The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation

Integration of Palliative Care in Neurosurgical Critical Care : Insights from a Single-Center Perspective

OBJECTIVE

Palliative care is a specialized approach designed to enhance the quality of life for both patients and their families, offering patient-centered care through comprehensive assessment and care planning. However, the integration of palliative care within neurocritical care settings has been relatively understudied. This descriptive study aims to identify the characteristics, palliative care needs, and outcomes of patients referred to palliative care services during admission to the neurosurgical intensive care unit (NS-ICU).

METHODS

A retrospective analysis of adults admitted to the NS-ICU at a referral hospital between December 2019 and December 2021 was conducted. The study focused on those referred to the inpatient palliative care team with diagnoses of non-traumatic brain hemorrhage, traumatic brain injury, or brain neoplasm. Excluded were patients who died before palliative care consultation or lacked sufficient information. The investigation assessed demographic and clinical characteristics at consultation, along with post-consultation hospital outcomes derived from medical records and interview notes.

RESULTS

In this study involving 38 enrolled patients, the median age was 65, with 42.1% females. The most prevalent diagnosis was nontraumatic brain hemorrhage (47.4%). Reasons for palliative care consultation included psychosocial support (95%), goal-of-care discussions (68%), decision-making support (50%), and communication facilitation (39%). The median time from NS-ICU admission to consultation was 3.5 days (interquartile range, 1-8 days), and all interviews involved family members. Key decision topics encompassed mechanical ventilation (23.7%) and tracheostomy (21.1%). Patient preferences for life-sustaining treatment could be estimated in only 47.4% of cases, often resulting in treatment disagreement. Among the 38 patients, 26 (68.4%) died during admission. Before the consultation, full code status, partial code status, and comfort care alone were reported as 32%, 66%, and 2%, respectively; post-consultation, these figures shifted to 11%, 42%, and 47%, respectively.

CONCLUSION

Palliative care was predominantly sought for psychosocial support and discussions concerning goals of care. Despite challenges in ascertaining patient treatment preferences, palliative care consultations proved invaluable in aiding family members and facilitating treatment decision-making. Our study suggests the potential integration of palliative care within neuro-critical care, contributing to a heightened utilization of comfort care at the end-of-life.

Moral distress, attitude toward death, and palliative care core competencies among ICU nurses: a cross-sectional study

BACKGROUND

Palliative care is becoming more widely acknowledged as a crucial part of intensive care for all patients with life-threatening illnesses. Intensive care unit (ICU) nurses regard as a lead role to facilitate this integration, which require nurses to possess professional and comprehensive core competencies. However, there is little knowledge about the palliative care core competencies among ICU nurses.

AIMS

To explore the association of moral distress, attitude toward death, and palliative care core competencies of ICU nurses, and explore the mediating role of attitude toward death.

METHODS

This is a quantitative, cross-sectional study. Random cluster sampling method was used. 342 ICU nurses were selected from 5 hospitals across 4 provinces in China. Participants were evaluated using the Moral Distress Scale-revised (MDS-R), the Attitude toward Death Profile-Revised (DAP-R), and the Palliative Care Nurses' Core Competencies Scale (PCNCC). This study followed the STROBE statement.

RESULTS

The level of palliative care core competencies among ICU nurses is moderate. Moral distress and negative attitude toward death are negatively associated while positive attitude toward death is positively associated with core competencies in palliative care among ICU nurses. Attitude toward death partially mediates the relationship between moral distress and core competencies.

CONCLUSION

Link between moral distress, attitude toward death, and palliative care core competencies among ICU nurses was found in this study.

Effects of early palliative care intervention on medical resource use among end-of-life patients

BACKGROUND

In Taiwan, as the population ages, palliative care services (PCS) have expanded significantly to include comprehensive benefit plans for critically ill individuals, supported by reimbursements from the National Health Insurance program. However, incorporating palliative care into the medical management of these patients presents several challenges. We aim to evaluate the effects of palliative care interventions on medical resources in end-of-life scenarios, to promote earlier palliative care access and provide high-quality healthcare services for patients.

METHODS

A total of 2202 patients were included in this study. Primary diagnosis and referral for PCS were assessed using ICD-10 and HNI code. All study subjects were divided into three groups: patients who did not receive PCS (no-PCS), patients who received PCS before their final hospital admission (PCS-before), and patients who received PCS after their final admission (PCS-after). We evaluated (i) the effects of PCS on eight medical resource utilization outcomes within the 30 days preceding death and (ii) the effects of early intervention on two major diseases.

RESULTS

Initiating PCS before a patient's last hospital admission was associated with less aggressive medical interventions in the 30 days before death, including reduced length of intensive care unit (ICU) [odds ratio (OR) = 0.25], and rates of endotracheal intubation (OR = 0.12), respiratory ventilator support (OR = 0.20), cardiopulmonary resuscitation (OR = 0.18), and blood transfusion (OR = 0.65). Among patients with cancer and lung diseases, those who received PCS prior to their final hospitalization of over 14 days experienced reduced hospitalization duration (OR = 0.52 and 0.24, respectively). Patients with lung disease also had significantly lower odds of ICU stays (OR = 0.44) and respiratory ventilation (OR = 0.33).

CONCLUSION

The timing of palliative care intervention critically impacts on duration of hospitalization and ICU stay and the need for intubation procedures or cardiopulmonary resuscitation. The findings can help the government and medical providers in developing comprehensive palliative care policies and programs to improve care quality and patient rights.

Palliative Care Consultation in the Intensive Care Unit Reduces Hospital Costs: A Cost-Analysis

BACKGROUND

Palliative care aims to improve or maintain quality of life for patients with life-limiting or life-threatening diseases. Limited research shows that palliative care is associated with reduced intensive care unit length of stay and use of high-cost resources.

METHODS

This was an observational, non-experimental comparison group study on all patients 18 years or older admitted to any intensive care unit (ICU) at Memorial Hermann - Texas Medical Center for 7 to 30 days from August 2013 to December 2015. Length of stay (LOS) and hospital costs were compared between the treatment group of patients with palliative care in the ICU and the control group of patients with usual care in the ICU. To adjust for confounding of the palliative care consultation on LOS and hospital cost, an inverse probability of treatment weighted method was conducted. Generalized linear models using gamma distribution and log link were estimated. All costs were converted to 2015 US dollars.

RESULTS

Mean LOS was 13 days and mean total hospital costs were USD 58,378. In adjusted and weighted analysis, LOS for the treatment group was 8% longer compared to the control group. The mean total hospital cost was estimated to decrease by 21% for the treatment group versus the control group. We found a reduction of USD 33,783 in hospital costs per patient who died in the hospital and reduction of USD 9113 per patient discharged alive.

CONCLUSION

Palliative care consultation was associated with a reduction in the total cost of hospital care for patients with life-limiting or life-threatening diseases.

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.

