Proactive palliative care in the intensive care units of an academic hospital
Palliative care (PC) is a specialty that improves the quality of care often for terminally ill patients and their family members by providing physical, psychosocial, and spiritual pain and symptom management. PC assists patients in decision making about their goals of care. These goals of care discussions help the treating physicians to better plan more appropriate treatment options specifically tailored for each patient based on their preferences. Due to the illness severity of the patients, approximately 20% of all hospital deaths occur in the intensive care unit (ICU). Recognition of and advocacy for integrating PC in the ICU have increased in the last decade following many studies which have shown the positive effects of PC for critically ill patients and their family members. This was a single-center retrospective study conducted at an academic hospital that examined the effects of a proactive PC intervention and the clinical outcomes on patients who died in the medical and neurological ICUs (MICU and NICU), since the majority of ICU deaths occurred in these two units. This study was a quality improvement project that examined only patients who died, in order to make a similar comparison between patients who ultimately had the same clinical outcome. This pre-intervention (phase 1) and post-intervention three phase analysis measured the effectiveness of a screening tool (phase 2), and a daily ICU huddle (phase 3) compared to the pre-intervention phase. The study analyzed the impact the interventions had on clinical measurable outcomes such as 1) day of PC consultation after ICU admission and after meeting criteria, 2) day of meeting criteria for PC based on a screening tool, 3) hospital and ICU lengths of stay, 4) direct cost per discharge, and 5) the average number of PC consultations per month. Electronic database review of all MICU and NICU patients who died from July 2010 to December 2011 and April 2013 to October 2014 were performed. Comparisons were made between patients who received a PC consultation and those who received usual care, from both pre-intervention and post-intervention phases. A total of 888 patients were included and analyzed in this study. The intervention reduced the average day of PC consultation after ICU admission from 9.55 in phase 1 to 4.95 in phase 2 and to 4.75 in phase 3 after the addition of the daily huddle. The average day of PC consultation after meeting criteria in the ICU was also reduced from 8.0 to 3.08 then to 2.18, respectively. The average number of PC consultations per month increased from 10.6 to 12.8 to 17.7 in the three respective phases. The cost per discharge was not significantly different from patients who received a PC consultation and for patients who received usual care. PC service did not reduce the length of stay for patients when compared to patients who received usual care. The sensitivity and specificity of the screening tool in phase 2 were 66.2% and 70.8%, respectively. The sensitivity and specificity of the screening tool with daily huddle in phase 3 were 65.7% and 62.5%, respectively. Proactive screening for PC eligibility and discussion of that eligibility with the critical care team improves access to PC in the ICU. The screening tool and daily ICU huddle helped critical care physicians identify the group of patients most appropriate for PC consultation. The analysis suggests that the critical care physicians were able to accurately discriminate which end-of-life patients they could manage on their own. However, the low sensitivity and specificity of the screening tool suggests that there is still significant room for refinement in order for the screening tool to be more discriminatory and effective. Further research is needed to confirm these findings.