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

Ma, Jessica MD1; Chi, Stephen MD2; Buettner, Benjamin MD2; Pollard, Katherine MD3; Muir, Monica DO4; Kolekar, Charu MD4; Al-Hammadi, Noor MBChB, MPH5; Chen, Ling PhD5; Kollef, Marin MD3; Dans, Maria MD4

doi: 10.1097/CCM.0000000000004016
Clinical Investigations
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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.

1Duke Palliative Care, Department of Medicine, Duke University and Health System, Durham, NC.

2Department of Medicine, Washington University School of Medicine, St. Louis, MO.

3Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.

4Division of Palliative Medicine, Washington University School of Medicine, St. Louis, MO.

5Division of Biostatistics, Department of Medicine, Washington University School of Medicine, St. Louis, MO.

Registration: ClinicalTrials.gov Identifier: NCT03263143.

Drs. Ma, Chi, Buettner, Pollard, Muir, Kolekar, Kollef, and Dans were involved in substantial contributions to conception or design of the work, drafting of the work or revising it critically for important intellectual content. All authors were involved in substantial contributions to the acquisition, analysis, and interpretation of data for the work. They also had final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

This publication in part was supported by The Foundation for Barnes-Jewish Hospital and their generous donors, and the Washington University Institute of Clinical and Translational Sciences which is, in part, supported by the National Institutes of Health/National Center for Advancing Translational Sciences, Clinical Translational Sciences Award grant UL1TR002345.

Drs. Ma and Chi disclosed that the study is supported by The Foundation for Barnes-Jewish Hospital and Washington University Institute of Clinical and Translational Sciences (ICTS) which is, in part, supported by the National Institutes of Health (NIH)/National Center for Advancing Translational Sciences, Clinical Translational Sciences Award grant UL1TR002345. Drs. Chi, Buettner, Al-Hammadi, and Kollef received support for article research from the NIH. Dr. Buettner’s institution received funding from ICTS Just In Time award. Drs. Buettner’s and Dans’s institutions received funding from Barnes-Jewish Hospital Foundation. Dr. Chen disclosed work for hire. Dr. Kollef’s effort was supported by the Barnes-Jewish Hospital Foundation. Dr. Dans’ institution also received funding from ICTS at Washington University School of Medicine and Barnes Jewish Hospital Foundation, and she received funding from National Comprehensive Cancer Network (NCCN) (Guidelines Panel Chair for the Palliative Care Guidelines. The NCCN reimburses travel & accommodation expenses for attending their annual conference). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: kollefm@wustl.edu

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