293 Goals of Care Determination Prior to Transfer: A Missed Opportunity

Abstract

To determine the prevalence of goals of care discussion documentation by sending institutions among adults transferred to our tertiary care medical center who died within the first 48 hours of their transfer. We performed a retrospective chart review of patients 18 years and older transferred from outlying hospital emergency departments and inpatient units to our rural tertiary medical center as either floor level or critical care level patients from October 2011 through April 2016 who died within 48 hours of arriving. Data was abstracted from both the referring hospital’s documentation provided upon transfer and our electronic medical record. Physiologic and laboratory data was abstracted from the referring facilities chart or our electronic medical record reflecting the patient’s condition at the time of transfer; this was used to calculate the Charlson Age-Comorbidity Index. The presence of documented goals of care was specifically determined through review transfer documentation accompanying the patient. Data was analyzed using STATA 10 statistical software. A total of 181 patients met the inclusion criteria. The average age was 69.3 years and 47.5% were female. 76% of the referring hospitals were critical access hospitals. 45 % came from emergency departments, 55% from inpatient units. The mean Charlson Age-Comorbidity Index score was 5.5±2.7. Mode of transfer to our facility was local EMS 52.5% of the time, critical care helicopter 32%, and critical care ground transport 15.5%. The cause of death was septic shock for 24.9%, cerebrovascular accident for 14.4%, and acute myocardial infarction or cardiogenic shock for 12.7%. Documented goals of care discussion was available in 18 of 181 (10%) of transfer records. Our chart review revealed 22 (12%) instances of initial goals of care discussion taking place on admission to the hospital which resulted in the decision to transition to a comfort-based end-of-life care upon arrival. Care was transitioned to a comfort-based care within the first 24 hours for 88 (49%) of the patients. While transfer to a higher level of care is often necessary, the sought after care should be in line with the patient’s goals. In this single center review of critically ill patients, it was striking that only 1 in 10 patients who were critically ill had a discussion about their goals of care addressed and documented prior to transfer. Although the decision to transfer a critically ill patient must often be made with in information, these results suggest an opportunity to improve on the current state. The 12% of patients transitioned to comfort-based care upon arrival to our hospital suggests an opportunity to improve patient care while also decreasing unnecessary transfer. Addressing goals of care along with aggressive medical interventions is important to providing a therapy consistent with our patients’ goals and avoiding costly and invasive treatments that do not align with their goals of care.