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Feasibility and Economic Impact of Dedicated Hospice Inpatient Units for Terminally Ill ICU Patients*

Binney, Zachary O. MPH1; Quest, Tammie E. MD2; Feingold, Paul L. MD3; Buchman, Timothy MD, PhD3,4; Majesko, Alyssa A. MD, MS1,4

doi: 10.1097/CCM.0000000000000120
Clinical Investigations

Objectives: End-of-life care is frequently provided in the ICU because patients receiving life-sustaining treatments are often unsuitable for transfer to home or community hospices. In-hospital dedicated hospice inpatient units are a novel option. This study was designed to 1) demonstrate the feasibility of ICU to dedicated hospice inpatient unit transfer in critically ill terminal patients; 2) describe the clinical characteristics of those transferred and compare them to similar patients who were not transferred; and 3) assess the operational and economic impact of dedicated hospice inpatient units.

Design: Retrospective chart review.

Setting: ICUs and dedicated hospice inpatient units at two southeast urban university hospitals.

Interventions: Charts of ICU and dedicated hospice inpatient unit deaths over a 6-month period were reviewed.

Patients: Dedicated hospice inpatient unit transfers were identified from hospice administrator records. Missed opportunities were patients admitted to the hospital for more than 48 hours who either adopted a comfort care course or had a planned termination of life-sustaining therapy. Patients were excluded if they were declared brain dead, were organ donors, required high-frequency ventilation, or if there was insufficient information in the medical record to make a determination.

Measurements and Main Results: We identified 167 transfers and 99 missed opportunities; 37% of appropriate patients were not transferred. Transfers were older (66.9 vs 60.4 yr; p < 0.05), less likely to use mechanical ventilation (71.9% vs 90.9%) and vasopressors (70.9% vs 95.0%; p < 0.05), and less likely to receive a palliative care consult (70.4% vs 43.4%; p < 0.05) than missed opportunities. Transfers saved 585 ICU bed days.

Conclusions: Dedicated hospice inpatient units are a feasible way to provide care for terminal ICU patients, but barriers including lack of knowledge of the units and provider or family comfort with leaving the ICU remain. Dedicated hospice inpatient units are potentially significant sources of bed days and cost savings for hospitals and the healthcare system overall.

1Emory Palliative Care Center, Emory University, Atlanta, GA.

2U.S. Department of Veterans Affairs Medical Center and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA.

3Department of Surgery, Emory University School of Medicine, Atlanta, GA.

4Emory Center for Critical Care Medicine, Emory University, Atlanta, GA.

* See also p. 1288.

This work was performed at Emory University Hospital, Atlanta, GA, and Emory University Hospital Midtown, Atlanta, GA.

Dr. Quest is employed by Gentiva Hospice. Dr. Buchman’s institution received grant support from the James S. McDonnell Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins