., advance directive completion, interdisciplinary team meetings). Conclusions: Application of the CCB in the neuro-ICU is useful for examining adherence to time-based triggers of palliative care standards. The novel scoring system offers opportunities to motivate improvement and reduce variation in palliative care integration.

Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?

BACKGROUND

Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients.

METHODS

Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT.

RESULTS

Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001).

CONCLUSIONS

Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.

Changing the Care Paradigm for Patients: Advanced Illness Beds Care Model

BACKGROUND

Over 90 million Americans suffer from advanced illness (AI) and spend their last days of life in critical care units receiving costly, unwanted, aggressive medical care.

OBJECTIVE

Evaluate the impact of a specialized care model in medical/surgical units for hospitalized geriatric patients and patients with complex care requirements where designated AI beds align care with patient's wishes/goals, minimize aggressive interventions, and influence efficient resource utilization.

DESIGN

US based multi-facility retrospective, longitudinal descriptive study of screened positive AI patients in AI Beds (N = 1,237) from 3 facilities from 2015 to 2017.

RESULTS

Patient outcomes included 60% referrals to AI beds from ICU, a decrease of 39-49% in average ICU LOS, a 23% reduction of AI bed patient expirations, 9.0% referrals to hospice, and projected cost savings of $4,361.66/patient, US dollars.

CONCLUSION

Allocating AI beds to deliver care to AI patients resulted in a decreased cost of care by reducing overall hospital LOS, mortality, and efficient use of both critical care and hospital resources.

Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation

Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.

Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission

PURPOSE

To describe patients who die within 24 h of ICU admission in order to better optimize care delivery.

METHODS

This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression.

RESULTS

Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6).

CONCLUSION

Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.

Role of Critical Care Medicine Training in the Cardiovascular Intensive Care Unit: Survey Responses From Dual Certified Critical Care Cardiologists

Background Cardiovascular intensive care units ( CICUs ) have evolved from coronary care wards into distinct units for critically ill patients with primary cardiac diseases, often suffering from illnesses that cross multiple disciplines. Mounting evidence has demonstrated improved survival with the incorporation of dedicated CICU providers with expertise in critical care medicine ( CCM ). This is the first study to systematically survey dual certified physicians in order to assess the relevance of CCM training to contemporary CICU care. Methods and Results Utilizing American Board of Internal Medicine data through 2014, 397 eligible physicians had obtained initial certification in both cardiovascular disease and CCM . A survey to delineate the role of critical care training in the CICU was provided to these physicians. Among those surveyed, 120 physicians (30%) responded. Dual certified physicians reported frequent use of their CCM skills in the CICU , highlighting ventilator management, multiorgan dysfunction management, end-of-life care, and airway management. The majority (85%) cited these skills as the reason CCM training should be prioritized by future CICU providers. Few (17%) agreed that general cardiology fellowship alone is currently sufficient to care for patients in the modern CICU . Furthermore, there was a consensus that there is an unmet need for cardiologists trained in CCM (70%) and that CICU s should adopt a level system similar to trauma centers (61%). Conclusions Citing specific skills acquired during CCM training, dual certified critical care cardiologists reported that their additional critical care experience was necessary in their practice to effectively deliver care in the modern CICU .

Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting

OBJECTIVE

In the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients' wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State.

METHOD

A retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form.

RESULT

There were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.

SIGNIFICANCE OF RESULTS

Completing an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.

Palliative care infections and antibiotic cost: a vicious circle

Aim: In this study our aim was to evaluate the nosocomial infections and to understand factors affecting the cost of used antibiotics in palliative care unit.Materials and methods: Between 2016 and 2017, 113 patients were included in the study in palliative care unit of University of Health Sciences Bursa Yuksek Ihtisas Research and Training Hospital. Patients medical records were analyzed retrospectively for nosocomial infections, chronic diseases, presence of decubitis ulcers, opioid use, enteral, parenteral feedings, mortality and antibiotic cost.Results: Nosocomial infections were observed in 74.3% of the cases and 92.0% of patients used antibiotics. The mean duration of antibiotic use was 23.13 ± 18.06 days; and the average antibiotic cost was 2009.72 ± 2153.37 TL. Length of stay, male sex, presence of decubitus ulcers, tracheostomy, enteral and parenteral nutrition significantly increased antibiotic cost. Antibiotic cost and mortality were not related statistically.Conclusions: A vicious circle in palliative care involves the following order: length of stay, increased rate of infection, use of antibiotics, infection with resistant microorganisms, use of broad spectrum antibiotics, increased length of stay; all affecting each other. Therefore, using antibiotics for aggressive treatment of infections in palliative care is contraindicated as it opposes to real philosophy of palliative care.

