ICU readmission was most predictive of the need for palliative care among patients in the surgical intensive care unit, based on a study of six potential trigger criteria associated with in-hospital death or discharge to hospice.
To facilitate proactive case findings of patients who would benefit from a palliative care consult, a team of surgical ICU and palliative care clinicians at the Icahn School of Medicine at Mount Sinai, N.Y., developed and tested a system of palliative care triggers. The study was published online in the Journal of Critical Care (http://dx.doi.org/10.1016/j.jcrc.2016.04.010).
Based on a literature review, the researchers created a six-item list of potential triggers for palliative care: length of stay over 10 days, ICU readmission, intensivist referral, status post cardiac arrest, metastatic cancer, and a match of two or more on a set of secondary criteria.
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Data were collected for the period from Sept. 4, 2013, through May 30, 2014, at the surgical ICU of a 1,170-bed tertiary medical center. Patients who received a palliative care consultation were compared with those who did not, and the trigger list was tested for accuracy in predicting patient outcomes. The primary outcomes were hospital death, hospice discharge, and a combined endpoint of these two outcomes. Patients who died in the hospital or were released to hospice care were assumed to be those most in need of a palliative care consult.
Bivariate analysis was done to calculate the unadjusted odds ratios of individual triggers to each of these outcomes. Then, the team used logistic regression analysis to calculate the adjusted odds ratios of triggers to outcomes.
Of the 512 patients admitted to the SICU in the study period, those not discharged by the end of the study were excluded, leaving 492 patients in the study.
Bivariate analysis found that all of the triggers were significantly associated with in-hospital death. With the multivariate analysis and adjusted odds ratios, SICU readmission, status post cardiac arrest, metastatic cancer, and secondary triggers were significantly associated with hospital death.
For the combined outcome of hospital death or release to hospice care, the relationships were stronger. In particular, repeat SICU readmissions and metastatic cancer triggers were strongly associated with the combined outcome (odds ratio, 19.41, CI 5.81-54.86 and OR, 16.40, CI 4.69-57.36, respectively). The secondary triggers did not show the same strength of association, although they were associated significantly with the combined outcome (OR, 4.41, CI 2.05-9.53).
The most prominent finding is the strength of repeat SICU admissions with the hospital death or release to hospice. The strong relationship between repeat SICU admission and outcomes led the researchers to conclude “that one might consider adapting this clinical criterion as a standalone criterion. This would require all patients who are readmitted to the SICU to be seen by palliative care to assess their overall goals of care and understanding of their serious illness. This approach may be particularly useful for smaller palliative care teams that do not have the resources to screen daily with a series of triggers.”
The American Federation of Aging Research and the National Institute on Aging funded the study.