Characteristics,ICU Interventions,and Clinical Outcomes of Patients With Palliative Care Triggers in a Mixed Community-Based Intensive Care Unit

Abstract

Objective: Integration of palliative care initiatives in the intensive care unit (ICU) benefit patients and improve outcomes. Palliative care triggers (PCTs) is a screening tool that aides in stratifying patients who would benefit most from an early palliative care approach. There is no consensus on PCT selection or best timing for implementation. We evaluated the clinical characteristics, ICU and palliative care interventions, and clinical outcomes of critically ill patients with PCT in a community-based mixed ICU. Methods: This retrospective study was conducted in a 44-bed adult, mixed ICU in a 407-bed community-based teaching hospital in Florida. Eleven PCTs were used as a screening tool during multidisciplinary rounds (MDRs). Patients were analyzed based on presence or absence of PCT as well as having met high (>2) versus low (<2) PCT. Data collected included patient demographics, ICU resource utilization and clinical outcomes. We considered a two-sided P value of less than .05 to indicate statistical significance with a 95% confidence interval. Results: Of 388 ICU patients, 189 (48.7%) met at least 1 PCT and 199 (51.3%) did not. The trigger group had higher Acute Physiology and Chronic Evaluation (APACHE) and Sequential Organ Failure Assessment (SOFA) scores within 24 h of ICU admission. The most common PCTs identified were ICU length of stay greater than 7 days or readmission to ICU, terminal prognosis and assisting family in transitioning goals of care. There were statistically significant differences in ICU resource utilization, palliative care interventions, and overall worse clinical outcomes in the trigger-detected group. Similar findings were seen in the cohort with high PCT (>2). Conclusions: Our study supports the implementation of a tailored 11-item palliative care screening tool to effectively identify ICU patients with high ICU and palliative care interventions and worse clinical outcomes.

Keywords

palliative care critical care intensive care multidisciplinary quality improvement

Get full access to this article

View all access options for this article.

References

Hsu-Kim

Friedman

Gracely

Gasperino

. Integrating palliative care into critical care: a quality improvement study. J Intensive Care Med. 2015;30(6):358‐364.

Chi

Buettner

, et al. Early palliative care consultation in the medical ICU: a cluster randomized crossover trial. Crit Care Med. 2019;47(12):1707‐1715.

Nelson

Bassett

Boss

, et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU project (improving palliative care in the ICU). Crit Care Med. 2010;38(9):1765‐1772.

Wysham

Hua

Hough

, et al. Improving ICU-based palliative care delivery: a multicenter, multidisciplinary survey of critical care clinician attitudes and beliefs. Crit Care Med. 2017;45(4):e372‐e378.

Khandelwal

Kross

Engelberg

Coe

Long

Curtis

. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med. 2015;43(5):1102‐1111.

Wang

Heidt

. Emergency department admission triggers for palliative consultation may decrease length of stay and costs. J Palliat Med. 2021;24(4):554‐560.

Imhof

Kaskie

Wyatt

. Finding the way to a better death: an evaluation of palliative care referral tools. J Gerontol Nurs. 2007;33(6):40‐49.

Weissman

Meier

. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the center to advance palliative care. J Palliat Med. 2011;14(1):17‐23.

Nelson

Curtis

Mulkerin

, et al. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the improving palliative care in the ICU (IPAL-ICU) advisory board. Crit Care Med. 2013;41(10):2318‐2327.

10.

Kistler

Stevens

Scott

Philpotts

Greer

Greenwald

. Triggered palliative care consults: a systematic review of interventions for hospitalized and emergency department patients. J Pain Symptom Manage. 2020;60(2):460‐475.

11.

Butner

Silverberg

Hayes

. Identifying palliative care triggers & reason for not consulting specialist in critical care setting. Crit Care Med. 2014;42(12):A1570‐A1571.

12.

Knaus

Draper

Wagner

Zimmerman

. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818‐829.

13.

Vincent

Moreno

Takala

, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European society of intensive care medicine. Intensive Care Med. 1996;22(7):707‐710.

14.

Hua

Blinderman

Wunsch

. Estimates of the need for palliative care consultation across United States intensive care units using a trigger-based model. Am J Respir Crit Care Med. 2014;189(4):428‐36.

15.

Rocker

Cook

Sjokvist

, et al. Clinician predictions of intensive care unit mortality. Crit Care Med. 2004;32(5):1149‐1154.

16.

Chang

Kim

Huh

Hong

Koh

Lim

. Outcomes of critically ill patients according to the perception of intensivists on the appropriateness of intensive care unit admission. Acute Crit Care. 2021;36(4):351-360.

17.

Copeland-Fields

Griffin

Jenkins

Buckley

Wise

. Comparison of outcome predictions made by physicians, by nurses, and by using the mortality prediction model. Am J Crit Care. 2001;10(5):313‐319.

18.

Kruse

Thill-Baharozian

Carlson

. Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit. JAMA. 1988;260(12):1739‐1742.

19.

Bradley

Weaver

Brasel

. Addressing access to palliative care services in the surgical intensive care unit. Surgery. 2010;147(6):871‐877.

20.

