LO02: Heart failure and palliative care in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S27-S28
Author(s):  
M. Lipinski ◽  
D. Eagles ◽  
L.M. Fischer ◽  
L. Mielneczuk ◽  
I.G. Stiell
Keyword(s):  
Heart Failure ◽  
Palliative Care ◽  
High Risk ◽  
Mortality Rate ◽  
Hospital Admissions ◽  
Mortality And Morbidity ◽  
Early Palliative Care ◽  
Icd 10 ◽  
Ed Visits ◽  
One Year

Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.

scholarly journals Biomarkers-based personalized follow-up in chronic heart failure improves patient’s outcomes and reduces care associate cost

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Antonio Leon-Justel ◽  
Jose I. Morgado Garcia-Polavieja ◽  
Ana Isabel Alvarez-Rios ◽  
Francisco Jose Caro Fernandez ◽  
Pedro Agustin Pajaro Merino ◽  
...  
Keyword(s):  
Heart Failure ◽  
Hospital Admissions ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Secondary Outcome ◽  
Ventricular Ejection Fraction ◽  
Number Of Patients ◽  
Ed Visits ◽  
The Impact

Abstract Background Heart failure (HF) is a major and growing medical and economic problem, with high prevalence and incidence rates worldwide. Cardiac Biomarker is emerging as a novel tool for improving management of patients with HF with a reduced left ventricular ejection fraction (HFrEF). Methods This is a before and after interventional study, that assesses the impact of a personalized follow-up procedure for HF on patient’s outcomes and care associated cost, based on a clinical model of risk stratification and personalized management according to that risk. A total of 192 patients were enrolled and studied before the intervention and again after the intervention. The primary objective was the rate of readmissions, due to a HF. Secondary outcome compared the rate of ED visits and quality of life improvement assessed by the number of patients who had reduced NYHA score. A cost-analysis was also performed on these data. Results Admission rates significantly decreased by 19.8% after the intervention (from 30.2 to 10.4), the total hospital admissions were reduced by 32 (from 78 to 46) and the total length of stay was reduced by 7 days (from 15 to 9 days). The rate of ED visits was reduced by 44% (from 64 to 20). Thirty-one percent of patients had an improved functional class score after the intervention, whereas only 7.8% got worse. The overall cost saving associated with the intervention was € 72,769 per patient (from € 201,189 to € 128,420) and €139,717.65 for the whole group over 1 year. Conclusions A personalized follow-up of HF patients led to important outcome benefits and resulted in cost savings, mainly due to the reduction of patient hospitalization readmissions and a significant reduction of care-associated costs, suggesting that greater attention should be given to this high-risk cohort to minimize the risk of hospitalization readmissions.

External validation of a heart failure risk prediction model in a remote monitoring cohort submitted to cardiac resynchronization therapy

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
I Cardoso ◽  
M Coutinho ◽  
G Portugal ◽  
A Valentim ◽  
A.S Delgado ◽  
...  
Keyword(s):  
Heart Failure ◽  
Heart Rate ◽  
High Risk ◽  
Remote Monitoring ◽  
Hospital Admissions ◽  
External Validation ◽  
Left Ventricular Ejection ◽  
National Database ◽  
Failure Risk

Abstract Background Patients (P) submitted to cardiac ressynchronization therapy (CRT) are at high risk of heart failure (HF) events during follow-up. Continuous analysis of various physiological parameters, as reported by remote monitoring (RM), can contribute to point out incident HF admissions. Tailored evaluation, including multi-parameter modelling, may further increase the accuracy of such algorithms. Purpose Independent external validation of a commercially available algorithm (“Heart Failure Risk Status” HFRS, Medtronic, MN USA) in a cohort submitted to CRT implantation in a tertiary center. Methods Consecutive P submitted to CRT implantation between January 2013 and September 2019 who had regular RM transmissions were included. The HFRS algorithm includes OptiVol (Medtronic Plc., MN, USA), patient activity, night heart rate (NHR), heart rate variability (HRV), percentage of CRT pacing, atrial tachycardia/atrial fibrillation (AT/AF) burden, ventricular rate during AT/AF (VRAF), and detected arrhythmia episodes/therapy delivered. P were classified as low, medium or high risk. Hospital admissions were systematically assessed by use of a national database (“Plataforma de Dados de Saúde”). Accuracy of the HFRS algorithm was evaluated by random effects logistic regression for the outcome of unplanned hospital admission for HF in the 30 days following each transmission episode. Results 1108 transmissions of 35 CRT P, corresponding to 94 patient-years were assessed. Mean follow-up was 2.7 yrs. At implant, age was 67.6±9.8 yrs, left ventricular ejection fraction 28±7.8%, BNP 156.6±292.8 and NYHA class >II in 46% of the P. Hospital admissions for HF were observed within 30 days in 9 transmissions. Stepwise increase in HFRS was significantly associated with higher risk of HF admission (odds ratio 12.7, CI 3.2–51.5). HFRS had good discrimination for HF events with receiving-operator curve AUC 0.812. Conclusions HFRS was significantly associated with incident HF admissions in a high-risk cohort. Prospective use of this algorithm may help guide HF therapy in CRT recipients. Funding Acknowledgement Type of funding source: None