Prediction of mortality in Intensive Care Units: a multivariate feature selection

CONTEXT

The critical nature of patients in Intensive Care Units (ICUs) demands intensive monitoring of their vital signs as well as highly qualified professional assistance. The combination of these needs makes ICUs very expensive, which requires investment to be prioritized. Administrative issues emerge, and health institutions face dilemmas such as: "How many beds should an ICU provide to serve the population, at the lowest costs" and "Which is the most critical body information to monitor in an ICU?". Due to financial and ethical implications, these judgments require technical and precise knowledge. Decisions have usually relied on clinical scores, like the APACHE (Acute Physiology And Chronic Health Evaluation) and SOFA (Sequential Organ Failure Assessment) scores, which are imprecise and outdated. The popularization of machine learning techniques has shed some light on the topic as a way to renew score purposes. In 2012, the PhysioNet/Computing in Cardiology launched the Challenge - ICU Patients. This Challenge aimed to stimulate the development of techniques to predict mortality in ICUs. Based on biometric and physiological features collected from patients, the participants predicted the patient's death risk by using their classifiers. Several participants achieved results that were better than the results produced by the SOFA and the APACHE scores; the prediction levels were ≈54%, which is weak.

OBJECTIVES

Here, we investigate the reasons that led to these results as a means to ground our solution. Then, we propose alternative practices in an attempt to improve the results. Our main goal is to improve the prediction of mortality in ICUs by using the same data employed during the 2012 PhysioNet Challenge. Our specific objectives are (i) to simplify the problem by reducing the dimensionality; (ii) to reduce the uncontrolled variance, and (iii) to make classifiers less dependent on the training set.

METHODS

Accordingly, we propose a methodology based on extensive steps, including sample filter and data normalization. To select features and to reduce the intra-group variance, we employ multivariate data analysis by using Principal Component Analysis, Factor Analysis, Spectral Clustering, and Tukey's HSD Test, recursively. After that, we use machine learning techniques to create classifiers according to different methods. We evaluate our results with the same metrics proposed by the 2012 PhysioNet Challenge.

RESULTS

For classifiers constructed and tested by using independent datasets, our best classifier was a linear SVM, which provided results of ≈0.73. These results were significantly better than the ≈0.54 achieved in previous work at >99% confidence interval. Furthermore, our approach only demanded twelve features, which was consistently smaller than the number of features required by the previous approaches.

CONCLUSION

Our results indicated that our approach presented: (a) higher performance to predict death risks (+20%); (b) smaller dependence on the training set; and (c) lower costs for ICU monitoring (few features). Besides the better prediction power, our approach also demanded lower costs for implementation and a more extensive range of potential ICUs. Future studies should employ our proposal to investigate the possibility of including some physiological features that were not available for the 2012 PhysioNet Challenge.

Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation

BACKGROUND

Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence.

RESEARCH QUESTION

The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea.

STUDY DESIGN AND METHODS

This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation.

RESULTS

Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00).

INTERPRETATION

Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.

Which Cost Components Influence the Cost of Palliative Care in the Last Hospitalization? A Retrospective Analysis of Palliative Care Versus Usual Care at a Swiss University Hospital

CONTEXT

Although the number of studies on the economic impact of palliative care (PC) is growing, the great majority report costs from North America.

OBJECTIVES

We aimed to provide a comprehensive overview of PC hospital cost components from the perspective of a European mixed funded health care system by identifying cost drivers of PC and quantifying their effect on hospital costs compared to usual care (UC).

METHODS

We performed a retrospective, observational analysis examining cost data from the last hospitalization of patients who died at a large academic hospital in Switzerland comparing patients receiving PC vs. UC.

RESULTS

Total hospital costs were similar in PC and UC with a mean difference of CHF -2777 [95% CI -12,713 to 8506, P = 0.60]. Average costs per day decreased by CHF -3224 [95% CI -3811 to -2631, P < 0.001] for PC patients with significant reduction of costs for diagnostic intervention and medication. Higher cost components for PC patients were catering, room, nursing, social counseling, and nonmedical therapists. In sensitivity analyses, when we restricted PC exposure to three days from admission, total costs and average costs per day were significantly lower for PC.

CONCLUSION

Studies measuring the impact of PC on hospital costs should analyze various cost components beyond total costs to understand wanted and potentially unwanted cost-reducing effects. An international definition of a set of cost components, specific for cost-impact PC studies, may help avoid superficial and potentially dangerous cost discussions.

Tranexamic acid in the routine treatment of postpartum hemorrhage in the United States: a cost-effectiveness analysis

BACKGROUND

The World Maternal Antifibrinolytic trial demonstrated that tranexamic acid administered during postpartum hemorrhage reduces hemorrhage-related mortality and laparotomies. The World Health Organization has thus recommended early use of tranexamic acid in the treatment of postpartum hemorrhage. This recommendation has not been universally adopted in the United States, in part because of concerns about cost-effectiveness.

OBJECTIVE

We aim to demonstrate the cost-effectiveness of routine tranexamic acid administration in the treatment of postpartum hemorrhage in the United States, where the rate of hemorrhage-related mortality is lower than that described in the World Maternal Antifibrinolytic trial.

STUDY DESIGN

We constructed a decision tree comparing 3 strategies in women with a clinical diagnosis of postpartum hemorrhage: no tranexamic acid, tranexamic acid given at any time, and ideal use of tranexamic acid given within 3 hours of delivery. The study was performed from a health care institution perspective with a time horizon of delivery until 6 weeks postpartum. We included interventions that differed by arm in the World Maternal Antifibrinolytic trial (hemorrhage-related mortality, laparotomies, and brace or compression sutures) and incorporated probabilities and costs based on available data for a population of women with postpartum hemorrhage in the United States. In our base case, the rate of postpartum hemorrhage-related mortality was 0.0388%, and the cost of tranexamic acid was $37.80. We assumed that the relative risk reduction in death and laparotomy with tranexamic acid would be similar to the World Maternal Antifibrinolytic trial (19% and 36%, respectively). The primary outcome was incremental cost per hemorrhage-related death averted, and a main secondary outcome was incremental cost per laparotomy avoided under each strategy. Another planned secondary outcome was cost per quality-adjusted life-year. We anticipated that the risk reduction (benefit) because of tranexamic acid in the United States may be less than in the World Maternal Antifibrinolytic trial; thus, we performed 1-way and 2-way sensitivity analyses to explore the parameter uncertainty across a wide range of data-supported estimates. Probabilistic sensitivity analyses with Monte Carlo simulation were performed.

RESULTS

Tranexamic acid strategies were dominant (more effective and cost saving) compared with no tranexamic acid for patients with postpartum hemorrhage in the United States. One-way analyses showed that tranexamic acid is cost saving as long as the relative risk reduction of death with tranexamic acid is greater than 4.7%; the model was not sensitive to any other variables. Threshold analyses outside the bounds defined in the model showed that tranexamic acid is cost saving as long as the relative risk reduction of laparotomy with tranexamic acid is greater than 7% or the cost of tranexamic acid is less than $194. A 2-way sensitivity analysis of the risk reduction of death because of tranexamic acid and the baseline risk of postpartum hemorrhage-related death confirmed that tranexamic acid is cost saving across a wide range of plausible estimates. Furthermore, probabilistic sensitivity analysis demonstrated that the tranexamic acid strategies are cost saving in >99.9% of 10,000 Monte Carlo simulations. Despite the initial cost of administration, the annual net cost savings expected from routine use of tranexamic acid for the treatment of postpartum hemorrhage in the United States is $11.3 million, and we estimate that 9 maternal deaths would be averted in 1 year with this strategy. Giving tranexamic acid within 3 hours would almost triple the cost savings and improve maternal outcomes much further.

CONCLUSION

A policy of routine tranexamic acid early in the treatment of postpartum hemorrhage is likely to be cost saving in the United States. This conclusion holds true even when the relative risk reduction with tranexamic acid is significantly less than reported in the World Maternal Antifibrinolytic trial and when tranexamic acid is significantly more expensive than currently reported.

Urgent need for standardised guidelines for reporting healthcare costs in ICUs - Results of an integrative review of costing methodologies

OBJECTIVES

Diverse costing methodologies in critical care have produced discrepant results. We aimed to critically review studies addressing critical care patients' costs, to estimate total costs and cost categories and to delineate methodologies used and relevant limitations.

