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Dolmans RGF, Robertson FC, Eijkholt M, van Vliet P, Broekman MLD. Palliative Care in Severe Neurotrauma Patients in the Intensive Care Unit. Neurocrit Care 2023; 39:557-564. [PMID: 37173560 PMCID: PMC10689547 DOI: 10.1007/s12028-023-01717-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/17/2023] [Indexed: 05/15/2023]
Abstract
Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide and many patients with TBI require intensive care unit (ICU) management. When facing a life-threatening illness, such as TBI, a palliative care approach that focuses on noncurative aspects of care should always be considered in the ICU. Research shows that neurosurgical patients in the ICU receive palliative care less frequently than the medical patients in the ICU, which is a missed opportunity for these patients. However, providing appropriate palliative care to neurotrauma patients in an ICU can be difficult, particularly for young adult patients. The patients' prognoses are often unclear, the likelihood of advance directives is small, and the bereaved families must act as decision-makers. This article highlights the different aspects of the palliative care approach as well as barriers and challenges that accompany the TBI patient population, with a particular focus on young adult patients with TBI and the role of their family members. The article concludes with recommendations for physicians for effective and adequate communication to successfully implement the palliative care approach into standard ICU care and to improve quality of care for patients with TBI and their families.
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Affiliation(s)
- Rianne G F Dolmans
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Faith C Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Marleen Eijkholt
- Department of Ethics and Law in Healthcare, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter van Vliet
- Department of Intensive Care Medicine, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, The Netherlands
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Duncan AJ, Holkup LM, Sang HI, Sahr SM. Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients. Crit Care Explor 2023; 5:e0963. [PMID: 37649850 PMCID: PMC10465097 DOI: 10.1097/cce.0000000000000963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES To determine the effects of palliative care consultation if performed within 72 hours of admission on length of stay (LOS), mortality, and invasive procedures. DESIGN Retrospective observational study. SETTING Single-center level 1 trauma center. PATIENTS Trauma patients, admitted to ICU with palliative care consultation. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The ICU LOS was decreased in the early palliative care (EPC) group compared with the late palliative care (LPC) group, by 6 days versus 12 days, respectively. Similarly, the hospital LOS was also shorter in the EPC group by 8 days versus 17 days in the LPC group. In addition, the EPC group had lower rates of tracheostomy (4% vs 14%) and percutaneous gastrostomy tubes (4% vs 15%) compared with the LPC group. There was no difference in mortality or discharge disposition between patients in the EPC versus LPC groups. It is noteworthy that the patients who received EPC were slightly older, but there were no other significant differences in demographics. CONCLUSIONS EPC is associated with fewer procedures and a shorter amount of time spent in the hospital, with no immediate effect on mortality. These outcomes are consistent with studies that show patients' preferences toward the end of life, which typically involve less time in the hospital and fewer invasive procedures.
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Affiliation(s)
- Anthony J Duncan
- Department of Surgery, University of North Dakota, Grand Forks, ND
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
| | - Lucas M Holkup
- Department of Surgery, University of North Dakota, Grand Forks, ND
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
| | - Hilla I Sang
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
| | - Sheryl M Sahr
- Department of Surgery, University of North Dakota, Grand Forks, ND
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
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Cook MR, Schultz Reed K, Crannell WC, Brasel KJ, Siegel TR. Integrating Surgical Palliative Care Into the Full Spectrum of Medical Education. Am Surg 2023:31348231157418. [PMID: 36793013 DOI: 10.1177/00031348231157418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
We describe our institutional approach to incorporating surgical palliative care education into the Undergraduate Medical Education, Graduate Medical Education and Continuing Medical Education spaces as a model to help guide similarly interested educators. We had a well-established Ethics and Professionalism Curriculum, but an educational needs assessment revealed that both the residents and faculty felt that additional training in palliative care principles was crucial. We describe our full spectrum palliative care curriculum, which begins with the medical students on their surgical clerkship and continues with a 4 week surgical palliative care rotation for categorical general surgery PGY-1 residents, as well as a Mastering Tough Conversations course over several months at the end of the first year. Surgical Critical Care rotations, Intensive Care Unit debriefs after major complications, deaths, and other high-stress events are described, as is the CME domain, which includes routine Department of Surgery Death Rounds and a focus on palliative care concepts in Departmental Morbidity and Mortality conference. The Peer Support program and Surgical Palliative Care Journal Club round out our current educational endeavor. We describe our plans to create a full spectrum surgical palliative care curriculum that is fully integrated with the 5 clinical years of surgical residency, and include our proposed educational goals and year-specific objectives. The development of a Surgical Palliative Care Service is also described.