Chemotherapy use at the end of life in Brazil.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e24003-e24003
Author(s):  
Munir Murad Junior ◽  
Thiago Henrique Mascarenhas Nébias ◽  
Marcos Antonio da Cunha Santos ◽  
Mariangela Cherchiglia
Keyword(s):  
Palliative Care ◽  
Cancer Treatment ◽  
End Of Life ◽  
Cancer Patients ◽  
Stage Iv ◽  
Breast Cancers ◽  
Early Palliative Care ◽  
Study Population ◽  
One Year

e24003 Background: Chemotherapy in the last days of life is not associated with a survival benefit, and recent data suggest it may cause harm by decreasing quality of life and increasing costs. Both ESMO and ASCO have published position statements encouraging discussions about the appropriate cessation of chemotherapy. End-of-life chemotherapy rates vary worldwide but in summary, up to a fifth of cancer patients are treated with chemotherapy in the last month of life with no clear benefits. The aim of this study is to describe the rate of chemotherapy use in the last month of life in patients who are candidates for palliative care in Brazil. Methods: It is a prospective non-concurrent cohort carried out from a database developed through probabilistic and deterministic linkage of data from information systems of the Brazilian Public Health System. The study population is composed of all patients who started cancer treatment between 2009 and 2014 and who was hospitalized at least 1 time after starting treatment. To address the indication for palliative care, patients whose death occurred within one year after the first hospitalization were selected. Results: A total of 299,202 patients started cancer treatment in that period and 62,249 died 1year after hospitalization. Among the deceased patients, the median age was 62 years, 50.9% of them were in stage IV and 34.1% in stage III and 46% lived in the southeastern region of the country. The most common cancers were lung (n = 17805; 28.6%) colorectal (n = 12273; 19.7%) and gastric (n = 10248; 16.5%). The average number of hospitalizations was 2.7 and 89% of these patients required emergency hospitalization. About half (45,4%; n=28,250) of the patients underwent chemotherapy at the last 30 days of life. The rates of use of chemotherapy in the last month was 44% for lung cancer, 74,4% for colon, 50.2% for gastric and 51.8% breast cancers. Conclusions: Despite international recommendations on the use of chemotherapy at the end of life, this seems to be a common practice unfortunately. Measures to implement early palliative care should be a priority for the care of cancer patients in Brazil.

Analysis of health administration data to inform health service planning for paediatric palliative care

2020 ◽  
pp. bmjspcare-2020-002449
Author(s):  
Alison Pauline Bowers ◽  
Natalie Bradford ◽  
Raymond Javan Chan ◽  
Anthony Herbert ◽  
Patsy Yates
Keyword(s):  
Palliative Care ◽  
Health Service ◽  
Health Services ◽  
Hospital Admissions ◽  
Demographic Characteristics ◽  
Service Planning ◽  
Service Usage ◽  
Paediatric Palliative Care ◽  
Icd 10 ◽  
Limiting Condition