Predictors of End-of-Life Care in Nonelderly Adults With Severe Traumatic Brain Injury

INTRODUCTION

Older age is a well-established risk factor for withdrawal of life-sustaining therapy (WDLST) and discharge to hospice (DH) in traumatic brain injury (TBI). However, a paucity of data exists in identifying factors associated with end-of-life (EoL) care in younger patients with TBI. We sought to identify hospital and patient factors associated with EoL care and timing of EoL care in younger adults with severe TBI.

METHODS

This is a retrospective analysis of the National Trauma Databank (2019). Adults (18-65 y) with severe TBI (Glasgow coma scale <9) were included in the analysis. Inclusion criteria included death, WDLST, or DH during the hospital stay. Exclusion criteria included Glasgow coma scale >8, death in the emergency department, and missing WDLST status. The primary outcome was EoL Care defined as those who either underwent WDLST or DH. The secondary outcome was early EoL care defined as EoL care within 72 h of admission.

RESULTS

A total of 1239 patients were included in the study, the median age was 43 y, and the majority were males (77%) and of white race (68%). A total of 667 (54%) patients underwent EoL Care. On multivariable analysis, increasing age (adjusted odd's ratio [aOR]: 1.02; 95% confidence interval [CI]: 1.01-1.03) and chronic alcoholism (aOR: 1.78; 95% CI: 1.05-3.03) were independently associated with EoL. Conversely, patients of Black race (aOR: 0.33; 95% CI: 0.22-0.49) and those admitted to university hospitals (odd's ratio 0.51 95% CI 0.33-0.74) and level II trauma centers (odd's ratio 0.57; 95% CI 0.37-0.88) were less likely to undergo EoL care. A total of 225 (34%) patients underwent early EoL Care. On multivariable analysis, presence of nonreactive pupils and absence of intracranial pressure monitor were independently associated with early EoL care.

CONCLUSIONS

Significant variation in EoL care exists in patients presenting with severe TBI. Better understanding of patient and hospital factors that influence these complex decisions may allow for targeted interventions to reduce variability in EoL practice in TBI across institutions.

European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review

OBJECTIVES

This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes.

METHODS

The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement.

RESULTS

This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.

Healthcare Professionals' Experiences in Providing Palliative Care in an Intensive Care Unit in Indonesia: A Phenomenological Study

Background

In the Intensive Care Unit (ICU), it is vital to meticulously monitor symptoms and thoroughly understand the treatment objectives for critically ill patients. This highlights the necessity of integrating palliative care in this environment. Despite the potential advantages, several barriers impede the effective integration of palliative care in the ICU. Notably, many healthcare professionals (HCPs) in Indonesian ICUs have not fully leveraged the incorporation of palliative care.

Purpose

This study aimed to investigate and clarify the experiences of healthcare providers (HCPs) involved in administering palliative care to ICU patients in Indonesia.

Methods

This research employed a qualitative descriptive phenomenological approach. Semi-structured, in-depth individual interviews were conducted with four nurses and three doctors working in an Indonesian hospital. Colaizzi's method was used for data analysis.

Results

The analysis identified six themes from the interviews, reflecting the experiences of healthcare professionals in delivering palliative care in the ICU. These themes are: 1) Provide Professional Caring, 2) Caring and curing collaboration, 3) Quality Intensive Communication, 4) End-of-Life Care, 5) Controlling Feelings, and 6) Provide Holistic Caring.

Conclusion

Providing care for ICU patients demands not only the expertise of HCPs but also compassion, communication skills, and a holistic approach to patient care. By offering comprehensive palliative care in the ICU, healthcare professionals can address the diverse needs of patients and their families, promoting comfort, respect, and an improved quality of life throughout the illness. This inclusive approach enhances the experience for both patients and their families while supporting healthcare providers in delivering empathetic and patient-centered care. It is recommended that hospitals develop policies to enhance palliative care services in Indonesia.

Racial disparities in end-of-life suffering within surgical intensive care units

Background

End-of-life (EOL) care is associated with high resource utilization. Recognizing and effectively communicating that EOL is near promotes more patient-centered care, while decreasing futile interventions. We hypothesize that provider assessment of futility during the surgical intensive care unit (SICU) admission would result in higher rates of Do Not Resuscitate (DNR).

Methods

We performed a retrospective review of a prospective SICU registry of all deceased patients across a health system, 2018-2022. The registry included a subjective provider assessment of patient's expected survival. We employed multivariable logistic regression to adjust for clinical factors while assessing for association between code status at death and provider's survival assessment with attention to race-based differences.

Results

746 patients-105 (14.1%) traumatically injured and 641 (85.9%) non-traumatically injured-died over 4.5 years in the SICU (mortality rate 5.9%). 26.3% of these deaths were expected by the ICU provider. 40.9% of trauma patients were full code at the time of death, compared with 15.6% of non-traumatically injured patients. Expected death was associated with increased odds of DNR code status for non-traumatically injured patients (OR 1.8, 95% CI 1.03 to 3.18), but not for traumatically injured patients (OR 0.82, 95% CI 0.22 to 3.08). After adjusting for demographic and clinical characteristics, black patients were less likely to be DNR at the time of death (OR 0.49, 95% CI 0.32 to 0.75).

Conclusion

20% of patients who died in our SICU had not declared a DNR status, with injured black patients more likely to remain full code at the time of death. Further evaluation of this cohort to optimize recognition and communication of EOL is needed to avoid unnecessary suffering.

Level of evidence

Level III/prognostic and epidemiological.

Oncology Intensive Care Units: Distinguishing Features and Clinical Considerations

The rapidly advancing field of cancer therapeutics has led to increased longevity among cancer patients as well as increasing complexity of cancer-related illness and associated comorbid conditions. As a result, institutions and organizations that specialize in the in-patient care of cancer patients have similarly evolved to meet the constantly changing needs of this unique patient population. Within these institutions, the intensive care units that specialize in the care of critically ill cancer patients represent an especially unique clinical resource. This article explores some of the defining and distinguishing characteristics associated with oncology ICUs.

Palliative care consultation in patients hospitalized with out-of-hospital cardiac arrest: Impact on invasive procedures, do-not-resuscitate orders, and healthcare costs

BACKGROUND

The impact of palliative care consultation on the management and outcomes of patients hospitalized with out-of-hospital cardiac arrest (OHCA) remains poorly understood. This study examined associations between palliative care consultation and in-hospital outcomes of patients hospitalized with OHCA, stratified by survival status.

METHOD

This cross-sectional study used data from the National Inpatient Sample (2016-2021). Adult patients hospitalized with OHCA who received cardiopulmonary resuscitation were included. Multivariable analyses assessed associations between palliative care consultation and outcomes in non-terminal and terminal OHCA hospitalizations, adjusting for demographics, hospital characteristics, and comorbidities.

