Comfort Care Order Research Articles

End of Life Outcomes Following Comfort Care Orders: A Single Center Experience.

Background: Few studies have explored the outcomes of patients placed on comfort care with respect to hospice disposition. The objective of this study was to perform a retrospective analysis of patients who transitioned to comfort care. Methods: We conducted a retrospective study of patients placed on the comfort care order set between July 1st, 2021, until June 30th, 2022. Each individual patient chart was then analyzed to collect multiple clinical variables. IRB approval was obtained as per institutional guidelines. Results: 541 patients were included in the analysis. An average of 1.5 patients were placed on comfort care a day. 424 (78.37%) patients died while in the hospital. The median time on comfort care was 1 day. For subspecialty and hospital medicine patients the median time was 2 days. 40% of non-ICU patients were discharged with hospice services. 60% of patients were in the intensive care unit (ICU) and spent a median of 2.33 hours on comfort care. 19% of these patients were on comfort care for over 12 hours. 94% of the patients placed on comfort care in the ICU died in the hospital as compared to 53% of subspecialty and 59% of hospital medicine patients. Conclusions: The majority of patients placed on comfort care died during their hospitalization demonstrating a real need for comprehensive end of life care and immediate hospice services. For those discharged with hospice services, they spent an excessive amount of time in the hospital waiting for services to be arranged.

Outcomes of patients placed on comfort care at a large, urban, quaternary care medical center.

229 Background: End-of-life care in the typical hospital setting has several drawbacks including lack of interdisciplinary hospice teams, less comfortable environments, and lack of provider experience. In addition, patients at the end of their life are often severely symptomatic and imminently dying and thus have barriers to appropriate disposition. Few studies have explored the outcomes of patients placed on comfort care with respect to hospice disposition. The objective of this study was to perform a retrospective analysis of patients who transitioned to comfort care at Thomas Jefferson University Hospital (TJUH) to better understand the ultimate disposition of patients placed on comfort care. Methods: We conducted a retrospective study of patients placed on the comfort care order set between July 1st, 2021, until June 30th, 2022. A report of all patients placed on our institutions “comfort care order set” was run using Qlik analytics and data platform. Each individual patient chart was then analyzed to collect multiple clinical variables, including diagnoses, palliative care involvement, time on comfort care, hospital length of stay (in total and after comfort care order set placed), healthcare utilization prior to hospitalization, and IV medications used for symptom management. Participants were limited to those 18 years or older. IRB approval was obtained as per institutional guidelines. Results: 541 patients were included in the analysis. 424 (78.37%) patients died while still admitted to the hospital. This amounts to 1.5 patients a day requiring comfort care support. 60% of patients on comfort care were in the intensive care unit (ICU). The ICU population spent on average 11.04 (+/- 24) hours on comfort care. 19% of these patients were on comfort care for longer than 12 hours. Subspecialty and hospital medicine patients were on comfort care for 3.3 (+/- 3.3) days and 5 (+/- 9.5) days respectively. Within oncology patients, the average time was 3 (+/- 2.4) days. 94% of the patients placed on comfort care in the ICU died in the hospital as compared to 53% of subspecialty and 59% of hospital medicine patients. 40% of non-ICU patients were discharged with hospice services. The average length of stay for the study population was 12.5 (+/- 13.0) days. Conclusions: The majority of patients placed on comfort care died during their hospitalization demonstrating a real need for comprehensive end of life care and immediate hospice services for our patient population. For those discharged with hospice services, they spent an excessive amount of time in the hospital waiting for services to be arranged. Establishing a hospital based inpatient hospice unit has the potential to improve the patient and family experience, provide better end of life care, and reduce length of stay. Previous studies have also demonstrated decreased costs. Ongoing work is underway at our institution to provide optimal end of life care for this patient population.

Palliative Medicine and End of Life Care Between Races in an Academic Intensive Care Unit.

