A Case–Control Study Evaluating the Impact of Dedicated Palliative Care Training on Critical Care Interventions at the end of Life

2021 ◽  
pp. 082585972110374
Author(s):  
Jee Y. You ◽  
Lie D. Ligasaputri ◽  
Adarsh Katamreddy ◽  
Kiran Para ◽  
Elizabeth Kavanagh ◽  
...  

Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P = .24) and need for mechanical ventilation (59% vs 44%, P = .13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P = .05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P = .19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 23-23
Author(s):  
Karen S. Fernandez ◽  
Rober J. Lucia ◽  
Rachel Buchheit ◽  
Michele J. Holman ◽  
Penelope Sandiford ◽  
...  

23 Background: Patients with solid tumors (ST) have the highest rate of relapse and mortality among pediatric oncology. Many patients suffer from acute and chronic therapy-related toxicity that have major implications in the patients’ lives. An early introduction of palliative care consultation (PCC) for patients with ST was implemented in 2012. Objectives: To assess the impact of the early introduction of PCC for children with ST on 1) Facilitation of interdisciplinary meetings (IDM) and goals of care 2) Counseling support including coping, advocacy, self-care, 3) Grieving, 4) End-of-life decision making/planning, and 5) Bereavement. Methods: An audit of all PCC from November/2012 to May/2014 was performed. Newly diagnosed patients with high risk ST (metastatic disease, need for HSCT or risk for relapse of > 30%) were eligible for early PCC (36/44). Patients with brain tumors were excluded (19). Counselors were introduced to the patient/family at diagnosis. The perception of the intervention was explored among physicians and counselors. Results: 29/35 patients (72%) were offered early PCC, 1 declined the intervention. 17/29 developed disease relapse or progression (58%), 11/17 died. 9/29 had high risk ST without relapse (31%), 6/29 had loss of physical function (21%), 5/29 had other chronic diseases (17%). 20 had IDM for re-direction of goals of care. 25 (86%) received at least 1 of 3 counseling aspects. 20 received grieving support during treatment (6 due to loss of physical function, 4 during relapse and 11 during the dying process). 11 received end-of-life and bereavement support. Median number of visits/patient was 14. Pediatric oncologists felt early PCC favored effective communication between patients/families and medical teams, counselors felt early PCC was critical for rapport and trust building for an effective and productive professional relationship that strengthen the continuity of care. Conclusions: Early PCC for children with ST is feasible, and well-accepted by patients/families and physicians. It facilitates the comprehensive care of patients with ST throughout the disease trajectory.


Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 109-109
Author(s):  
Hannah R. Abrams ◽  
Ryan D. Nipp ◽  
Lara Traeger ◽  
Mitchell W. Lavoie ◽  
Matthew J. Reynolds ◽  
...  