RESULTS

Among 488,700 OHCA hospitalizations, palliative care consultation was associated with lower odds of invasive procedures in non-terminal hospitalizations, including percutaneous coronary intervention (PCI) (aOR 0.30, 95 % CI 0.25-0.36), mechanical circulatory support (aOR 0.54, 95 % CI 0.44-0.68), permanent pacemaker (aOR 0.27, 95 % CI 0.20-0.37), implantable cardioverter defibrillator insertion (aOR 0.22, 95 % CI 0.16-0.31), and cardioversion (aOR 0.62, 95 % CI 0.55-0.70). In terminal hospitalizations, palliative care was associated with lower odds of PCI (aOR 0.78, 95 % CI 0.70-0.87) and cardioversion (aOR 0.91, 95 % CI 0.85-0.97), but higher odds of therapeutic hypothermia (aOR 3.12, 95 % CI 2.72-3.59), gastrostomy (aOR 1.22, 95 % CI 1.05-1.41), and renal replacement therapy (aOR 1.19, 95 % CI 1.12-1.26). Palliative care was associated with higher DNR utilization in both subgroups and lower hospital costs in non-terminal hospitalizations but higher costs in terminal hospitalizations.

CONCLUSION

Palliative care consultation in OHCA is associated with differences in invasive procedures, DNR utilization, and hospital costs, varying by survival status.

Palliative Care Consultation and Family-Centered Outcomes in Patients With Unplanned Intensive Care Unit Admissions

Context: Hospitalized patients who experience unplanned intensive care unit (ICU) admissions face significant challenges, and their family members have unique palliative care needs. Objectives: To identify predictors of palliative care consultation among hospitalized patients with unplanned ICU admissions and to examine the association between palliative care consultation and family outcomes. Methods: We conducted a prospective cohort study of patients with unplanned ICU admissions at two medical centers in Seattle, WA. This study was approved by the institutional review board at the University of Washington (STUDY00008182). Using multivariable logistic regression, we examined associations between patient characteristics and palliative care consultation. Family members completed surveys assessing psychological distress within 90 days of patient discharge. Adjusted ordinal probit or binary logistic regression models were used to identify associations between palliative care consultation and family symptoms of psychological distress. Results: In our cohort (n = 413 patients and 272 family members), palliative care was consulted for 24% of patients during hospitalization (n = 100), with the majority (93%) of these consultations occurring after ICU admission. Factors associated with palliative care consultation after ICU transfer included enrollment site (OR, 2.29; 95% CI: 1.17-4.50), Sequential Organ Failure Assessment score at ICU admission (OR, 1.12; 95% CI: 1.05-1.19), and reason for hospital admission (kidney dysfunction [OR, 7.02; 95% CI: 1.08-45.69]). There was no significant difference in family symptoms of depression or posttraumatic stress based on palliative care consultation status. Conclusions: For patients experiencing unplanned ICU admission, palliative care consultation often happened after transfer and was associated with illness severity, comorbid illness, and hospital site. Patient death was associated with family symptoms of psychological distress.

Association of Inpatient Palliative Care Consultation with Clinical and Financial Outcomes for Pancreatic Cancer

BACKGROUND

Palliative care consultation (PCC) has been shown to improve quality of life and reduce costs for various chronic life-threatening diseases. Despite PCC incorporation into modern pancreatic cancer care guidelines, limited data regarding its specific utilization and impact on resource use is available.

METHODS

The 2016-2020 Nationwide Readmissions Database was used to identify all adult hospitalizations entailing pancreatic cancer. Only patients with at least one readmission within 90 days were included to account for uncaptured out-of-hospital mortality. Multivariable regression models were used to ascertain the relationship between inpatient PCC during initial hospitalization and index as well as cumulative costs, overall length of stay (LOS), readmission rate, and number of repeat hospitalizations.

RESULTS

Of an estimated 175,805 patients with pancreatic cancer, 11.1% had inpatient PCC during the index admission. PCC utilization significantly increased from 10.5% in 2016 to 11.6% in 2020 (nptrend < 0.001). After adjustment, PCC was associated with reduced index hospitalization costs [β: - $1100; 95% confidence interval (CI) - 1500, - 800; P < 0.001] and cumulative 90-day costs (β: - $11,700; 95% CI - 12,700, - 10,000; P < 0.001). PCC was associated with longer index LOS (β: + 1.12 days, 95% CI 0.92-1.31, P < 0.001) but significantly reduced cumulative LOS (β: - 3.16 days; 95% CI - 3.67, - 2.65; P < 0.001). Finally, PCC was linked with decreased odds of 30-day nonelective readmission (AOR: 0.48, 95% CI 0.45-0.50, P < 0.001).

DISCUSSION

PCC was associated with decreased costs, readmission rates, and number of hospitalizations among patients with pancreatic cancer. Directed strategies to increase utilization and reduce barriers to consultation should be implemented to encourage practitioners to maximize inpatient PCC referral rates.

Home-Based Pediatric Hospice and Palliative Care Provider Visits: Effects on Healthcare Utilization

OBJECTIVE

This hypothesis-generating study sought to assess the impact of home-based hospice and palliative care (HBHPC) provider home visits (HV) on healthcare use.

STUDY DESIGN

Retrospective review of individuals ages 1 month to 21 years receiving an in-person HBHPC provider (MD/DO or APN) HV through 2 HBHPC programs in the Midwest from January 1, 2013, through December 31, 2018. Descriptive statistics were calculated for healthcare use variables. Paired t test or Wilcoxon signed-rank test compared the changes in healthcare use the year before and year after initial provider HVs.

RESULTS

The cohort included 195 individuals (49% female), with diagnoses composed of 49% neurologic, 30% congenital chromosomal, 11% oncologic, 7% cardiac, and 3% other. After implementation of HBHPC services, these patients showed decreases in the median (IQR) number of intensive care unit days (before HV, 12 [IQR, 4-37]; after HV, 0 [IQR, 0-8]; P < .001); inpatient admissions (before HV, 1 [IQR, 1-3]; after HV, 1 [IQR, 0-2]; P = .005); and number of inpatient days (before HV, 5 [IQR, 1-19]; after HV, 2 [IQR, 0-8]; P = .009). There was an increase in clinically relevant phone calls to the HBHPC team (before HV, 1 [IQR, 0-4] vs after HV, 4 [IQR, 1-7]; P < .001) and calls to the HBHPC team before emergency department visits (before HV, 0 [IQR, 0-0] vs after HV, 1 [IQR, 1-2]; P < .001).

CONCLUSION

HBHPC provider HVs were associated with fewer inpatient admissions, hospital days, and intensive care unit days, and increased clinically relevant phone calls and phone calls before emergency department visit. These findings indicate that HBHPC HV may contribute to decreased inpatient use and increased use of the HBHPC team.