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Affiliation(s)
- Mackenzie R Cook
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
| | - Kristen Schultz Reed
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
| | | | - Karen J Brasel
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
| | - Timothy R Siegel
- Department of Surgery, 6684Oregon Health & Science University, Portland, OR, USA
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4
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Schultz K, Howard S, Moreno K, Siegel T, Zonies D, Brasel K, Cook M. What Should the Surgeons Do at the Family Meeting: A Multi-Disciplinary Qualitative Description of Surgeon Participation in Palliative Care Discussions. JOURNAL OF SURGICAL EDUCATION 2023; 80:110-118. [PMID: 36089480 DOI: 10.1016/j.jsurg.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/12/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE National guidelines have suggested that quality surgical care should incorporate effective palliative care (PC). Numerous barriers to surgeon participation remain and the domains of optimal surgeon participation are unclear. DESIGN Eight semi-structured and multi-professional focus groups with 34 total participants. Discussion was transcribed, and qualitative approaches were used to encode, identify, and categorize emergent themes. SETTING Oregon Health & Science University, Portland Oregon. A tertiary care teaching hospital. PARTICIPANTS 34 multi-disciplinary participants in eight focus groups, identified on a volunteer basis. RESULTS Key themes defining domains of optimal surgeon/palliative practice include: (1) "primary/secondary PC" which detailed conflict between the surgeon's desire to be part of palliative discussions and competing clinical/time demands. (2) "role/responsibility" described the tension surgeons feel around a desire to provide honest and goal concordant care (3) "teamwork/conflict" detailed the approach to disagreement among multidisciplinary teams. CONCLUSIONS In this qualitative analysis, emergent themes suggest that surgeons want to be involved in the PC of their patients but are limited by available time and competing for ethical obligations. Tension between competing communication and care obligations and PC goals is common, and discord around patient goals remains an issue. This work highlights the need for a standardized curriculum to improve the PC of surgical patients.
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Affiliation(s)
- Kristen Schultz
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Shannon Howard
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kirstin Moreno
- Office of Educational Improvement Innovation, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Medicine, Division of Hematology/Medical Oncology, Oregon Health & Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karen Brasel
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Mackenzie Cook
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon.
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Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention. J Am Coll Surg 2022; 235:278-284. [PMID: 35839403 DOI: 10.1097/xcs.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older trauma patients present with poor preinjury functional status and more comorbidities. Advances in care have increased the chance of survival from previously fatal injuries with many left debilitated with chronic critical illness and severe disability. Palliative care (PC) is ideally suited to address the goals of care and symptom management in this critically ill population. A retrospective chart review was done to identify the impact of PC consults on hospital length of stay (LOS), ICU LOS, and surgical decisions. STUDY DESIGN A Level 1 Trauma Center Registry was used to identify adult patients who were provided PC consultation in a selected 3-year time period. These PC patients were matched with non-PC trauma patients on the basis of age, sex, race, Glasgow Coma Scale, and Injury Severity Score. Chi-square tests and Student's t-tests were used to analyze categorical and continuous variables, respectively. Any p value >0.05 was considered statistically significant. RESULTS PC patients were less likely to receive a percutaneous endoscopic gastric tube or tracheostomy. PC patients spent less time on ventilator support, spent less time in the ICU, and had a shorter hospital stay. PC consultation was requested 16.48 days into the patient's hospital stay. Approximately 82% of consults were to assist with goals of care. CONCLUSION Specialist PC team involvement in the care of the trauma ICU patients may have a beneficial impact on hospital LOS, ICU LOS, and surgical care rendered. Earlier consultation during hospitalization may lead to higher rates of goal-directed care and improved patient satisfaction.
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Schultz K, Howard S, Moreno K, Siegel T, Zonies D, Brasel K, Cook M. Teaching primary palliative care to general surgical residents: A novel pedagogical approach drawn from multi-disciplinary focus group data. Am J Surg 2022; 224:396-399. [DOI: 10.1016/j.amjsurg.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 01/23/2023]
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Schultz K, Howard S, Siegel T, Zonies D, Brasel K, Cook M, Moreno K. Supporting surgical residents learning clinical palliative care: Insights from multi-disciplinary focus groups. Am J Surg 2022; 224:676-680. [DOI: 10.1016/j.amjsurg.2022.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/26/2022] [Accepted: 02/25/2022] [Indexed: 12/18/2022]
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Edsall A, Howard S, Dewey EN, Siegel T, Zonies D, Brasel K, Cook MR, Nagengast AK. Critical decisions in the trauma intensive care unit: Are we practicing primary palliative care? J Trauma Acute Care Surg 2021; 91:886-890. [PMID: 34695065 DOI: 10.1097/ta.0000000000003324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Devastating injuries require both urgent assessment by a trauma service and early attention to patients' goals of care (GOC). American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines recommend an initial palliative assessment within 24 hours of admission and family meeting, if needed, within 72 hours. We hypothesize that a primary palliative care-based practice improves adherence to TQIP guidelines in trauma patients. METHODS All adult trauma patients who died while inpatient from January 2014 to December 2018 were reviewed. Timing of GOC discussions, transition to comfort measures only (CMO), and the utilization of specialty palliative services were analyzed with univariate analysis. RESULTS During the study period, 415 inpatients died. Median Injury Severity Score was 26 (interquartile range [IQR], 17-34), median age was 67 years (IQR, 51-81 years), and 72% (n = 299) transitioned to CMO before death. Documented GOC discussions increased from 77% of patients in 2014 to 95% of patients in 2018 (p < 0.001), and in 2018, the median time to the first GOC discussion was 15 hours (IQR, 7- 24 hours). Specialty palliative care was consulted in 7% of all patients. Of patients who had at least one GOC discussion, 98% were led by the trauma intensive care unit (TICU) team. Median time from admission to first GOC discussion was 27 hours (IQR, 6-91 hours). Median number of GOC discussions was 1 (IQR, 1-2). Median time to CMO after the final GOC discussion was 0 hours (IQR, 0-3). Median time to death after transition to CMO was 4 hours (IQR, 1-18 hours). CONCLUSION Of those who died during index admission, we demonstrated significant improvement in adherence to American College of Surgeons TQIP palliative guidelines across the 5-year study period, with the TICU team guiding the majority of GOC discussions. Our TICU team has developed an effective primary palliative care approach, selectively consulting specialty palliative care only when needed. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Andrew Edsall
- From the Department of Surgery (A.E., S.H., E.N.D., T.S., D.Z., K.B., M.R.C., A.K.N.), Oregon Health and Science University; and Operative Care Division (A.K.N.), VA Portland Medical Center, Portland, Oregon
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Ammar MA, Ammar AA, Cheung CC, Akhtar S. Pharmacological Adjuncts to Palliation in the Trauma Patient: Optimal Symptom Management. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kirkland KD, Chabanon-Hicks C, Acquista E. Implementation of a Surgical Intensivist Model Increases Palliative Care Consultation in the Care of Trauma ICU Patients. Am J Hosp Palliat Care 2021; 39:270-273. [PMID: 34235976 DOI: 10.1177/10499091211025733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study investigated patient outcomes of care before and after transitioning to a surgical intensivist-led trauma-intensive care unit (ICU) team. The intensivist team provided daily multidisciplinary rounds and continuity of care. Prior to an intensivist model, general surgeons cared for trauma patients admitted to the unit. METHODS Outcomes of 1,078 trauma patients, admitted to the ICU at a Level II trauma center, under care of general surgeons (1/2011-8/2012, n = 449) were retrospectively compared with care managed by a surgical intensivist team (1/2013-5/2015, n = 629) by Pearson Chi-squared and Wilcoxon tests. A multivariable logistic regression technique was used to control for covariates. Demographics and injury severity were analyzed. The primary outcome was ICU mortality. The secondary outcomes were length of stay (LOS), ventilator-free and ICU-free days, and ICU readmission rate. Other data collected included palliative care consultation. Results: There were no statistically significant differences in ICU mortality (P = 0.055), hospital LOS (P = 0.481), ventilator-free days (P = 0.174), or ICU readmission rate (P = 0.587). The surgical intensivist team consulted palliative care more frequently (4.0% vs 13.5%, P < 0.001), while managing more trauma patients who were older than 65 years (P < 0.001) with lower Glasgow Coma Scale (P = 0.048) and higher injury severity (P = 0.025) and abbreviated injury scale (P < 0.001) scores. DISCUSSION There were no differences in outcomes. However, incorporating palliative care consultation in the ICU is essential in the support of critically ill patients and their families. These data demonstrate that a surgical intensivist team utilized palliative care more often in the management of trauma patients admitted to the ICU.
