Análisis de la evolución de pacientes en probable situación de últimos días en un servicio de Urgencias

Abstract

ObjectiveTo analyse the outcome of patients with expected poor prognosis in an Emergency Department (probably at the end of life) using a computerized clinical history review. Material and methodA descriptive study. We present a prospective review of the computerized clinical history of inpatients at the Emergency Department in University Hospital 12 de Octubre (Madrid) during one month. Patients with a comment of expected poor prognosis or end-of-life situation (less than 15 days) in their computerized clinical history were included in the study. The inpatients were followed up for 17 days.. The variables analysed included: oncological or non-malignant condition; main disease; emergency medical or palliative care in the Emergency Department; medical tests that patients underwent; time until patients died; place where they died. The statistical analysis was performed using the student-t test for quantitative variables, and Chi squared and Fisher tests for qualitative variables. The Kruskal Wallis test was used to compare the location at discharge. The SPSS v11.0 software program was used for statistical analysis. ResultsWe reviewed 1455 computerized clinical histories. Fifty four patients were included in the study (30 oncology and 24 non-oncology patients). The Palliative Care Support Team (PCST) treated 14, mainly oncology, patients (25.92%). At the end of the follow-up, 19 oncology patients (79.17%) and 16 non-oncology patients (53.33%) had died. Of all the deceased patients, emergency medical services and the PCST attended to 23 and 12 patients, respectively. The mean number of blood and image tests performed in patients in probable last days of life was 3.57 and 1.83, respectively, with emergency medical services care; with PCST care it was 1.5 and 0.17, respectively. Six patients underwent invasive tests when they were seen by emergency doctors, but none of the patients seen by the PCST. Most of deceased patients (61%) attended by emergency medical services died in a Hospital Ward; 7% patients died in Palliative Care Unit, and none of them at home. Fifty per cent of deceased patients attended by the PCST died in a Palliative Care Unit or at home; 16% patients died in a Hospital Ward. ConclusionsFew referrals are carried out from Emergency Department to PCST when patients, mainly oncology patients, are in probable near-death situation.A clinical suspicion of poor prognosis detected in the computerized clinical history of an oncology patient predicts with greater reliability a shorter prognosis than in a non-oncology patient.Fewer diagnostic and invasive tests are performed in patients at the end of life in an Emergency Department when a PCST attends to them.Most of these patients die in a Hospital Ward when Emergency Medical Services attended to them, but PCST often referred them to a Palliative Care Unit.Based on the above results, we have initiated a pilot project to attend to palliative patients in the Emergency Department, so that we can improve the care to these patients.