Abstract Background: Patients with high-risk AML often experience intensive medical care at the end of life (EOL) such as hospitalization and intensive care unit (ICU) admission. Despite their poor prognosis, patients with AML and their caregivers often have substantial misperceptions of their prognosis, which may lead to difficult code status transitions near the end of life. However, studies examining code status transitions in patients with AML are lacking. Methods: We conducted a mixed-methods study of 200 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014-2021. High-risk AML was defined as: 1) new diagnosis ≥ 60 years, or 2) relapsed/refractory AML. Two physicians used consensus-driven medical record review to characterize code status transitions from time of diagnosis to death and identify patient, family, and palliative care involvement. Code status was coded as 'full' (confirmed or presumed), 'restricted' (i.e., do not resuscitate), or 'comfort measures only' (CMO). We used logistic regression to explore whether patient factors or features of the code status discussion were associated with the time between the last code status transition and death. Results: At diagnosis of high-risk AML, 86.0% of patients were 'full code' (38.5% presumed, 47.5% confirmed) and 8.5% had restrictions on life-sustaining therapies. Overall, 57% (114/200) of patients experienced a code status transition, with a median of two transitions (range 1-8) during their illness course. Overall, a total of 206 code status transitions were described across the cohort. Median time from diagnosis to first code status transition was 212 days (range 7-4507), and from last transition to death was 2 days (range 0-350). Most of these final code status transitions (71.1%, 81/114) were transitions to CMO near the end of life. Only 60.5% of patients (69/114) who underwent a code status transition participated in their last code status change. In contrast, patients and families participated in 87.7% (100/114) of the last code status transitions and palliative care was involved in 42.1% (48/114). A substantial minority of last code status transitions occurred in the ICU or emergency department (26.3%, 30/114). We identified three processes leading to code status transitions (Table 1): 1) pre-emptive conversations prior to any clinical change (15.6%, 32/206); 2) anticipatory conversations at the time of acute clinical deterioration (32.2%, 66/206); and 3) futility conversations after acute clinical deterioration, focused on withdrawing life-sustaining therapies (51.0%, 105/206). Older age (B = 0.07, P < 0.001), and receipt of non-intensive chemotherapy (B = 1.42, P = 0.003) were associated with a longer time from the last code status transition to death (Table 2). In contrast, futility conversations were associated with shorter time from last code status transition to death (B = -2.84, P < 0.001) compared to pre-emptive or anticipatory conversations. Conclusions: Almost half of patients were "presumed full code" at the time of diagnosis of high-risk AML and most experienced code status transitions at the end of life focused on futility of life-sustaining therapies after acute clinical deterioration. These results suggest that goals of care discussions occur too late in the typical illness course of patients with poor prognosis, high-risk AML. Interventions focused on enhancing patient engagement in timely discussions regarding their end of life care preferences are warranted. Figure 1 Figure 1. Disclosures LeBlanc: AbbVie: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; BMS/Celgene: Consultancy, Honoraria, Other: Travel fees, Research Funding, Speakers Bureau; Pfizer: Consultancy, Other: Advisory Board; Daiichi-Sankyo: Consultancy, Honoraria, Other: Advisory board; Flatiron: Consultancy, Other: Advisory board; Astellas: Consultancy, Honoraria, Other: Advisory board; American Cancer Society: Research Funding; Jazz Pharmaceuticals: Research Funding; AstraZeneca: Consultancy, Honoraria, Other: Advisory board, Research Funding; Agios: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Duke University: Research Funding; Otsuka: Consultancy, Honoraria, Other; NINR/NIH: Research Funding; CareVive: Consultancy, Other, Research Funding; Helsinn: Consultancy, Research Funding; Heron: Consultancy, Honoraria, Other: advisory board; Amgen: Consultancy, Other: travel; UpToDate: Patents & Royalties; Seattle Genetics: Consultancy, Other: Advisory board, Research Funding.


2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S110-S110
Author(s):  
Christina Maguire ◽  
Dusten T Rose ◽  
Theresa Jaso

Abstract Background Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI). ASO Outcome Definitions ASO Outcomes Methods This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site. Results This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018). Conclusion While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols. Disclosures All Authors: No reported disclosures


Author(s):  
Surinder Kaur M. S. Pada ◽  
Poh Lishi ◽  
Kim Sim Ng ◽  
Sarathamani Rethenam ◽  
Lilibeth Silagan Alenton ◽  
...  

Abstract Background Computerisation of various processes in hospitals and reliance on electronic devices raises the concern of contamination of these devices from the patient environment. We undertook this study to determine if an attached hand hygiene device that unlocks the screen of a computer on wheels (COW) on usage can be effective in decreasing the microbiological burden on computer keyboards. Methods An electronic hand sanitizer was integrated onto the COW. A prospective cohort study with a crossover design involving 2 control and 2 intervention wards was used. The study end point was the number of colony forming units found on the keyboards. Bacteria were classified into 4 main groups; pathogenic, skin flora, from the environment or those thought to be commensals in healthy individuals. We then used a mixed effects model for the statistical analysis to determine if there were any differences before and after the intervention. Results Thirty-nine keyboards were swabbed at baseline, day 7 and 14, with 234 keyboards cultured, colony forming units (CFUs) counted and organisms isolated. By mixed model analysis, the difference of mean bacteria count between intervention and control for week 1 was 32.74 (− 32.74, CI − 94.29 to 28.75, p = 0.29), for week 2 by 155.86 (− 155.86, CI − 227.45 to − 83.53, p < 0.0001), and after the 2-week period by 157.04 (− 157.04, CI − 231.53 to − 82.67, p < 0.0001). In the sub-analysis, there were significant differences of pathogenic bacteria counts for the Intervention as compared to the Control in contrast with commensal counts. Conclusion A hand hygiene device attached to a COW may be effective in decreasing the microbiological burden on computer keyboards.