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Challenges in the Development and Implementation of Older Adult Trauma Prognostication Tools to Facilitate Shared Decision-Making. J Surg Res 2021; 266:430-432. [PMID: 34116277 DOI: 10.1016/j.jss.2021.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/27/2021] [Accepted: 04/10/2021] [Indexed: 11/21/2022]
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Pieracci FM, Leasia K, Hernandez MC, Kim B, Cantrell E, Bauman Z, Gardner S, Majercik S, White T, Dieffenbaugher S, Eriksson E, Barns M, Benjamin Christie D, Lasso ET, Schubl S, Sauaia A, Doben AR. Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes? J Trauma Acute Care Surg 2021; 90:1014-1021. [PMID: 34016925 DOI: 10.1097/ta.0000000000003140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Fredric M Pieracci
- From the Department of Surgery (F.M.P., K.L.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (M.C.H., B.K.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (E.C., Z.B.), University of Nebraska Medical Center, Omaha, Nebraska; Department of Surgery (S.G., S.M., T.W.), Intermountain Medical Center, Murray, Utah; Department of Surgery (S.D., E.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.B., D.B.C.), The Medical Center, Navicent Health, Macon, Georgia; Department of Surgery (E.T.L., S.S.), University of California, Irvine, California; Department of Surgery (A.S.), University of Colorado School of Medicine, Aurora, Colorado; and Department of Surgery (A.R.D.), St. Francis Medical Center, Hartford, Connecticut
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Amen SS, Berndtson AE, Cain J, Onderdonk C, Cochran-Yu M, Gambles Farr S, Edwards SB. Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship. J Surg Res 2021; 266:236-244. [PMID: 34029763 DOI: 10.1016/j.jss.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 02/25/2021] [Accepted: 03/10/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation. METHODS The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows). RESULTS For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged. CONCLUSION Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes.
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Affiliation(s)
- Sara S Amen
- Department Of Surgery, California University of Science and Medicine, Colton, California
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California
| | - Julia Cain
- Doris A. Howell Palliative Teams, University Of California - San Diego, San Diego, California
| | - Christopher Onderdonk
- Doris A. Howell Palliative Teams, University Of California - San Diego, San Diego, California
| | - Meghan Cochran-Yu
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California; Department Of Surgery, Loma Linda University School Of Medicine, Loma Linda, California
| | - Samantha Gambles Farr
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California
| | - Sara B Edwards
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University Of California - San Diego, San Diego, California; Department Of Surgery, Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System and CECORC, Moreno Valley, California.