Clinical outcomes of a joint ICU and palliative care multidisciplinary rounding model: A retrospective cohort study

OBJECTIVES

This retrospective cohort study assessed whether implementation of a joint inpatient palliative care (IPC) and ICU multidisciplinary rounding model affected clinical outcomes including ICU length of stay (LOS).

METHODS

Beginning in October of 2018, an IPC physician joined the pre-existing ICU multidisciplinary rounds. Data were collected for ICU patients admitted during a 6-month period before this intervention and a 6-month period after the intervention. Data were extracted from an integrated electronic medical records (EMR) data system and compared by Wilcoxon and chi-square test for continuous and categorical variables respectively. Negative binomial regression was used to analyze the primary outcome measure, ICU LOS.

RESULTS

Patients in the intervention group spent fewer days in the ICU (3.7 vs. 3.9 days, p = 0.05; RR 0.82, 95% CI 0.70-0.97, p = 0.02) and in the hospital (7.5 vs. 7.8 days, p<0.01) compared to the pre-intervention group. The rate of CPR was lower in the intervention group, but the difference was not statistically significant [13(3.1%) vs. 23(5.3%), p = 0.10]. The groups did not differ significantly in rate of hospital mortality, number of days connected to mechanical ventilation via endotracheal tube, or bounceback to the ED or hospital. Multivariable analysis of the primary outcome demonstrated that patients with prior palliative care involvement had longer ICU LOS (RR 1.46, 95% CI 1.04-2.06, p = 0.03) when controlling for other variables.

CONCLUSION

The presented joint IPC-ICU multidisciplinary rounding model was associated with a statistically significant reduction in ICU and hospital LOS, but the clinical significance of this reduction is unclear.

Approach to Intensive Care Costing and Provision of Cost-effective Care

Intensive care unit (ICU) service is resource-intense, finite, and valuable. The outcome of critically ill patients has improved because of a better understanding of disease pathology, technological developments, and newer treatment modalities. These improvements have however come at a price, with ICUs contributing significantly to health budgets. Several costing tools are used to assess cost. Accurate assessment has been hampered by the lack of standardized methodology and the heterogeneity of ICUs. In a costing exercise, the level of disaggregation (micro-costing vs gross-costing) and the method of costing (top-down vs bottom-up) need to be considered. Intensive care unit costing also needs to be viewed from the perspective of stakeholders. While all stakeholders aim to provide quality health care, objectives may vary. For the public health care provider, the focus is on optimizing expenditure; for the private health care provider it is bottomline; for a patient, it is affordability; for an insurance service provider, it is minimizing payout; and for the regulator, it is ensuring quality standards and fair pricing. The field of health economics deals with the application of the principles of cost-minimization, cost-effectiveness, cost-utility, and cost-benefit to identify treatments that result in the best outcome at the lowest cost, without limiting resources to other competing interests. In the ICU setting, studies on the efficient use of available resources, and interventions that reduce cost and minimize avoidable cost, would not only translate to cost savings, lives saved, and quality-adjusted life years gained but also enable policymakers to better allocate health care resources.

HOW TO CITE THIS ARTICLE

Chacko B, Ramakrishnan N, Peter JV. Approach to Intensive Care Costing and Provision of Cost-effective Care. Indian J Crit Care Med 2023;27(12):876-887.

'Thank goodness you're here'. Exploring the impact on patients, family carers and staff of enhanced 7-day specialist palliative care services: A mixed methods study

BACKGROUND

Healthcare usage patterns change for people with life limiting illness as death approaches, with increasing use of out-of-hours services. How best to provide care out of hours is unclear.

AIM

To evaluate the effectiveness and effect of enhancements to 7-day specialist palliative care services, and to explore a range of perspectives on these enhanced services.

DESIGN

An exploratory longitudinal mixed-methods convergent design. This incorporated a quasi-experimental uncontrolled pre-post study using routine data, followed by semi-structured interviews with patients, family carers and health care professionals.

SETTING/PARTICIPANTS

Data were collected within specialist palliative care services across two UK localities between 2018 and 2020. Routine data from 5601 unique individuals were analysed, with post-intervention interview data from patients (n = 19), family carers (n = 23) and health care professionals (n = 33; n = 33 time 1, n = 20 time 2).

RESULTS

The mean age of people receiving care was 73 years, predominantly white (90%) and with cancer (42%). There were trends for those in the intervention (enhanced care) period to stay in hospital 0.16 days fewer, but be hospitalised 2.67 more times. Females stayed almost 3.5 more days in the hospital, but were admitted 2.48 fewer times. People with cancer had shorter hospitalisations (4 days fewer), and had two fewer admission episodes. Themes from the qualitative data included responsiveness (of the service); reassurance; relationships; reciprocity (between patients, family carers and staff) and retention (of service staff).

CONCLUSIONS

Enhanced seven-day services provide high quality integrated palliative care, with positive experiences for patients, carers and staff.

Palliative care: economic challenges for researchers

The economic challenges for researchers in palliative care is an emerging and challenging topic. Knowing where, how and how much is spent is fundamental for palliative care (PC) provision to be increasingly efficient and with lower costs. To accomplish this, there are three important factors to consider: early access to PC; specialised PC using standardised procedures and informal and home-based PC. Beyond costs, ethical aspects should always be present when this care is being provided in its different forms, locations and contexts. For those who want to study the economic challenges in PC, they need to comprehend the complexity of them, since they will always come from a careful articulation between ethics, the person´s needs, the cost of the care and who these costs are charged to.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BACKGROUND

Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.

METHODS

We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.

RESULTS

Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).

CONCLUSIONS

We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Palliative Care Consultation Utilization Among Patient Undergoing Surgery for Metastatic Spinal Tumors

OBJECTIVE

In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes.

METHODS

A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early (

RESULTS

Of 363 patients undergoing surgery for spinal metastasis, 62 (17.0%) patients received palliative care consultation during the same hospitalization, 11 (17.7%) were preoperative, and 51 (82.2%) were postoperative. Among same-stay consultations, 32 (51.6%) were early and 30 (48.4%) were late. Palliative care consultation recipients had worse preoperative Karnofsky Performance Scale (KPS) score (P < 0.001), were more likely to have other organ metastases (P = 0.005) or cord compression (P = 0.026), had longer hospitalization (P < 0.001), and were less likely to be discharged home (P < 0.001). Patients presenting with mechanical pain were more likely to receive preoperative consults compared with postoperative (P = 0.029), and earlier compared with later consultations (P = 0.046). Regarding long-term outcomes, patients with same-stay palliative care consultation had significantly shorter overall survival (log-rank; P < 0.001), worse KPS postoperatively (P = 0.017), and worse KPS and Modified McCormick Scale at the last follow-up (P < 0.001).

CONCLUSIONS

Only 1 in 6 patients received palliative care consultation. Patients receiving same-stay palliative care consultation had more advanced local and systemic disease burden. Increased utilization of palliative care consultation in patients with spine metastasis is needed.