2017 ◽  
Vol 44 (4) ◽  
pp. 548-558 ◽  
Author(s):  
Dudith Pierre-Victor ◽  
Mary Jo Trepka ◽  
Timothy F. Page ◽  
Tan Li ◽  
Dionne P. Stephens ◽  
...  

The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) immunization for 11- to 12-year-old adolescents. In 2008, Louisiana required the school boards to distribute HPV vaccine information to parents or guardian of students in Grades 6 to 12. This article investigates the impact of this policy on HPV vaccination among 13- to 17-year-old female adolescents using National Immunization Survey-Teen (NIS-Teen) data. Drawing on the data from the 2008 to 2012 NIS-Teen, we compared the difference in proportions of females who have been vaccinated before and after the policy. Using difference-indifference estimation, we explored the change in vaccination rates before and after the policy implementation in Louisiana compared with Alabama and Mississippi, two states that did not have such a policy in place. The difference-in-differences estimates for HPV vaccination were not significant. Physician recommendation for HPV vaccination was significantly associated with vaccination among females in Louisiana and Alabama (adjusted odds ratio [aOR] = 7.74; 95% confidence interval [CI; 5.22, 11.5]), and for those in Louisiana and Mississippi (aOR = 7.05; 95% CI [4.6, 10.5]). Compared to the proportion of female adolescents who had received physician recommendation in Alabama or Mississippi, the proportion in Louisiana did not increase significantly in the postpolicy period. HPV vaccination rates did not increase significantly in Louisiana compared to Alabama or Mississippi following the implementation of the policy. Despite Louisiana’s policy, physician recommendation remains the key determinant of HPV vaccination. HPV vaccine awareness does not necessarily result in HPV vaccination.


Author(s):  
Heather Carmichael ◽  
Hareklia Brackett ◽  
Maurice C Scott ◽  
Margaret M Dines ◽  
Sarah E Mather ◽  
...  

Abstract Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended “triggers” for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (&lt;72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived &gt;24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.


2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 330-330
Author(s):  
Teja Ganta ◽  
Stephanie Lehrman ◽  
Rachel Pappalardo ◽  
Madalene Crow ◽  
Meagan Will ◽  
...  

330 Background: Machine learning models are well-positioned to transform cancer care delivery by providing oncologists with more accurate or accessible information to augment clinical decisions. Many machine learning projects, however, focus on model accuracy without considering the impact of using the model in real-world settings and rarely carry forward to clinical implementation. We present a human-centered systems engineering approach to address clinical problems with workflow interventions utilizing machine learning algorithms. Methods: We aimed to develop a mortality predictive tool, using a Random Forest algorithm, to identify oncology patients at high risk of death within 30 days to move advance care planning (ACP) discussions earlier in the illness trajectory. First, a project sponsor defined the clinical need and requirements of an intervention. The data scientists developed the predictive algorithm using data available in the electronic health record (EHR). A multidisciplinary workgroup was assembled including oncology physicians, advanced practice providers, nurses, social workers, chaplain, clinical informaticists, and data scientists. Meeting bi-monthly, the group utilized human-centered design (HCD) methods to understand clinical workflows and identify points of intervention. The workgroup completed a workflow redesign workshop, a 90-minute facilitated group discussion, to integrate the model in a future state workflow. An EHR (Epic) analyst built the user interface to support the intervention per the group’s requirements. The workflow was piloted in thoracic oncology and bone marrow transplant with plans to scale to other cancer clinics. Results: Our predictive model performance on test data was acceptable (sensitivity 75%, specificity 75%, F-1 score 0.71, AUC 0.82). The workgroup identified a “quality of life coordinator” who: reviews an EHR report of patients scheduled in the upcoming 7 days who have a high risk of 30-day mortality; works with the oncology team to determine ACP clinical appropriateness; documents the need for ACP; identifies potential referrals to supportive oncology, social work, or chaplain; and coordinates the oncology appointment. The oncologist receives a reminder on the day of the patient’s scheduled visit. Conclusions: This workgroup is a viable approach that can be replicated at institutions to address clinical needs and realize the full potential of machine learning models in healthcare. The next steps for this project are to address end-user feedback from the pilot, expand the intervention to other cancer disease groups, and track clinical metrics.