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Wycech J, Fokin AA, Katz JK, Viitaniemi S, Menzione N, Puente I. Comparison of Geriatric Versus Non-geriatric Trauma Patients With Palliative Care Consultations. J Surg Res 2021; 264:149-157. [PMID: 33831601 DOI: 10.1016/j.jss.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/22/2021] [Accepted: 02/27/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Palliative care in trauma patients is still evolving. The goal was to compare characteristics, outcomes, triggers and timing for palliative care consultations (PCC) in geriatric (≥65 y.o.) and non-geriatric trauma patients. MATERIALS AND METHODS Retrospective study included 432 patients from two level 1 trauma centers who received PCC between December 2012 and January 2019. Non-geriatric (n = 61) and geriatric (n = 371) groups were compared for: mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Score (GCS), Do-Not-Resuscitate (DNR) orders, futile interventions (FI), duration of mechanical ventilation (DMV), ICU admissions, ICU and hospital lengths of stay (ICULOS; HLOS), timing to PCC, and mortality. Further propensity matching (PM) analysis compared 59 non-geriatric to 59 Geriatric patients matched by ISS, GCS, and DNR. RESULTS Geriatric patients were older (85.2 versus 49.7), with falls as predominant MOI. Non-geriatric patients comprised 14.1% of all patients with PCC and were more severely injured than Geriatrics: with statistically higher ISS (24.1 versus 18.5), lower RTS (5.4 versus 7.0), GCS (7.1 versus 11.5), with predominant MOI being traffic accidents, all P < 0.01. Non-Geriatrics had more ICU admissions (96.7% versus 88.1%), longer ICULOS (10.2 versus 4.7 days), DMV (11.1 versus 4.1 days), less DNR (57.4% versus 73.9%), higher in-hospital mortality (12.5% versus 2.6%), but double the time admission-PCC (11.3 versus 4.3 days) compared to Geriatrics, all P < 0.04. In PM comparison, despite same injury severity, Non-geriatrics had triple the time to PCC, five times the HLOS of geriatrics, and more FI (25.4% versus 3.4%), all P < 0.001. CONCLUSIONS PCC remains underutilized in non-geriatric trauma patients. Despite higher injury severity, non-geriatrics received more aggressive treatment, and had three times longer time to PCC, resulting in higher rate of FI than in Geriatrics.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida.
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Sari Viitaniemi
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Nicholas Menzione
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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Palliative care and aggressive interventions after falling: A Nationwide Inpatient Sample analysis. Palliat Support Care 2021; 20:101-106. [PMID: 33663643 DOI: 10.1017/s1478951521000158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The purpose of this study is to identify whether there is an opportunity for improvement to provide palliative care services after a serious fall. We hypothesized that (1) palliative care services would be utilized in less than 10% of patients over the age of 65 who fall and (2) more than 20% of patients would receive aggressive life-sustaining treatments (LSTs) prior to death. METHODS Using the 2017 Nationwide Inpatient Sample, we identified patients who were admitted to the hospital with a fall (ICD-10 W00-W19) and were hospitalized at least two days with valid discharge data. Palliative care services (Z51.5) or LSTs (cardiopulmonary resuscitation, ventilation, reintubation, tracheostomy, feeding tube placement, vasopressors, transfusion, total parenteral nutrition, and hemodialysis) were identified with ICD-10 codes. We examined the use of palliative care or LSTs by discharge destination (home, facility, and death). Logistic regression was used to identify factors associated with palliative care. RESULTS In total, 155,241 patients were identified (median 82 years old, interquartile range 74-88); 2.5% died in hospital, and 69.4% were transferred to a facility. Palliative care occurred in 4.5% of patients, and LST occurred in 15.1%. Patients who died were significantly more likely to have had palliative care (50.1% vs. 3.4% of home or facility discharges) and were more likely to have an LST [53.0% vs. 9.8% (home) vs. 15.9% (facility)]. Palliative care was associated with both death [adjusted odds ratio (AOR) 19.84, 95% confidence interval (CI) 18.39-21.41, p < 0.001] and LST (AOR 1.36, 95% CI 1.27-1.46, p < 0.001). SIGNIFICANCE OF RESULTS Palliative care is associated with both death and LST, suggesting that physicians use palliative care as a last resort after aggressive measures have been exhausted. Patients who fall would likely benefit from the early use of palliative care to align future goals of care.
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Cook M, Zonies D, Brasel K. Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient. CURRENT TRAUMA REPORTS 2020; 6:183-193. [PMID: 33145148 PMCID: PMC7595000 DOI: 10.1007/s40719-020-00201-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Purpose of Review Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU. Recent Findings The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication. Summary We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.