METHODS

Integrative review based on key-word searches of electronic databases targeting primary studies that report estimates of patient cost, in the last 21 years. We assessed the level transparency of reporting and the quality of the studies, by the SIGN tool.

RESULTS

Overall, 12 research articles were included, of which eight studies mentioned the specific approach used to identify the elements of cost. Most studies employed a micro-costing and one study a macro-costing approach. With regard to approaches to valuation of cost components, only one study identified the bottom-up approach. The total patient cost ranged from US$ 487 to US$ 39,300 and human resources was identified as the cost category mostly driving total costs.

CONCLUSIONS

Although valid methodologies to evaluate critical care patients' costs, such as micro-costing, are employed more frequently, a variety of non-standardized methods are still used. There is a pressing need to develop standardised guidelines for reporting of observational studies of cost in healthcare, with particular considerations for critical care.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments

BACKGROUND

Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent.

METHODS

We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days.

RESULTS

Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001).

CONCLUSION

Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Using a Validated Middle-Age and Geriatric Risk Tool to Identify Early (<48 Hours) Hospital Mortality and Associated Cost of Care

OBJECTIVES

(1) To demonstrate that a validated trauma triage score for middle-aged and geriatric patients could identify those at high risk of mortality within the first 2 days of hospitalization and (2) determine the cost of care for this cohort of patients.

DESIGN

Prospective cohort study.

SETTING

Single level 1 trauma center.

PATIENTS

Patients 55 years of age and older who were evaluated in the emergency department setting by orthopaedics or who met the American College of Surgeons Tier 1-3 criteria.

INTERVENTION

Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle-aged patients, using patient's demographic, injury severity, and functional status; main outcome measurements: length of stay, inpatient mortality, time between presentation and time of death, and direct variable costs of hospitalization.

RESULTS

A total of 1470 consecutive patients (mean age of 72.2 ± 11.9 years) were enrolled in this study, 17 of whom died within 48 hours of presentation to the emergency department. These patients had a significantly higher trauma triage score than the rest of the cohort with a score of 50.9% ± 37.2% versus 3.3% ± 9.5%, P < 0.001 indicating that they had a mean risk of inpatient mortality of over 50%. Mean total cost per day was much higher in the cohort of patients who died within 48 hours of admission compared with all other trauma patients [$49,367 ± $79,057 vs. $3966 ± $2897 (P = 0.031)].

CONCLUSIONS

To achieve value-based care in this high-risk cohort, targeted cost savings while improving patient outcomes and/or expediting goals-of-care and end-of-life goals is necessary and the STTGMA score allows for stratification of these patients in both mortality risk and cost profile.

Antimicrobial Use at the End of Life

At least one-third of patients at the end of life (EOL) receive interventions that are without benefit, and a similar proportion of patients die in the intensive care unit. Here, the authors discuss the role of antimicrobials in patients at the EOL, including the patient populations and scenarios in which antimicrobials may or may not have benefit. They also review adverse outcomes associated with antimicrobial use at the EOL, including societal harms. Finally, an algorithm to aid management of suspected infections at the EOL is proposed.

Legislative Enforcement of Nonconsensual Determination of Neurological (Brain) Death in Muslim Patients: A Violation of Religious Rights

Death is defined in the Quran with a single criterion of irreversible separation of the ruh (soul) from the body. The Quran is a revelation from God to man, and the primary source of Islamic knowledge. The secular concept of death by neurological criteria, or brain death, is at odds with the Quranic definition of death. The validity of this secular concept has been contested scientifically and philosophically. To legitimize brain death for the purpose of organ donation and transplantation in Muslim communities, Chamsi-Pasha and Albar (concurring with the US President's Council on Bioethics) have argued that irreversible loss of capacity for consciousness and breathing (apneic coma) in brain death defines true death in accordance with Islamic sources. They have postulated that the absence of nafs (personhood) and nafas (breath) in apneic coma constitutes true death because of departure of the soul (ruh) from the body. They have also asserted that general anesthesia is routine in brain death before surgical procurement. Their argument is open to criticism because: (1) the ruh is described as the essence of life, whereas the nafs and nafas are merely human attributes; (2) unlike true death, the ruh is still present even with absent nafs and nafas in apneic coma; and (3) the routine use of general anesthesia indicates the potential harm to brain-dead donors from surgical procurement. Postmortem general anesthesia is not required for autopsy. Therefore, the conclusion must be that legislative enforcement of nonconsensual determination of neurological (brain) death and termination of life-support and medical treatment violates the religious rights of observant Muslims.