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Key Words

• Overall survival
• Palliative care
• Spinal metastasis
• Spinal tumors

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MESH Headings

• Humans
• Palliative Care
• Spinal Neoplasms/secondary
• Retrospective Studies
• Case-Control Studies
• Spinal Cord Neoplasms
• Central Nervous System Neoplasms
• Referral and Consultation

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Affiliation(s)

Jeffrey W Chen Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Hani Chanbour Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Gabriel A Bendfeldt Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Lakshmi Suryateja Gangavarapu Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Mohana B Karlekar Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Amir M Abtahi Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Byron F Stephens Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Scott L Zuckerman Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Silky Chotai Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

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Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients

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.

Acute palliative care models: scoping review

OBJECTIVE

The goal of this scoping review is to identify the most commonly used models of palliative care delivery in acute care settings, their advantages and disadvantages, and to review existent research evidence in support of each model.

METHODS

We conducted an extensive search using EMBASE, Medline, CINAHL and Pubmed, using various combinations of terms relating to models in palliative care and acute care settings. Data were analysed using tabular summaries and content analysis.

RESULTS

41 articles were analysed. Four models were identified: primary, consultative, integrative and hybrid models of palliative care. All four models have varying characteristics in terms of access to specialist palliative care; fragmentation of healthcare services; therapeutic relationships between patients and providers; optimal usage of scarce palliative care resources; timing of provision of palliative care; communication and collaboration between providers and clarity of provider roles. Moreover, all four models have different patient outcomes and healthcare utilisation. Gaps in research limit the ability to determine what model of care is more applicable in an acute care setting.

CONCLUSION

No ideal model of care was identified. Each model had its advantages and disadvantages. Future work is needed to investigate which setting one model may be better than the other.

The impact of daylight and window views on length of stay among patients with heart disease: A retrospective study in a cardiac intensive care unit

Background

Heart disease is the leading cause of death in the United States. The length of stay (LOS) is a well-established parameter used to evaluate health outcomes among critically ill patients with heart disease in cardiac intensive care units (CICUs). While evidence suggests that the presence of daylight and window views can positively influence patients' LOS, no studies to date have differentiated the impact of daylight from window views on heart disease patients. Also, existing research studies on the impact of daylight and window views have failed to account for key clinical and demographic variables that can impact the benefit of such interventions in CICUs.

Methods

This retrospective study investigated the impact of access to daylight vs. window views on CICU patients' LOS. The study CICU is located in a hospital in the southeast United States and has rooms of the same size with different types of access to daylight and window views, including rooms with daylight and window views (with the patient bed located parallel to full-height, south-facing windows), rooms with daylight and no window views (with the patient bed located perpendicular to the windows), and windowless rooms. Data from electronic health records (EHRs) for the time-period September 2015 to September 2019 (n=2936) were analyzed to investigate the impact of room type on patients' CICU LOS. Linear regression models were developed for the outcome of interest, controlling for potential confounding variables.

Results

Ultimately, 2319 patients were finally included in the study analysis. Findings indicated that patients receiving mechanical ventilation in rooms with access to daylight and window views had shorter LOS durations (16.8 h) than those in windowless rooms. Sensitivity analysis for a subset of patients with LOS ≤3 days revealed that parallel bed placement to the windows and providing access to both daylight and window views significantly reduced their LOS compared to windowless rooms in the unit (P=0.007). Also, parallel bed placement to the window significantly reduced LOS in this patient subset for those with an experience of delirium (P=0.019), dementia (P=0.008), anxiety history (P=0.009), obesity (P=0.003), and those receiving palliative care (P=0.006) or mechanical ventilation (P=0.033).

Conclusions

Findings from this study could help architects make design decisions and determine optimal CICU room layouts. Identifying the patients who benefit most from direct access to daylight and window views may also help CICU stakeholders with patient assignments and hospital training programs.

Discharge optimization tool to decrease length of stay and improve satisfaction related to advanced practice provider communication

BACKGROUND

Prolonged length of stay (LOS) due to delayed hospital discharge is associated with increased patient morbidity and mortality and other poor outcomes. The length of stay (LOS) in patients undergoing elective, isolated coronary artery bypass grafting (CABG) at an urban, level 1 trauma center is 8.73 days, compared to the 7.0-day benchmark reported by the Society of Thoracic Surgeons (STS). Improving and reducing length of stay (LOS) can improve clinical, financial, and operational outcomes and decrease the costs of care for patients and the healthcare system.

OBJECTIVE

The purpose of this quality improvement project was to implement an evidence-based discharge optimization tool (DOT) within the Electronic Health Record to reduce LOS in patients undergoing isolated CABG and enhance communication satisfaction in cardiothoracic surgery advanced practice providers (APP).

METHODS

We used a DOT to communicate anticipated time to discharge in CABG patients to the multidisciplinary team. Outcomes included postoperative LOS and APP communication satisfaction. Data was obtained via chart review and statistically analyzed using a one sample T-test.

RESULTS

177 patients (mean age 64 years, 72% male, 66% Caucasian) were studied. The mean postoperative LOS decreased by 16% from 8.73 days to 7.31 days (p = 0.007; Standard deviation of 3.20). Cardiothoracic surgery APP communication satisfaction improved by 33%.

CONCLUSIONS

Utilization of a discharge optimization tool to communicate anticipated time to discharge can significantly decrease LOS and improve APP communication satisfaction.

End-of-life care trajectories among older adults with lung cancer

INTRODUCTION

Medicare decedents with cancer often receive intensive care during the last month of life; however, little information exists on longer end-of-life care trajectories.

MATERIALS AND METHODS

Using SEER-Medicare data, we selected older adults diagnosed with lung cancer between 2008 and 2013 who survived at least six months and died between 2008 and 2014. Each month we assessed claims to assign care categories ordered by intensity as follows: full-month inpatient/skilled nursing facility > cancer-directed therapy (CDT) only > concurrent CDT and symptom management and supportive care services (SMSCS) > SMSCS only > full-month hospice. We assigned each decedent to one of six trajectories: stable hospice, stable SMSCS, stable CDT with or without concurrent SMSCS, decreasing intensity, increasing intensity, and mixed. Multinomial logistic regression estimated associations between socio-demographics, calendar year, and area hospice use rates with end-of-life trajectory.

RESULTS

The sample (N = 24,342) was predominantly aged ≥75 years (59.4%) and non-Hispanic White (80.5%); 19.1% lived in healthcare referral regions where ≤50% of cancer decedents received hospice care. Overall, 6.5% were continuously hospice enrolled, 25.6% received SMSCS only, and 29.4% experienced decreasing intensity; 3.9% received CDT or concurrent care, while 8.7% experienced an increase in intensity. Higher healthcare referral region hospice rates were associated with decreasing end-of-life intensity; Black, non-Hispanic decedents had a higher risk of increasing intensity and mixed patterns.