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Affiliation(s)
- Mackenzie Cook
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - David Zonies
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
| | - Karen Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park Rd, Portland, OR 97230 USA
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Esquibel BM, Waller CJ, Borgert AJ, Kallies KJ, Harter TD, Cogbill TH. The role of palliative care in acute trauma: When is it appropriate? Am J Surg 2020; 220:1456-1461. [PMID: 33051066 DOI: 10.1016/j.amjsurg.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/21/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.
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Affiliation(s)
- Brendon M Esquibel
- General Surgery Residency, Department of Medical Education, Gundersen Health System, La Crosse, WI, USA
| | - Christine J Waller
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Thomas D Harter
- Department of Bioethics and Humanities, Gundersen Health System, La Crosse, WI, USA
| | - Thomas H Cogbill
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
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Stewart BT, Carrougher GJ, Curtis E, Schneider JC, Ryan CM, Amtmann D, Gibran NS. Mortality prognostication scores do not predict long-term, health-related quality of life after burn: A burn model system national database study. Burns 2020; 47:42-51. [PMID: 33092898 PMCID: PMC7533049 DOI: 10.1016/j.burns.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/20/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury. METHODS We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994-2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined. RESULTS The analysis included 1606 respondents (median age 42 years, IQR 28-53 years; 70% male). Median burn size was 16% TBSA (IQR 6-30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r2 0.01-0.12). CONCLUSION Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.
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Affiliation(s)
- Barclay T Stewart
- Department of Surgery, University of Washington, Northwest Regional Burn Model System; Northwest Regional Burn Model System.
| | | | - Elleanor Curtis
- Department of Surgery, University of California Davis Health, Department of Palliative Care, University of California Davis Health
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston-Harvard Burn Injury Model System
| | - Colleen M Ryan
- Department of Surgery, Harvard Medical School, Boston-Harvard Burn Injury Model System
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, Burn Model System
| | - Nicole S Gibran
- Department of Surgery, University of Washington, Northwest Regional Burn Model System; Northwest Regional Burn Model System
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Wycech J, Fokin AA, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation. J Palliat Med 2020; 24:705-711. [PMID: 32975481 DOI: 10.1089/jpm.2020.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | | | - Susan Koff
- TrustBridge Health, West Palm Beach, Florida, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida, USA
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Abstract
INTRODUCTION Elderly trauma patients are at high risk for mortality, even when presenting with minor injuries. Previous prognostic models are poorly used because of their reliance on elements unavailable during the index hospitalization. The purpose of this study was to develop a predictive algorithm to accurately estimate in-hospital mortality using easily available metrics. METHODS The National Trauma Databank was used to identify patients 65 years and older. Data were split into derivation (2007-2013) and validation (2014-2015) data sets. There was no overlap between data sets. Factors included age, comorbidities, physiologic parameters, and injury types. A two-tiered scoring system to predict in-hospital mortality was developed: a quick elderly mortality after trauma (qEMAT) score for use at initial patient presentation and a full EMAT (fEMAT) score for use after radiologic evaluation. The final model (stepwise forward selection, p < 0.05) was chosen based on calibration and discrimination analysis. Calibration (Brier score) and discrimination (area under the receiving operating characteristic curve [AuROC]) were evaluated. Because National Trauma Databank did not include blood product transfusion, an element of the Geriatric Trauma Outcome Score (GTOS), a regional trauma registry was used to compare qEMAT versus GTOS. A mobile-based application is currently available for cost-free utilization. RESULTS A total of 840,294 patients were included in the derivation data set and 427,358 patients in the validation data set. The fEMAT score (median, 91; S.D., 82-102) included 26 factors, and the qEMAT score included eight factors. The AuROC was 0.86 for fEMAT (Brier, 0.04) and 0.84 for qEMAT. The fEMAT outperformed other trauma mortality prediction models (e.g., Trauma and Injury Severity Score-Penetrating and Trauma and Injury Severity Score-Blunt, age + Injury Severity Score). The qEMAT outperformed the GTOS (AuROC, 0.87 vs. 0.83). CONCLUSION The qEMAT and fEMAT accurately estimate the probability of in-hospital mortality and can be easily calculated on admission. This information could aid in deciding transfer to tertiary referral center, patient/family counseling, and palliative care utilization. LEVEL OF EVIDENCE Epidemiological Study, level IV.