Background: Although palliative medicine (PM) is more commonly being integrated into the intensive care unit (ICU), research on racial disparities in this area is lacking. Our objectives were to (a) identify racial disparities in utilization of PM consultation for patients who received ICU care and (b) determine if there were differences in the use of code status or PM consultation over time based on race. Materials and Methods: Retrospective analysis of 571 patients, 18 years and above, at a tertiary care institution who received ICU care and died during their hospital stay. We analyzed two timeframes, 2008-2009 and 2018-2019. Univariate analysis was utilized to evaluate baseline characteristics. A multivariate logistic regression model and interaction P values were employed to assess for differential use of PM consultation, do not resuscitate (DNR) orders, and comfort care (CC) orders between races in aggregate and for changes over time. Results: There was a notable increase in Black/African-American (AA) (54% to 61%) and Hispanic/Latino (2% to 3%) patients over time in our population. Compared to White patients, we found no differences between PM consultation and CC orders. There was a lower probability of DNR orders for Black/AA (adjusted odds ratio [aOR] 0.569; P = .049; confidence interval [CI]: 0.324-0.997) and other/unknown/multiracial patients (aOR: 0.389; P = .273; CI: 0.169-0.900). Comparing our earlier time period to the later time period, we found an increased usage of PM for all patients. Interaction P values suggest there were no differences between races regarding PM, DNR, and CC orders. Conclusions: PM use has increased over time at our institution. Contrary to the previous literature, there were no differences in the frequency of utilization of PM consultation between races. Further analysis to evaluate the usage of PM in the ICU setting in varying populations and geographic locations is warranted.

Evaluations of Adaptations to a Comfort Care Order Set: A Retrospective Cohort Review

Evaluations of Adaptations to a Comfort Care Order Set: A Retrospective Cohort Review

899: COMPARISON OF CORTICOSTEROID DOSING IN NONINVASIVE POSITIVE PRESSURE VENTILATION COVID-19 PATIENTS

Introduction: High dose corticosteroids decrease ventilator free days in mechanically ventilated COVID-19 patients, however there is limited data on the benefit of higher doses in patients receiving non-invasive positive pressure ventilation. The purpose of this study was to compare high versus low dose corticosteroids’ impact on ventilator free days for COVID-19 patients who received continuous non-invasive positive pressure respiratory support. Methods: This retrospective study included COVID-19 positive patients diagnosed within 14 days of hospital admission, aged 18 years or older, and those who received at least 48 hours of corticosteroids while on continuous non-invasive positive pressure ventilation. Patients were excluded if they were pregnant, had active malignancy, transferred from an on outside facility, used oral corticosteroids within 10 days of hospitalization, and those who died or had comfort care orders placed within 24 hours of admission. The primary objective of this study compared ventilator free days between high dose (dexamethasone 20 mg or methylprednisolone ≥ 120 mg per day) and low dose (dexamethasone 6 mg per day) corticosteroids for patients who received continuous non-invasive positive pressure ventilation. Secondary objectives compared mortality, intensive care unit (ICU) length of stay, and hyperglycemia rates between groups. Results: A total of 72 patients were included in this study with 36 patients in each group. There was a statistically significant difference of 3 ventilator free days between the high and low dose corticosteroid groups (median [IQR], 12 days [8-16] vs 9 days [7-12], p=0.047). No difference was found between groups for ICU length of stay or inpatient mortality. There was an increased incidence of hyperglycemia in the high dose group compared to the low dose group (n [%], 32 patients [89] vs 24 patients [67], p=0.023). Conclusions: Initiating high dose corticosteroids for COVID-19 patients on non-invasive positive pressure ventilation is associated with an increase in ventilator-free days. The use of high dose corticosteroids in this patient population could help to delay or prevent intubation and the complications associated with mechanical ventilation. Future studies should evaluate duration of therapy and additional therapies for COVID-19 patients.

Choices and Outcomes of the Oldest Old Admitted During the First Wave of COVID-19 in New York City.

