by Ma, Jessica; Chi, Stephen; Buettner, Benjamin; Pollard,
Katherine; Muir, Monica; Kolekar, Charu; Al-Hammadi, Noor; Chen, Ling; Kollef,
Marin; Dans, Maria
Critical Care Medicine: December 2019
- Volume 47 - Issue 12 - p 1707-1715
Objectives:
To assess the impact of early triggered palliative care
consultation on the outcomes of high-risk ICU patients.
Design:
Single-center cluster randomized crossover trial. Setting: Two medical ICUs at
Barnes Jewish Hospital.
Patients:
Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018
with a positive palliative care screen indicating high risk for morbidity or
mortality. Interventions: The medical ICUs were randomized to intervention or
usual care followed by washout and crossover, with independent assignment of
patients to each ICU at admission. Intervention arm patients received a
palliative care consultation from an interprofessional team led by
board-certified palliative care providers within 48 hours of ICU admission.
Measurements and Main Results: Ninety-seven patients (48.7%) were
assigned to the intervention and 102 (51.3%) to usual care. Transition to
do-not-resuscitate/do-not-intubate occurred earlier and significantly more
often in the intervention group than the control group (50.5% vs 23.4%; p <
0.0001). The intervention group had significantly more transfers to hospice care
(18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p
< 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and
postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%;
p < 0.01). Although total operating cost was not significantly different,
medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were
significantly lower in the intervention group. There was no significant
difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay
(median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day
mortality between groups (35.1% vs 36.3%) (p > 0.05).
Conclusions:
Early triggered palliative care consultation was associated with greater
transition to do-not-resuscitate/do-not-intubate and to hospice care, as well
as decreased ICU and post-ICU healthcare resource utilization. Our study
suggests that routine palliative care consultation may positively impact the
care of high risk, critically ill patients.
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