BackgroundHealth service planning in paediatric palliative care is complex, with the diverse geographical and demographic characteristics adding to the challenge of developing services across different nations. Accurate and reliable data are essential to inform effective, efficient and equitable health services.AimTo quantify health service usage by children and young people aged 0–21 years with a life-limiting condition admitted to hospital and health service facilities in Queensland, Australia during the 2011 and 2016 calendar years, and describe the clinical and demographic characteristics associated with health services usage.DesignRetrospective health administrative data linkage of clinical and demographic information with hospital admissions was extracted using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Australian Modification (ICD-10-AM) diagnostic codes. Data were analysed using descriptive statistics.Setting/participantsIndividuals aged 0–21 years with a life-limiting condition admitted to a Queensland Public Hospital and Health Service or private hospital.ResultsHospital admissions increased from 17 955 in 2011 to 23 273 in 2016, an increase of 5318 (29.6%). The greatest percentage increase in admissions were for those aged 16–18 years (58.1%, n=1050), and those with non-oncological conditions (36.2%, n=4256). The greatest number of admissions by ICD-10-AM chapter for 2011 and 2016 were by individuals with neoplasms (6174, 34.4% and 7206, 31.0% respectively). Overall, the number of admissions by Indigenous children and young people increased by 70.2% (n=838).ConclusionsAdministrative data are useful to describe clinical and demographic characteristics and quantify health service usage. Available data suggest a growing demand for health services by children eligible for palliative care that will require an appropriate response from health service planners.

scholarly journals ED visits and hospital admissions of foreigners for psychiatric disorders in Rome from 2007 to 2018

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
A Nardi ◽  
G Migliara ◽  
A Angelozzi ◽  
S Caminada ◽  
M Giffi ◽  
...  
Keyword(s):  
Mental Health ◽  
High Risk ◽  
Hospital Admission ◽  
Psychiatric Disorders ◽  
Service Use ◽  
Hospital Admissions ◽  
Mental Health Service Use ◽  
Related Factors ◽  
Ed Visits ◽  
And Migration

Abstract Background First generation immigrants are at high risk of psychiatric disorders (PD). Moreover, cultural and migration related factors can act as barriers in the access to care. The aim of this study was to analyze the emergency department (ED) visits and the subsequent admissions to Umberto I, a large teaching hospital in Rome, for PD from 2007 to 2018 and to highlight the differences between Italian citizens and foreigners. Methods Adult patients were divided in 11 Nationality Groups (NGs). Basing on ICD9 codes, PD were classified in 5 categories: psychotic, mood, anxiety, personality and substance abuse disorders. Descriptive statistics were conducted for gender, age, educational level and triage. Poisson regression models, adjusted for sociodemographic variables, were used to estimate incidence rate ratios (IRRs) of different NGs, both for visits and hospital admissions, for the five psychiatric categories and for PD as a whole. Results In the period of interest there were 11,965 ED visits for PD, of which 19.2% made by foreigners. Compared to Italians, all NGs showed higher percentages of ED visits for PDs, except for Southern Asian (SA) and East-Southern east Asian (ESA); SA and ESA, together with Other Africa population, showed also higher proportion of psychosis. Regarding admissions, ESA had the highest percentage overall, while more than half of foreigner nationality groups had higher percentages of admissions for psychosis than Italians. Poisson regressions showed that only EU citizens have greater risk of ED visit (IRR 1.69, IC95% 1.46-1.96) and of hospital admission for PD (IRR 1.23, IC95% 1.02-1.49) than Italians, while Romanians, SA and ESA have lower risk. Conclusions Different risk in ED visits for PDs among NGs can be due to heterogeneity in psychopathology, cultural factors, barriers, and migrant status. More studies are necessary to better understand the needs of foreigners and to enhance their mental health service use. Key messages The risk of ED visit and hospital admission for psychiatric disorders differ among foreign populations. Different study design are needed to understand which cultural and migration related factors influence the risks, in order to provide more tailored mental health services for high risk populations.

scholarly journals POSSUM and P-POSSUM Scoring in Hip Fracture Mortalities

2020 ◽  
Vol 11 ◽  
pp. 215145932093167
Author(s):  
William L. Johns ◽  
Benjamin Strong ◽  
Stephen Kates ◽  
Nirav K. Patel
Keyword(s):  
Hip Fracture ◽  
High Risk ◽  
Mortality Rate ◽  
Clinical Decision Making ◽  
Tertiary Care ◽  
Significant Risk ◽  
Screening Tools ◽  
Morbidity And Mortality ◽  
Mortality And Morbidity ◽  
Operative Severity Score