Mun

Ceria-Ulep

Umbarger

Nakatsuka

. Trend of decreased length of stay in the intensive care unit (ICU) and in the hospital with palliative care integration into the ICU. Perm J. 2016;20(4):16‐36.

21.

Dobb

Knuiman

Finn

Lee

Webb

. A comparison of admission and worst 24-h acute physiology and chronic health evaluation II scores in predicting hospital mortality: a retrospective cohort study. Crit Care. 2006;10(1):R4.

22.

Gunning

Rowan

. ABC Of intensive care: outcome data and scoring systems. Br Med J. 1999;319(7204):241‐244.

23.

Ferreira

Bota

Bross

Mélot

Vincent

. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286(14):1754‐1758.

24.

Vincent

de Mendonça

Cantraine

, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793‐1800.

25.

Nelson

Mercado

Camhi

, et al. Communication about chronic critical illness. Arch Intern Med. 2007;167(22):2509‐2515.

26.

Cox

Martinu

Sathy

, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009;37(11):2888‐2894.

27.

George

Moseley

Eber

, et al. Deep learning to predict long-term mortality in patients requiring 7 days of mechanical ventilation. PLoS One. 2021;16(6):e0253443.

28.

Sinuff

Adhikari

Cook

, et al. Mortality predictions in the intensive care unit: comparing physicians with scoring systems. Crit Care Med. 2006;34(3):878‐885.

29.

Lemeshow

Klar

Teres

. Outcome prediction for individual intensive care patients: useful, misused, or abused? Intensive Care Med. 1995;21(9):770‐776.

30.

Wen

Jiang

Koncicki

, et al. Trends and racial disparities of palliative care use among hospitalized patients with ESKD on dialysis. J Am Soc Nephrol. 2019;30(9):1687‐1696.

31.

Cruz-Flores

Rodriguez

Chaudhry

MRA

, et al. Racial/ethnic disparities in hospital utilization in intracerebral hemorrhage. Int J Stroke. 2019;14(7):686‐695.

32.

Faigle

Ziai

Urrutia

Cooper

Gottesman

. Racial differences in palliative care use after stroke in majority-white, minority-serving, and racially integrated U.S. Hospitals. Crit Care Med. 2017;45(12):2046‐2054.

33.

Cole

Nguyen

Meirkhanov

, et al. Association of care at minority-serving vs non-minority-serving hospitals with use of palliative care among racial/ethnic minorities with metastatic cancer in the United States. JAMA Netw Open. 2019;2(2):e187633.

34.

Shavers

Bakos

Sheppard

. Race, ethnicity, and pain among the U.S. adult population. J Health Care Poor Underserved. 2010;21(1):177‐220.

35.

Anderson

Green

Payne

. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187‐1204.

36.

Cintron

Morrison

. Pain and ethnicity in the United States: a systematic review. J Palliat Med. 2006;9(6):1454‐1473.

37.

Welch

Teno

Mor

. End-of-life care in black and white: race matters for medical care of dying patients and their families. J Am Geriatr Soc. 2005;53(7):1145‐1153.

38.

Loggers

Maciejewski

Paulk

, et al. Racial differences in predictors of intensive end-of-life care in patients with advanced cancer. J Clin Oncol. 2009;27(33):5559‐5564.

39.

Palmer

Kent

Forsythe

, et al. Racial and ethnic disparities in patient-provider communication, quality-of-care ratings, and patient activation among long-term cancer survivors. J Clin Oncol. 2014;32(36):4087‐4094.

40.

Mack

Paulk

Viswanath

Prigerson

. Racial disparities in the outcomes of communication on medical care received near death. Arch Intern Med. 2010;170(17):1533‐1540.

41.

Johnson

Kuchibhatla

Tulsky

. What explains racial differences in the use of advance directives and attitudes toward hospice care? J Am Geriatr Soc. 2008;56(10):1953‐1958.

42.

Rhodes

Teno

Connor

. African American bereaved family members’ perceptions of the quality of hospice care: lessened disparities, but opportunities to improve remain. J Pain Symptom Manage. 2007;34(5):472‐479.

43.

Rhodes

Batchelor

Lee

Halm

. Barriers to end-of-life care for African Americans from the providers’ perspective: opportunity for intervention development. Am J Hosp Palliat Care. 2015;32(2):137‐143.

44.

Moss

Deutsch

Hollen

Rovnyak

Williams

Rose

. Understanding end-of-life decision-making terminology among African American older adults. J Gerontol Nurs. 2018;44(2):33‐40.

45.

Coats

Crist

Berger

Sternberg

Rosenfeld

. African American elders’ serious illness experiences: narratives of “god did,” “god will,” and “life is better”. Qual Health Res. 2017;27(5):634‐648.

46.

De Souza

Gillett

Froggatt

Walshe

. Perspectives of elders and their adult children of black and minority ethnic heritage on end-of-life conversations: a meta-ethnography. Palliat Med. 2020;34(2):195‐208.

47.

LoPresti

Dement

Gold

. End-of-life care for people with cancer from ethnic minority groups: a systematic review. Am J Hosp Palliat Care. 2016;33(3):291‐305.

48.

Quill

Abernethy

. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med. 2013;368(13):1173‐1175.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB

0.01 MB