DISCUSSION

Among older decedents with lung cancer, 62% had six-month end-of-life trajectories indicating low or decreasing intensity, but few received persistent CDT. Demographic characteristics, including race/ethnicity, and contextual measures, including area hospice use patterns, were associated with end-of-life trajectory.

Estimating the Impact of Inpatient Palliative Care Consultations on Health Care Costs in a Low- and Middle-Income Country

Background: The escalating cost of health care has important implications on national economies and public health. Palliative care (PC) consultations have been shown to reduce health costs while improving the quality of life. Aim: To assess the impact of PC consultations on hospital costs in a low- and middle-income country. Methods: We analyzed billing data of patients who received a PC consultation at our tertiary care hospital over a one-year period. Controls were patients with a serious illness who had at least one admission during the study period. Analysis was conducted for patients discharged alive and those who died during their hospitalization. The primary outcome was cost of hospitalization. Readmission rates, length of stay (LOS), and number of emergency department (ED) visits after discharge were secondary outcomes. Results: Daily hospital costs were 10% lower for patients who received a PC consult (n = 346) compared with controls (n = 698). This difference was more pronounced among patients who died during their hospitalization and when the consult was conducted earlier in the hospital course. LOS (4.92 vs. 4.68, p < 0.0001), readmissions (24.78% vs. 36.41%, p < 0.001), and ED visits after discharge were lower in the PC group compared with the control group (relative risk [RR] = 2.46). Conclusions: We used readily available hospital billing data to demonstrate the cost benefits of inpatient PC consultations. This simple approach can provide powerful data to justify the need for PC services.

Palliative and end-of-life care in intensive care units in low- and middle-income countries: A systematically constructed scoping review

PURPOSE

Death is common in intensive care units, and integrating palliative care enhances outcomes. Most research has been conducted in high-income countries. The aim is to understand what is known about the type and topics of research on the provision of palliative care within intensive care units in low- and middle-income countries MATERIALS AND METHODS: Scoping review with nine databases systematically searched for literature published in English on palliative care in intensive care units in low- and middle- income settings (01/01/1990 to 31/05/2021). Two reviewers independently checked search results and extracted textual data, which were analyzed and represented as themes.

RESULTS

Thirty papers reported 19 empirical studies, two clinical case reports and six discussion papers. Papers originated from Asia and Africa, primarily using observational designs and qualitative approaches, with no trials or other robust evaluative or comparative studies. No studies directly sought data from patients or families. Five areas of research focus were identified: withholding and withdrawing treatment; professional knowledge and skills; patient and family views; culture and context; and costs of care.

CONCLUSIONS

Palliative care in intensive care units in low-and middle-income countries is understudied. Research focused on the specific needs of intensive care in low- and middle-income countries is required to ensure optimal patient outcomes.

An examination of the most expensive adult hospitalizations in America

BACKGROUND

While no hospitalization is inexpensive, some are extremely costly. Learning from these exceptions is critical. The patients and conditions that ultimately translate into the most exorbitant adult hospitalizations have not been characterized.

OBJECTIVE

To analyze and detail characteristics of extreme high-cost adult hospitalizations in the United States using the most recently available Nationwide Inpatient Sample (NIS) data.

DESIGN/SETTING/PARTICIPANTS

The NIS 2018 database was queried for all adult hospitalizations with hospital charges greater than $333,000. Multivariable linear regression was used in the analyses.

MEASURES

The main outcome measures were total charges, mortality, length of stay, admitting diagnosis, and procedures.

RESULTS

There were 538,121 adults age ≥18 years with total hospital charges ≥$333,333. Among these patients 481,856 (89.5%) survived their hospitalization and 56,265 (10.4%) died. Males, older patients, being insured by Medicare, having more comorbid illness, and those who were transferred from another hospital were significantly more likely to die during the incident hospitalization (all p < 0.01). Patients who died had even more costly hospitalizations with more procedures (mean [SD]: 10.7 [±6.4] versus 7.0 [± 5.9], p < 0.01), and longer lengths of stay after adjustment for confounders (p = 0.01).

CONCLUSIONS

Hundreds of thousands of adult patients are hospitalized in the US each year at extremely high costs. For both those who survive and the 10% who die, there may be opportunities for reducing the expense. Interventions, such as predictive modeling and systematic goals of care discussions with all patients, deserve further study.

Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention

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.

Impact of Palliative Care on Interhospital Transfers to the Intensive Care Unit

Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.

Evaluation of a Standardized Protocol for Medical Management of Uncomplicated Acute Type B Aortic Dissection

OBJECTIVES

The goals of medical management for uncomplicated acute type B aortic dissection are to prevent expansion of the false lumen and malperfusion syndrome. This is accomplished with antihypertensive agents, but medication selection and titration are typically provider dependent. Given the paucity of data on evidence-based management of this population, we hypothesized that a standardized type B aortic dissection medical management protocol would reduce resource utilization and costs, without compromising patient outcomes.

METHODS

A multidisciplinary team developed a goal-directed protocol to standardize the medical management of uncomplicated acute type B aortic dissection, with an emphasis on early initiation of oral medications, weaning of anti-hypertensive infusions and frequent assessment for de-escalation of care. Implementation was in April 2018. A retrospective review of acute type B aortic dissection patients presenting to our institution from April 2016- April 2020 was performed. Patients requiring aortic or peripheral intervention were excluded. Included patients were analyzed based on treatment before or after protocol implementation. Patient demographics, systolic blood pressure, presence of acute kidney injury at presentation, length of stay, cost metrics, and 30-day mortality were compared.

RESULTS

39 patients were included, 21 pre- and 18 post-protocol implementation. Baseline demographics, systolic blood pressure, and presence of acute kidney injury at presentation were similar between the groups. Post-protocol patients had shorter total (8.6 vs 5.5 days, p=.02) and intensive care unit (3.2 vs 1.8 days, p=.002) length of stay. The protocol was associated with significantly decreased total hospital ($38,928 vs $28,066, p=.04), total variable ($23,115 vs $15,627, p=0.02), and pharmacy ($5,094 vs $1,181, p<.001) costs, while inpatient care costs ($15,152 vs $11,467, p=.09) trended down. Post-protocol patients required fewer oral antihypertensive agents at discharge (3.8 vs 2.7, p=.005). No significant difference in 30-day mortality was observed.

CONCLUSIONS

A goal directed protocol reduces resource utilization and costs without compromising early mortality rates for patients with uncomplicated acute type B aortic dissection. Such a strategy may have broader application in medical management of acute aortic syndromes.

Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill

Background

Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.

Methods

The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset.

Results

In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008].

Conclusions

Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03971-9.

Gathering policymakers' perspectives as an essential step in planning and implementing palliative care services at a national level: an example from a resource-limited country

BACKGROUND

Despite increasing recognition of the role played by palliative care (PC) services, the priorities of policymakers in supporting PC remain unclear and have sometimes engendered controversy. There are few studies exploring policymakers' perspectives towards PC services, with most shedding light on obstacles to PC development. Furthermore, no study has explored policymakers' perspectives towards providing PC at the national level in resource-limited countries. This study provides a platform for providing PC as part of the Palestinian healthcare system (HCS) by exploring policymakers' perspectives on PC, an essential step to developing a PC programme.

