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Crit Care Med. 2019 Dec;47(12):1707-1715. doi: 10.1097/CCM.0000000000004016.

Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial.

Author information

1
Duke Palliative Care, Department of Medicine, Duke University and Health System, Durham, NC.
2
Department of Medicine, Washington University School of Medicine, St. Louis, MO.
3
Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
4
Division of Palliative Medicine, Washington University School of Medicine, St. Louis, MO.
5
Division of Biostatistics, Department of Medicine, Washington University School of Medicine, St. Louis, MO.

Abstract

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.

PMID:
31609772
PMCID:
PMC6861688
[Available on 2020-12-01]
DOI:
10.1097/CCM.0000000000004016

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