2016 ◽  
Vol 9 (2) ◽  
pp. 181 ◽  
Author(s):  
Rajeev Kumar Singh ◽  
Helmut Yabar ◽  
Rie Murakami-Suzuki ◽  
Noriko Nozaki ◽  
Randeep Rakwal

<p>Environmental policies are designed to deal with externalities either by internalizing environmental costs or imposing specific standards for environmental pollution. This study aims to examine the impact of environmental regulations related to End-of-Life Vehicles (ELV) on innovation in Japan. We determined whether there is any statistical difference in patent activity comparing the periods before and after the regulations were enacted. In order to control for exogenous factors such as business cycles, we also analyzed the ratios of ELV and total environmental patents during the same periods. Results showed that environmental regulations drive innovations and the number of ELV-related patents were larger even after controlling for such exogenous factors. We concluded that environmental policy for ELV in Japan was effective in inducing innovation. However, we also found that the weakness in these types of command and control policy is the lack of incentives for further innovation.</p>


2017 ◽  
Vol 13 (9) ◽  
pp. e729-e737 ◽  
Author(s):  
David J. Einstein ◽  
Susan DeSanto-Madeya ◽  
Matthew Gregas ◽  
Jessica Lynch ◽  
David F. McDermott ◽  
...  

Purpose: Patients with advanced cancer benefit from early involvement of palliative care. The ideal method of palliative care integration remains to be determined, as does its effectiveness for patients treated with targeted and immune-based therapies. Materials and Methods: We studied the impact of an embedded palliative care team that saw patients in an academic oncology clinic specializing in targeted and immune-based therapies. Patients seen on a specific day accessed the embedded model, on the basis of automatic criteria; patients seen other days could be referred to a separate palliative care clinic (usual care). We abstracted data from the medical records of 114 patients who died during the 3 years after this model’s implementation. Results: Compared with usual care (n = 88), patients with access to the embedded model (n = 26) encountered palliative care as outpatients more often ( P = .003) and earlier (mean, 231 v 109 days before death; P < .001). Hospice enrollment rates were similar ( P = .303), but duration was doubled (mean, 57 v 25 days; P = .006), and enrollment > 7 days before death—a core Quality Oncology Practice Initiative metric—was higher in the embedded model (odds ratio, 5.60; P = .034). Place of death ( P = .505) and end-of-life chemotherapy (odds ratio, 0.361; P = .204) did not differ between the two arms. Conclusion: A model of embedded and automatically triggered palliative care among patients treated exclusively with targeted and immune-based therapies was associated with significant improvements in use and timing of palliative care and hospice, compared with usual practice.


2021 ◽  
Author(s):  
Ahmed M Badheeb ◽  
Mohamed A Badheeb ◽  
Hamdi A Alhakimi

Abstract Background: The aim of this paper is to compare the patterns and determinants of cancer mortality in Najran region before and after the COVID-19 epidemics. The association between cancer mortality and each of age, sex, site of cancer, stage, and the 30-days survival rate after the last dose of chemotherapy were assessed.Materials & Methods: Adult cancer patients who died of cancer in King Khalid Hospital in Najran Saudi Arabia, were included in this retrospective observational study. We compared mortality patterns in a period of 6 months in 2020 (March to August) with the corresponding period of 2019.Results: 50 dead adult cancer patients were included, 24 in 2019 and 26 in 2020. Among them, 21% vs 42% were younger than 65 years of age; 61% vs 62% were males, for the years 2019 & 2020 respectively. The top three killers in 2019 were colorectal, gastro-esophageal cancers, and hepatocellular carcinoma, while in 2020 were colorectal, hepatocellular carcinoma, and lymphomas. About 16.7% of patients died within 30 days of receiving anti-cancer treatment in 2019 in comparison with 7.7% in 2020. The difference in the 30-days mortality after receiving anti-cancer treatment was not statistically significant between 2019 and 2020 (p = 0.329).Conclusion: The Year 2020, the time of the COVID-19pandemic, was not associated with a significant increase in short-term mortality among patients with malignancy in Najran, Saudi Arabia. Our results generally reflect the crucial role of strict preventive national measures in saving lives and warrants further exploration.


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