METHODS

A descriptive qualitative study design was employed using semi-structured interviews. Participants were those identified as responsible for making executive and legislative decisions about health services (including PC) in the HCS. Data were analysed using qualitative content analysis.

RESULTS

Twelve decision and policymakers participated in the study. Four categories were generated from the content analysis: (1) the nature of current PC healthcare services, (2) the potential benefits of PC, (3) challenges to providing PC, and (4) considerations in providing PC. The current PC services provided to Palestinian patients with life-limiting illnesses and their families are not comprehensive, and are limited to symptom management. There is a Palestinian national strategic plan for developing PC; however, the development goals are not clearly defined, and the plan's capabilities are inadequate. Several challenges to the provision of PC were found to relate to issues of education and training, the allocation of funding, and the availability of medications.

CONCLUSIONS

Integrating PC into the Palestinian university curricula as a compulsory course and establishing higher degree programmes in PC to overcome the shortage of PC specialists is required. Developing policies aligned with national laws could help enhance health services to patients and their families and resolve several challenges. Cooperating with national and international institutions in seeking funding could boost PC development and medication availability.

Development of an electronic Poor Outcome Screening (ePOS) Score to identify critically ill patients with potential palliative care needs

PURPOSE

To develop and validate an electronic poor outcome screening (ePOS) score to identify critically ill patients with potentially unmet palliative care (PC) needs at 48 hours after ICU admission.

MATERIALS AND METHODS

Retrospective single-centre cohort study of 1'772 critically ill adult patients admitted to a tertiary academic ICU in Switzerland between 2017 and 2018. We used data available from electronic health records (EHR) in the first 48 hours and least absolute shrinkage and selection operator (LASSO) logistic regression to develop a prediction model and generate a score to predict the risk of all cause 6-month mortality.

RESULTS

Within 6 months of the ICU admission, 598 patients (33.7%) had died. At a cut-off of 20 points, the ePOS score (range 0-46 points) had a sensitivity of 0.81 (95% CI 0.78 to 0.84) and a specificity of 0.51 (0.48 to 0.54) for predicting 6-month mortality and showed good discriminatory performance (AUROC 0.72, 0.67 to 0.77).

CONCLUSIONS

The ePOS score can easily be implemented in EHR and can be used for automated screening and stratification of ICU patients, pinpointing those in whom a comprehensive PC assessment should be performed. However, it should not replace clinical judgement.

Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill

PURPOSE

With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them.

STUDY DESIGN AND METHODS

A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS).

RESULTS

The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease.

CONCLUSION

Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.

Does a Hospital Palliative Care Team Have the Potential to Reduce the Cost of a Terminal Hospitalization? A Retrospective Case-Control Study in a Czech Tertiary University Hospital

Background:

More than 50% of patients worldwide die in hospitals and end-of-life care is costly. We aimed to explore whether support from the palliative team can influence end-of-life costs.

Methods:

This was a descriptive retrospective case–control study conducted at a Czech tertiary hospital. We explored the difference in daily hospital costs between patients who died with and without the support of the hospital palliative care team from January 2019 to April 2020. Big data from registries of routine visits were used for case–control matching. As secondary outcomes, we compared the groups over the duration of the terminal hospitalization, intensive care unit (ICU) days, intravenous antibiotics, magnetic resonance imaging/computed tomography scans, oncological treatment in the last month of life, and documentation of the dying phase. Standard descriptive statistics were used to describe the data, and differences between the case and control groups were tested using Fisher's exact test for categorical variables and the Mann–Whitney U test for numerical data.

Results:

In total, 213 dyads were identified. The average daily costs were three times lower in the palliative group (4392.4 CZK per day = 171.3 EUR) than in the nonpalliative group (13992.8 CZK per day = 545.8 EUR), and the difference was probably associated with the shorter time spent in the ICU (16% vs. 33% of hospital days).

Conclusions:

We showed that the integration of the palliative care team in the dying phase can be cost saving. These data could support the implementation of hospital palliative care in developing countries.

Characteristics and resource utilization of high-cost users in the intensive care unit: a population-based cohort study

Background

Healthcare expenditure within the intensive care unit (ICU) is costly. A cost reduction strategy may be to target patients accounting for a disproportionate amount of healthcare spending, or high-cost users. This study aims to describe high-cost users in the ICU, including health outcomes and cost patterns.

Methods

We conducted a population-based retrospective cohort study of patients with ICU admissions in Ontario from 2011 to 2018. Patients with total healthcare costs in the year following ICU admission (including the admission itself) in the upper 10th percentile were defined as high-cost users. We compared characteristics and outcomes including length of stay, mortality, disposition, and costs between groups.

Results

Among 370,061 patients included, 37,006 were high-cost users. High-cost users were 64.2 years old, 58.3% male, and had more comorbidities (41.2% had ≥3) when likened to non-high cost users (66.1 years old, 57.2% male, 27.9% had ≥3 comorbidities). ICU length of stay was four times greater for high-cost users compared to non-high cost users (22.4 days, 95% confidence interval [CI] 22.0–22.7 days vs. 5.56 days, 95% CI 5.54–5.57 days). High-cost users had lower in-hospital mortality (10.0% vs.14.2%), but increased dispositioning outside of home (77.4% vs. 42.2%) compared to non-high-cost users. Total healthcare costs were five-fold higher for high-cost users ($238,231, 95% CI $237,020–$239,442) compared to non-high-cost users ($45,155, 95% CI $45,046–$45,264). High-cost users accounted for 37.0% of total healthcare costs.

Conclusion

High-cost users have increased length of stay, lower in-hospital mortality, and higher total healthcare costs when compared to non-high-cost users. Further studies into cost patterns and predictors of high-cost users are necessary to identify methods of decreasing healthcare expenditure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07318-y.

Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives

Background

Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care.

Aim

To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context.

Methods

For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years.

Results

Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident.

Conclusion

Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.

Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project

OBJECTIVES

We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients.

METHODS

The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions.

RESULTS

Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05).

CONCLUSIONS

Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.

Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews

BACKGROUND

As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings.

METHODS

Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions.

RESULTS

A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent.

CONCLUSIONS

Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.