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Fokin AA, Wycech J, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Palliative Care Consultations in Trauma Patients and Role of Do-Not-Resuscitate Orders: Propensity-Matched Study. Am J Hosp Palliat Care 2020; 37:1068-1075. [PMID: 32319314 DOI: 10.1177/1049909120919672] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To delineate characteristics of trauma patients associated with a palliative care consultation (PCC) and to analyze the role of do-not-resuscitate (DNR) orders and related outcomes. METHODS Retrospective study included 864 patients from 2 level one trauma centers admitted between 2012 and 2019. Level 1 trauma centers are designated for admission of the most severe injured patients. Palliative care consultation group of 432 patients who received PCC and were compared to matched control (MC) group of 432 patients without PCC. Propensity matching covariates included Injury Severity Score, mechanism of injury, gender, and hospital length of stay (HLOS). Analysis included patient demographics, injury parameters, intensive care unit (ICU) admissions, ICU length of stay (ICULOS), duration of mechanical ventilation, timing of PCC and DNR, and mortality. Palliative care consultation patients were further analyzed based on DNR status: prehospital DNR, in-hospital DNR, and no DNR (NODNR). RESULTS Palliative care consultation compared to MC patients were older, predominantly Caucasian, with more frequent traumatic brain injury (TBI), ICU admissions, and mechanical ventilation. The average time to PCC was 5.3 days. Do-not-resuscitate orders were significantly more common in PCC compared to MC group (71.5% vs 11.1%, P < .001). Overall mortality was 90.7% in PCC and 6.0% in MC (P < .001). In patients with DNR, mortality was 94.2% in PCC and 18.8% in MC. In-hospital DNR-PCC compared to NODNR-PCC patients had shorter ICULOS (5.0 vs 7.3 days, P = .04), HLOS (6.2 vs 13.2 days, P = .006), and time to discharge (1.0 vs 6.3 days, P = .04). CONCLUSIONS Advanced age, DNR order, and TBI were associated with a PCC in trauma patients and resulted in significantly higher mortality in PCC than in MC patients. Combination of DNR and PCC was associated with shorter ICULOS, HLOS, and time from PCC to discharge.
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Affiliation(s)
- Alexander A Fokin
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA
| | | | - Susan Koff
- 535241TrustBridge Health, West Palm Beach, FL, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, 24637Delray Medical Center, Delray Beach, FL, USA.,Department of Surgery, Charles E. Schmidt College of Medicine, 306688Florida Atlantic University, Boca Raton, FL, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL, USA.,Department of Surgery, Herbert Wertheim College of Medicine, 306688Florida International University, Miami, FL, USA
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Lee KC, Udelsman BV, Streid J, Chang DC, Salim A, Livingston DH, Lindvall C, Cooper Z. Natural Language Processing Accurately Measures Adherence to Best Practice Guidelines for Palliative Care in Trauma. J Pain Symptom Manage 2020; 59:225-232.e2. [PMID: 31562891 DOI: 10.1016/j.jpainsymman.2019.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive. OBJECTIVES To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review. METHODS Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery. RESULTS There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay. CONCLUSION NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Brooks V Udelsman
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ali Salim
- Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David H Livingston
- Division of Trauma and Surgical Critical Care, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery, University of California, San Diego, La Jolla, California, USA; Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Duration of Respiratory Failure After Trauma Is Not Associated With Increased Long-Term Mortality. Crit Care Med 2019; 46:1263-1268. [PMID: 29742591 DOI: 10.1097/ccm.0000000000003202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival. DESIGN Retrospective cohort of trauma patients. SETTING Single center, level 1 trauma center. PATIENTS Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (> 14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33-65 yr) and Injury Severity Score was 19 (11-29). Median respiratory failure duration was 3 days (2-6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9-9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality. CONCLUSIONS Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.
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Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions. Injury 2019; 50:1064-1067. [PMID: 30745124 DOI: 10.1016/j.injury.2019.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/08/2019] [Accepted: 01/12/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Many injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources. METHODS Trauma Quality Improvement Program (2013-2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student's t tests or Wilcoxon rank sum tests; significance for p < 0.05. RESULTS We identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC. CONCLUSION WLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.