Objectives: Morbidity and mortality are higher in older adults with COVID-19, but their decisions about aggressive care, severity of disease, and outcomes during the first surge in New York City are not well characterized. We sought to determine if the oldest patients chose intubation and comfort care at different rates compared to younger geriatric patients. We also studied outcomes among patients admitted with severe disease and those who chose aggressive versus comfort care. Methods: This retrospective analysis used electronic health record data from patients 65 years and older at two medical centers in New York City admitted between 3/5/2020 and 5/15/2020. The primary outcome was comfort care orders, and secondary outcomes included death, palliative care consultation, goals of care discussion, code status, and ventilator weaning. Results: Of the 854 patients, 214 were in the oldest old (OO, age > = 85) group, 269 middle old (MO, age 75-84), and 371 young old (YO, age 65-74). Among those with serious disease, the OO were more likely to choose comfort care (45% vs. 21% MO and 6.8% YO), less likely to be intubated (17% vs. 37% MO and 44% YO), more likely to have a palliative care consult, more likely to be DNR/DNI on admission (60% vs. 17% MO and 9.3%% YO), and more likely to die during admission (65% vs. 42% MO and 21% YO) (all p-values < 0.001). Of all 216 intubated patients, 78% of the OO died, versus 66% of the MO and 36% of the YO (p = <0.001). Conclusions: Adults 85 and above admitted with COVID-19 were more likely to forego intubation and die with comfort-based care. Irrespective of intubation choice, patients 85 and older had a markedly poorer prognosis than other cohorts over 65.

The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit.

Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.

Improving Provider Training for Implementing a Comfort Care Order Set in Veterans Affairs Medical Centers (VAMC): Palliative Care Consult Team Members’ Perspectives (SCI902)

Improving Provider Training for Implementing a Comfort Care Order Set in Veterans Affairs Medical Centers (VAMC): Palliative Care Consult Team Members’ Perspectives (SCI902)

Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial.

There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. One hundred thirty-two providers from PCCTs at 47 VAMCs. Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. ClinicalTrials.gov identifier: NCT02383173.

Adapting a Comfort Care Order Set in a Large Health System during the COVID-19 Pandemic.

Adapting a Comfort Care Order Set in a Large Health System during the COVID-19 Pandemic.

Implementation of the BEACON II Comfort Care Order Set in Veterans Affairs (VA) Medical Centers: Palliative Care Consult Team Members' Perspectives (S705)

Implementation of the BEACON II Comfort Care Order Set in Veterans Affairs (VA) Medical Centers: Palliative Care Consult Team Members' Perspectives (S705)

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses.

Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress. Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients. Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting. Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress "some, most, or all of the time" when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient's course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late. The majority of providers and nurses reported that comfort care was started too late in a patient's course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.

ECG Monitoring during End of Life Care: Implications on Alarm Fatigue

Excessive numbers of clinical alarms in the intensive care unit (ICU) contribute to alarm fatigue. Efforts to eliminate unnecessary alarms, including during end of life (EOL) care, are pivotal. This study describes electrocardiographic (ECG) arrhythmia alarm usage following the decision for comfort care. We conducted a review of electronic health records (EHR) in patients who died and had comfort care orders that were in place during our study. The occurrences of ECG arrhythmia alarms among these patients were examined. We found 151 arrhythmia alarms that were generated in 11 patients after comfort care was initiated: 72% were audible, 21% were manually muted, and 7% had an unknown audio label. Level of alarm: 33% crisis, 58% warning, 1% message, and 8% were labeled unknown. Our report shows that ECG monitoring was commonly maintained during the EOL care. Since the goal of care during this phase is for both patient and family comfort, it is important for the clinicians to weigh the benefits versus harms of the continuous ECG monitoring.

Abstract 140: Reducing Costs and Length of Stay Using Standardized Dysphagia Evaluation in Acute Stroke Patients