Intensive Care Unit Nurse: Could We Call a Palliative Care Consult? Intensive Care Unit Provider: It's Too Early. Palliative Care Integration in the Intensive Care Unit: The Struggle to Translate Evidence Into Practice

Despite evidence regarding the value of palliative care, there remains a translation-to-practice gap in the intensive care setting. The purpose of this article is to describe challenges and propose solutions to palliative care integration through the presentation and discussion of a critical care patient scenario. We also present recommendations for a collaborative palliative care practice framework that holds the potential to improve quality of life for patients and families. Collaborative palliative care is characterized by close working relationships with families, interprofessional intensive care unit healthcare teams, and palliative care specialists. The shortage of palliative care specialists has become a pressing policy and practice issue and highlights the importance of increasing primary palliative care delivery by the intensive care team. Underexplored aspects of collaborative palliative care delivery include the interprofessional communication required, identification of key skills, and expected outcomes. Increased recognition of intensive care unit palliative care as a process of engagement among nurses, providers, patients, and their family members heralds a vital culture shift toward collaborative palliative care. The interprofessional palliative specialist team has the expertise to support intensive care teams in developing their primary palliative skills and recognizing when specialist palliative care support is required. Promotion of strategic palliative care delivery through this collaborative framework has the potential to decrease suffering among patients and families and reduce moral distress among healthcare professionals.

Delirium and Associated Length of Stay and Costs in Critically Ill Patients

Purpose

Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis.

Materials and Methods

Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS.

Results

Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001).

Conclusion

ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.

Decade-Long Nationwide Trends and Disparities in Use of Comfort Care Interventions for Patients With Ischemic Stroke

Background Stroke remains one of the leading causes of disability and death in the United States. We characterized 10-year nationwide trends in use of comfort care interventions (CCIs) among patients with ischemic stroke, particularly pertaining to acute thrombolytic therapy with intravenous tissue-type plasminogen activator and endovascular thrombectomy, and describe in-hospital outcomes and costs. Methods and Results We analyzed the National Inpatient Sample from 2006 to 2015 and identified adult patients with ischemic stroke with or without thrombolytic therapy and CCIs using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. We report adjusted odds ratios (ORs) and 95% CI of CCI usage across five 2-year periods. Of 4 249 201 ischemic stroke encounters, 3.8% had CCI use. CCI use increased over time (adjusted OR, 4.80; 95% CI, 4.15-5.55) regardless of acute treatment type. Advanced age, female sex, White race, non-Medicare insurance, higher income, disease severity, comorbidity burden, and discharge from non-northeastern teaching hospitals were independently associated with receiving CCIs. In the fully adjusted model, thrombolytic therapy and endovascular thrombectomy, respectively, conferred a 6% and 10% greater likelihood of receiving CCIs. Among CCI users, there was a significant decline in in-hospital mortality compared with all other dispositions over time (adjusted OR, 0.46; 95% CI, 0.38-0.56). Despite longer length of stay, CCI hospitalizations incurred 16% lower adjusted costs. Conclusions CCI use among patients with ischemic stroke has increased regardless of acute treatment type. Nonetheless, considerable disparities persist. Closing the disparities gap and optimizing access, outcomes, and costs for CCIs among patients with stroke are important avenues for further research.

Palliative care consultation in patients with Staphylococcus aureus bacteremia

BACKGROUND

Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with Staphylococcus aureus bacteremia remains unclear despite its high mortality.

AIM

To examine the frequency of palliative care consultation and factors associated with palliative care consult in Staphylococcus aureus bacteremia patients in the United States.

DESIGN

A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality.

SETTING/SUBJECTS

All inpatients with a discharge diagnosis of Staphylococcus aureus bacteremia (ICD-9-CM codes; 038.11 and 038.12).

MEASUREMENTS

Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult.

RESULTS

A total of 111,320 Staphylococcus aureus bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant Staphylococcus aureus bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult (p < 0.001).

CONCLUSIONS

Palliative care consultation was infrequent during the management of Staphylococcus aureus bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in Staphylococcus aureus bacteremia. Selecting patients who may benefit the most should be explored.

Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice

BACKGROUND

There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting.

OBJECTIVES

This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines.

METHODS

This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time.

RESULTS

Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285).

CONCLUSION

This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.

Chaplaincy Care in the MICU: Examining the Association Between Spiritual Care and End-of-Life Outcomes

BACKGROUND

Seriously ill patients admitted to the Intensive Care Unit (ICU) experience severe spiritual and existential distress. Patients' surrogate decision makers face the burden of making complex decisions about their loved ones' care. Experienced chaplains may play a role in assisting with decision-making, possibly by aligning patients' values and wishes with treatment plans and avoiding non-beneficial aggressive measures.

OBJECTIVES

To identify associations between chaplaincy care and length of stay (LOS) in the medical ICU (MICU).

METHODS

This was a retrospective observational study of usual spiritual care in the adult MICUs of 4 medical centers in the United States over a 3-month period. Inclusion criteria were death in the MICU or discharge to palliative care or hospice. Measures included medical, treatment, and spiritual care information. Through bivariate and multivariable analyses associations between spiritual care and LOS were examined.

RESULTS

In multivariable analysis of the 254 patients, receiving spiritual care was associated with an increased likelihood of being in a higher LOS tertile (adjusted odds ratio = 2.94, p < .001). In post hoc bivariate analysis, cases receiving spiritual care within the first 48 hours of MICU admission revealed a trend toward lower LOS (p = .181).

CONCLUSION

Spiritual care in the MICU was associated with longer LOS. Early intervention by chaplains who are well-integrated in the ICU may assist patients and their loved ones in coming to terms with grave illness and making difficult treatment decisions. Further well-designed studies of spiritual care interventions that may affect outcomes are needed.

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

BACKGROUND

A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada.

METHODS

We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12-2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC).

RESULTS

We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs.

CONCLUSIONS

High users - persistent and non-persistent - are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

Palliative Care Consultation and Effect on Length of Stay in a Tertiary-Level Neurological Intensive Care Unit

Background: Patients admitted to an acute care setting with a devastating brain injury are at high risk for morbidity and mortality. These patients and their families can benefit from the psychosocial and decision-making support of a palliative care consultation.

Objective: We aim to investigate the characteristics and impact of palliative care consultation for patients under the management of neurosurgical and critical care services with a devastating brain injury in a neurological intensive care unit (ICU) at a large tertiary-care hospital.

Design: Data were collected by retrospective review of the electronic medical record and metrics collected by the palliative care service. Data were analyzed using descriptive statistics. Linear regression analysis was performed to assess effect of timing of palliative care consultation.

Results: Fifty-five patients admitted to the neurological ICU under the management of the neurosurgical service received a palliative care consultation for the following: hemorrhagic stroke (49%), metastatic cancer (22%), and traumatic brain injury (18%). Of these, 73% had at least one neurosurgical intervention. Palliative care was most frequently consulted for assistance in defining a patient's goals of care (88%). When compared with late consultation, early palliative care consultation was significantly associated with shorter mean length of stay (LOS) and positively correlated in linear regression analysis without an effect on mortality.

Conclusions: When compared with a late consultation, early palliative care consultation corresponded to shorter LOS without increasing mortality. One reason for this effect may be that palliative care can help to clarify and document goals of care earlier and more concretely.