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective

Purpose of report: Understanding the impact of palliative care interventions on intensive care unit (ICU) costs and utilization is critical for demonstrating the value of palliative care. Performing these economic assessments, however, can be challenging. The purpose of this special report is to highlight and discuss important considerations when assessing ICU utilization and costs from the hospital perspective, with the goal of providing recommendations on methods to consider for future analyses.

FINDINGS

ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies.

SUMMARY

ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions.

Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays

Importance

High health care costs encourage initiatives that avoid overuse of resources and identify opportunities to promote appropriate care.

Objective

To investigate the causes of potentially avoidable surgical intensive care unit (SICU) admissions and disposition delays to determine whether targeted interventions could decrease these stays.

Design, Setting, and Participants

This prospective, observational study focused on potentially avoidable SICU days, as determined by observers with input from the rounding intensivists at a 24-bed open SICU at an urban, academic hospital. The preintervention phase occurred from April 6 through June 21, 2015; after implementation of targeted interventions, the postintervention phase occurred from April 4 through June 28, 2016. Data collected included demographic characteristics, reason for admission, and length of stay. All patients admitted to the SICU during the preintervention and postintervention phases were included in the analysis.

Interventions

Based on results collected in the preintervention phase, targeted interventions were designed and implemented from July 1, 2015, through March 31, 2016, including (1) reducing SICU care for minor traumatic brain injury, (2) optimizing postoperative airway management, (3) enhancing communication between services regarding transfers to the SICU, (4) identifying and facilitating more timely end-of-life conversations and supportive care consultations, and (5) encouraging early disposition of patients to floor beds.

Main Outcomes and Measures

Changes in the proportion of potentially avoidable SICU days owing to potentially avoidable admissions and/or disposition delays.

Results

A total of 459 patients (253 men [55.1%] and 206 women [44.9%]; median age, 62 years [interquartile range, 46-75 years]) were admitted during the preintervention and postintervention phases. Of 261 patients admitted during the preintervention period and 245 during the postintervention period, median SICU and hospital length of stay remained unchanged. A reduction was noted in the percentage of postintervention SICU days owing to potentially avoidable admissions (152 of 1168 days [13%] vs 118 of 1338 days [8.8%]; P = .001) and disposition delays (138 of 1168 days [11.8%] vs 97 of 1338 days [7.2%]; P < .001). During the postintervention period, decreases were noted in the SICU days related to the most common sources of potentially avoidable admissions (SICU stay ≤24 hours, airway concerns, and somnolence) and disposition delays (end-of-life decisions and floor bed unavailable) as well as in the overall rate of potentially avoidable days (269 of 1168 days [23%] vs 205 of 1338 days [15.3%]; P < .001).

Conclusions and Relevance

Nearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.

Organ Support After Death by Neurologic Criteria in Pediatric Patients

OBJECTIVES

We sought to 1) evaluate how pediatricians approach situations in which families request continuation of organ support after declaration of death by neurologic criteria and 2) explore potential interventions to make these situations less challenging.

DESIGN

A survey on management and personal experience with death by neurologic criteria was distributed electronically to pediatric intensivists and neurologists. We compared responses from individuals who practice in states with accommodation exceptions (accommodation states where religious or moral beliefs must be taken into consideration when declaring death: California, Illinois, New Jersey, New York) to those from non-accommodation states.

SETTING

United States.

SUBJECTS

The survey was opened by 254 recipients, with 186 meeting inclusion criteria and providing data about the region in which they practice; of these, 26% were from accommodation states.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

More than half of physicians (61% from both accommodation states and non-accommodation states) reported they cared for a pediatric patient whose family requested continuation of organ support after declaration of death by neurologic criteria (outside of organ donation; range, 1-17 times). Over half of physicians (53%) reported they would not feel comfortable handling a situation in which a pediatric patient's family requested care be continued after declaration of death by neurologic criteria. Nearly every physician (98%) endorsed that something needs to be done to make situations involving families who object to discontinuation of organ support after declaration of death by neurologic criteria easier to handle. Respondents felt that public education, physician education, and uniform state laws about these situations are warranted.

CONCLUSIONS

It is relatively common for pediatricians who care for critically ill patients to encounter families who object to discontinuation of organ support after death by neurologic criteria. Management of these situations is challenging, and guidance for medical professionals and the public is needed.