Introduction: Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) are general surgical tools used to efficiently assess mortality and morbidity risk. Data suggest that these tools can be used in hip fracture patients to predict morbidity and mortality; however, it is unclear what score indicates a significant risk on a case-by-case basis. We examined the POSSUM and P-POSSUM scores in a group of hip fracture mortalities in order to assess their accuracy in identification of similar high-risk patients. Materials and Methods: Retrospective analysis of all consecutive mortalities in hip fracture patients at a single tertiary care center over 2 years was performed. Patient medical records were examined for baseline demographics, fracture characteristics, surgical interventions, and cause of death. Twelve physiological and 6 operative variables were used to retrospectively calculate POSSUM and P-POSSUM scores at the time of injury. Results: Forty-seven hip fracture mortalities were reviewed. Median patient age was 88 years (range: 56-99). Overall, 68.1% (32) underwent surgical intervention. Mean predicted POSSUM morbidity and mortality rates were 73.9% (28%-99%) and 31.1% (5%-83%), respectively. The mean predicted P-POSSUM mortality rate was 26.4% (1%-91%) and 53.2% (25) had a P-POSSUM predicted mortality of >20%. Subgroup analysis demonstrated poor agreement between predicted mortality and observed mortality rate for POSSUM in operative (χ2 = 127.5, P < .00001) and nonoperative cohorts (χ2 = 14.6, P < .00001), in addition to P-POSSUM operative (χ2 = 101.9, P < .00001) and nonoperative (χ2 = 11.9, P < .00001) scoring. Discussion/Conclusion: Hip fracture patients are at significant risk of both morbidity and mortality. A reliable, replicable, and accurate tool to represent the expected risk of such complications could help facilitate clinical decision-making to determine the optimal level of care. Screening tools such as POSSUM and P-POSSUM have limitations in accurately identifying high-risk hip fracture patients.

Early palliative care is associated with improved quality of end-of-life care for women with high risk gynecologic malignancies

2017 ◽  
Vol 145 ◽  
pp. 26
Author(s):  
N.S. Nevadunsky ◽  
C. Zanartu ◽  
P. Pinto ◽  
R. Barrera ◽  
A.R. Van Arsdale ◽  
...  
Keyword(s):  
Palliative Care ◽  
High Risk ◽  
End Of Life ◽  
End Of Life Care ◽  
Life Care ◽  
Gynecologic Malignancies ◽  
Early Palliative Care

Using Patients and Their Caregivers Feedback to Develop ENABLE CHF-PC: An Early Palliative Care Intervention for Advanced Heart Failure

2018 ◽  
Vol 34 (2) ◽  
pp. 103-110 ◽  
Author(s):  
Imatullah Akyar ◽  
J. Nicholas Dionne-Odom ◽  
Marie A. Bakitas
Keyword(s):  
Heart Failure ◽  
Palliative Care ◽  
Formative Evaluation ◽  
Controlled Trial ◽  
Nyha Class ◽  
Complex Interventions ◽  
Class Iii ◽  
Early Palliative Care ◽  
Care Intervention ◽  
Care Assessment

Objective: Models of early, community-based palliative care for individuals with New York Heart Association (NYHA) class III/IV heart failure and their families are lacking. We used the Medical Research Council process of developing complex interventions to conduct a formative evaluation study to translate an early palliative care intervention from cancer to heart failure. Method: One component of the parent formative evaluation pilot study was qualitative satisfaction interviews with 8 patient–caregiver dyad participants who completed Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare For Patient and Caregivers (ENABLE CHF-PC) intervention. The ENABLE CHF-PC consists of an in-person palliative care assessment, weekly telehealth coaching sessions, and monthly follow-up. Subsequent to completing the coaching sessions, patient and caregiver participants were interviewed to elicit their experiences with ENABLE CHF-PC. Digitally recorded interviews were transcribed and analyzed using a thematic approach. Results: Patients (n = 8) mean age was 67.3, 62.5% were female, 75% were married/living with a partner; caregivers (n = 8) mean age was 56.8, and 87.5% were female. Four themes related to experiences with ENABLE CHF-PC included “allowed me to vent,” “gained perspective,” “helped me plan,” and “gained illness management and decision-making skills.” Recommendations for intervention modification included (1) start program at diagnosis, (2) maintain phone-based approach, and (3) expand topics and modify format. Conclusion: Patients and caregivers unanimously found the intervention to be helpful and acceptable. After incorporating modifications, ENABLE CHF-PC is currently undergoing efficacy testing in a large randomized controlled trial.

scholarly journals Analysis of the effect of pneumonia on mortality (ORACLE-RF)

