The role of palliative care in COVID-19

In light of the COVID-19 pandemic, many healthcare systems are experiencing an increased demand for palliative care (PC). To meet this challenge, the PC team at Cleveland Clinic designed an enterprise-wide response plan organized around 4 domains: staff (educational resources and tools), stuff (medications and supplies), space (recommendations for optimizing physical space and facilities), and systems to facilitate high-quality PC delivery to patients. To mitigate isolation during end-of-life care, the Clinic offers "compassionate exceptions" to strict visitation policies, provides personal protective equipment to visitors of these patients, and facilitates virtual visitation via electronic devices.

Surgical Versus Medical Team Assignment and Secondary Palliative Care Services for Patients Dying in a Cardiac Hospital

Background:

Secondary palliative care (SPC) provides several benefits for patients with cardiovascular disease, but historically, it has been underutilized in this population. Prior research suggests a low rate of SPC consultation by surgical teams in general, but little is known about how surgical teams utilize SPC in the setting of severe cardiovascular disease.

Aim:

To determine if surgical team assignment affects the probability of SPC for inpatients dying of cardiovascular disease.

Design:

Retrospective, cohort study.

Methods:

We identified all inpatients at a large cardiac hospital who had anticipated death under the care of a cardiology, cardiac surgery, or vascular surgery team in 2016. Our primary outcome was referral to SPC, including palliative medicine consultation or inpatient hospice care. Informed by univariate analysis, we created a multivariable logistic regression model, the significance of which was assessed with the Wald test.

Results:

Two hundred thirty-seven patients were included in our analysis: 93 (39%) received SPC and 144 (61%) were “missed opportunities.” Secondary palliative care was less frequent in patients assigned to a surgical, versus medical, team (11% vs 47%, P < .001). On multivariate analysis, surgical versus medical team assignment was the strongest risk-adjusted predictor of SPC (odds ratio [OR]: 0.10, P < .001). Other predictors of SPC included do not resuscitate status on admission (OR: 14, P < .001), length of stay (OR = 1.05/day, P < .001), and having Medicare (OR = 3.9, P = .002).

Conclusions:

Primary inpatient care by a surgical team had a strong inverse relationship with SPC. This suggests a possible cultural barrier within surgical disciplines to SPC.

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients

Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005-12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision-making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.