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Bonanno AM, Kiraly LN, Siegel TR, Brasel KJ, Cook MR. Surgical palliative care training in general surgery residency: An educational needs assessment. Am J Surg 2019; 217:928-931. [DOI: 10.1016/j.amjsurg.2019.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/03/2019] [Accepted: 01/13/2019] [Indexed: 12/15/2022]
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Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee. J Trauma Acute Care Surg 2019; 86:737-743. [DOI: 10.1097/ta.0000000000002155] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lilley EJ, Lee KC, Scott JW, Krumrei NJ, Haider AH, Salim A, Gupta R, Cooper Z. The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge. J Trauma Acute Care Surg 2018; 85:992-998. [PMID: 29851910 PMCID: PMC6202158 DOI: 10.1097/ta.0000000000002000] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. METHODS This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. RESULTS Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). CONCLUSION Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
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Affiliation(s)
- Elizabeth J Lilley
- From the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts (E.J.L., K.C.L., J.W.S., A.H.H., A.S., Z.C.); Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (E.J.L., N.J.K., R.G.); Department of Surgery, University of California San Diego, La Jolla, California (K.C.L.); and Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., Z.C.)
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Increased hospice enrollment and decreased neurosurgical interventions without changes in mortality for older Medicare patients with moderate to severe traumatic brain injury. Am J Surg 2018. [DOI: 10.1016/j.amjsurg.2018.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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A comparison of prognosis calculators for geriatric trauma: A Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium study. J Trauma Acute Care Surg 2017; 83:90-96. [PMID: 28422904 DOI: 10.1097/ta.0000000000001506] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The nine-center Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium has validated the Geriatric Trauma Outcome Score (GTOS) as a prognosis calculator for injured elders. We compared GTOS' performance to that of the Trauma Injury Severity Score (TRISS) in a multicenter sample. METHODS Three Prognostic Assessment of Life and Limitations After Trauma in the Elderly centers not submitting subjects to the GTOS validation study identified subjects aged 65 years to 102 years admitted from 2000 to 2013. GTOS was specified using the formula [GTOS = age + (Injury Severity Score [ISS] × 2.5) + 22 (if transfused packed red cells (PRC) at 24 hours)]. TRISS uses the Revised Trauma Score (RTS), dichotomizes age (<55 years = 0 and ≥55 years = 1), and was specified using the updated 1995 beta coefficients. TRISS Penetrating was specified as [TRISSP = -2.5355 + (0.9934 × RTS) + (-0.0651 × ISS) + (-1.1360 × Age)]. TRISS Blunt was specified as [TRISSB = -0.4499 + (0.8085 × RTS Total) + (-0.0835 × ISS) + (-1.7430 × Age)]. Each then became the sole predictor in a separate logistic regression model to estimate probability of mortality. Model performances were evaluated using misclassification rate, Brier score, and area under the curve. RESULTS Demographics (mean + SD) of subjects with complete data (N = 10,894) were age, 78.3 years ± 8.1 years; ISS, 10.9 ± 8.4; RTS = 7.5 ± 1.1; mortality = 6.9%; blunt mechanism = 98.6%; 3.1 % of subjects received PRCs. The penetrating trauma subsample (n = 150) had a higher mortality rate of 20.0%. The misclassification rates for the models were GTOS, 0.065; TRISSB, 0.051; and TRISSP, 0.120. Brier scores were GTOS, 0.052; TRISSB, 0.041; and TRISSP, 0.084. The area under the curves were GTOS, 0.844; TRISSB, 0.889; and TRISSP, 0.897. CONCLUSION GTOS and TRISS function similarly and accurately in predicting probability of death for injured elders. GTOS has the advantages of a single formula, fewer variables, and no reliance on data collected in the emergency room or by other observers. LEVEL OF EVIDENCE Prognostic, level II.
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Llompart-Pou JA, Pérez-Bárcena J, Chico-Fernández M, Sánchez-Casado M, Raurich JM. Severe trauma in the geriatric population. World J Crit Care Med 2017; 6:99-106. [PMID: 28529911 PMCID: PMC5415855 DOI: 10.5492/wjccm.v6.i2.99] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.
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