2020 ◽  
Vol 9 (2) ◽  
Author(s):  
Alexander G. Arutyunov ◽  
Anna V. Sokolova ◽  
Grigoriy P. Arutyunov ◽  
Dmitry O. Dragunov
Keyword(s):  
Heart Failure ◽  
Chronic Kidney Disease ◽  
Mortality Rate ◽  
Final Analysis ◽  
Men And Women ◽  
Death Risk ◽  
Favorable Prognosis ◽  
Associated Diseases ◽  
One Year ◽  
Overall Mortality

Objective — To analyze the effect of pneumonia on mortality among patients with circulatory decompensation. Material and methods — The study was based on the ORACLE-RF registry containing information obtained from 20 cities in Russia. Patients were monitored for one year. The research included men and women with symptoms of chronic heart failure during circulatory decompensation period. The patients' average age was 67±13 years. Final analysis included 2404 patients. Results — Hospital mortality was at 9%. By the 30th day of observation, overall mortality rate stood at 13%. Within the year, the overall mortality rate was 43%. Pneumonia and chronic kidney disease (CKD) had the most pronounced effect on death risk – 49.5% and 47.2%. The study showed that patients who do not have pneumonia and CKD among other associated diseases were 2.5 times more likely to survive after 360 days of observation than patients who have them among other associated diseases. The chances of favorable prognosis in patients without pneumonia are 1.7 times higher than in patients with pneumonia among other diseases. Conclusion — Pneumonia probably triggered the decompensation mechanism and significantly increased mortality in these patients.

scholarly journals MP44: TEC4Home heart failure: using home telemonitoring to decrease ED readmissions and clinical flow

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S56-S57
Author(s):  
H. Novak Lauscher ◽  
K. Ho ◽  
J. L. Cordeiro ◽  
A. Bhullar ◽  
R. Abu Laban ◽  
...  
Keyword(s):  
Heart Failure ◽  
Length Of Stay ◽  
Hospital Admissions ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Total Hospital ◽  
Home Telemonitoring ◽  
Patient Health ◽  
Ed Visits ◽  
Improve Patient

Introduction: Patients with Heart failure (HF) experience frequent decompensation necessitating multiple emergency department (ED) visits and hospitalizations. If patients are able to receive timely interventions and optimize self-management, recurrent ED visits may be reduced. In this feasibility study, we piloted the application of home telemonitoring to support the discharge of HF patients from hospital to home. We hypothesized that TEC4Home would decrease ED revisits and hospital admissions and improve patient health outcomes. Methods: Upon discharge from the ED or hospital, patients with HF received a blood pressure cuff, weight scale, pulse oximeter, and a touchscreen tablet. Participants submitted measurements and answered questions on the tablet about their HF symptoms daily for 60 days. Data were reviewed by a monitoring nurse. From November 2016 to July 2017, 69 participants were recruited from Vancouver General Hospital (VGH), St. Pauls Hospital (SPH) and Kelowna General Hospital (KGH). Participants completed pre-surveys at enrollement and post-surveys 30 days after monitoring finished. Administrative data related to ED visits and hospital admissions were reviewed. Interviews were conducted with the monitoring nurses to assess the impact of monitoring on patient health outcomes. Results: A preliminary analysis was conducted on a subsample of participants (n=22) enrolled across all 3 sites by March 31, 2017. At VGH and SPH (n=14), 25% fewer patients required an ED visit in the post-survey reporting compared to pre-survey. During the monitoring period, the monitoring nurse observed seven likely avoided ED admissions due to early intervention. In total, admissions were reduced by 20% and total hospital length of stay reduced by 69%. At KGH (n=8), 43% fewer patients required an ED visit in the post-survey reporting compared to the pre-survey. Hospital admissions were reduced by 20% and total hospital length of stay reduced by 50%. Overall, TEC4Home participants from all sites showed a significant improvement in health-related quality of life and in self-care behaviour pre- to 90 days post-monitoring. A full analysis of the 69 patients will be complete in February 2018. Conclusion: Preliminary findings indicate that home telemonitoring for HF patients can decrease ED revisits and improve patient experience. The length of stay data may also suggest the potential for early discharge of ED patients with home telemonitoring to avoid or reduce hospitalization. A stepped-wedge randomized controlled trial of TEC4Home in 22 BC communities will be conducted in 2018 to generate evidence and scale up the service in urban, regional and rural communities. This work is submitted on behalf of the TEC4Home Healthcare Innovation Community.

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