Introduction: Dysphagia is common after acute stroke. Variability in predicting who will require a gastrostomy tube (G-tube) prior to discharge can prolong length of hospital stay (LOS) and increase costs. Objectives: We propose a novel protocol to standardize speech therapy evaluation and G-tube recommendations among acute stroke patients with dysphagia to reduce LOS and costs. Methods: A cohort of acute stroke patients with dysphagia was identified through an administrative data set using ICD-10 codes for ischemic stroke and CPT codes for speech therapy evaluation, and if applicable, CPT code for G-tube placement. Patients with tracheostomy, comfort care orders, or discharge to hospice were excluded. A multidisciplinary team from speech therapy, neurology, and radiology applied quality improvement principles to design and implement a G-tube indicator score (Figure 1) to address variability in dysphagia evaluation. Median LOS and duration from initial speech therapy evaluation to final diet recommendation were compared between the pre- and post-intervention period. Cost savings were calculated using LOS and average daily institutional bed cost. Results: Between January 2016 to January 2017, 174/278 (62%) of acute stroke patients had dysphagia and 61/174 (35%) of these patients received G-tubes. Their median LOS was 21.7 days compared to 5 days for stroke patients without G-tube. In the post-implementation period from Feb-May 2017, 25/45 (55%) of acute stroke patients had dysphagia and 5/25 (20%) received G-tubes. Their median LOS was 16.4 days following the protocol implementation. This resulted in cost savings of $14,654 per G-tube patient. Conclusions: This novel G-tube indicator score standardized speech therapy evaluation and reduced LOS by more than 5 days among acute stroke patients requiring G-tube prior to discharge. Future studies will prospectively validate the score. Increased adoption would result in significant cost savings.

Abstract WP310: Timing of Comfort Care Decisions in Ischemic Stroke Patients: Implications for Publicly Reported Outcomes

Introduction: Risk-adjusted stroke mortality is a publicly-reported CMS quality measure. Patients (pts) admitted with stroke who are discharged to hospice prior to the first midnight are excluded in reported metrics. It is difficult to prognosticate outcomes early in ischemic stroke; additionally, the sudden nature of the disease makes it difficult for families to make rapid decisions. We hypothesized that the decision to proceed to comfort care in ischemic stroke pts takes longer than 24 hours. Methods: This was an observational study of all ischemic stroke pts seen at Intermountain Medical Center in 2016 (n=581) who were discharged to hospice (n=27) or died in hospital on comfort care (n=27). A Wilcoxon sign rank test was used to compare time to decision regarding comfort care to the CMS standard of 24 hours. Differences in the time to decision or death for the pt characteristics were also compared using Wilcoxon-Mann-Whitney test. Results: The average age was 80 years old ± 13 (range 44 - 98), 59% were female, all were Caucasian Non-Hispanic, and 65% reported a religious affiliation. NIH stroke score was reported in 42 subjects with an average of 15.9±7.9 (range 2-31). The mean time from admission to initiation of comfort care orders was 3.12 days (±3.6) with a median of 1.8 days and a range from 12.5 hours to 14.1 days. The time was significantly greater than 24 hours (p&lt;0.0001) with only a third (n=18) having the time less than 24 hours and with only a fifth (n=11) having the time before the first midnight. The table below contains the differences in the times based on pt characteristics and none of these were significantly associated with time differences. Conclusions: The decision to transition to comfort care or hospice often takes greater than 24 hours. If the stroke mortality metric is meant to exclude hospice pts or those that prefer comfort measures only, the time window for initiation of those orders should be extended beyond the first midnight.

Does Admission to the ICU Prevent African American Disparities in Withdrawal of Life-Sustaining Treatment?

We sought to determine whether black patients admitted to an ICU were less likely than white patients to withdraw life-sustaining treatments. We performed a retrospective cohort study of hospital discharges from October 20, 2015, to October 19, 2016, for inpatients 18 years old or older and recorded those patients, along with their respective races, who had an "Adult Comfort Care" order set placed prior to discharge. A two-sample test for equality of two proportions with continuity correction was performed to compare the proportions between blacks and whites. University of Florida Health. The study cohort included 29,590 inpatient discharges, with 21,212 Caucasians (71.69%), 5,825 African Americans (19.69%), and 2,546 non-Caucasians/non-African Americans (8.62%). Withdrawal of life-sustaining treatments. Of the total discharges (n = 29,590), 525 (1.77%) had the Adult Comfort Care order set placed. Seventy-eight of 5,825 African American patients (1.34%) had the Adult Comfort Care order set placed, whereas 413 of 21,212 Caucasian patients (1.95%) had this order set placed (p = 0.00251; 95% CI, 0.00248-0.00968). Of the 29,590 patients evaluated, 6,324 patients (21.37%) spent at least one night in an ICU. Of these 6,324 patients, 4,821 (76.24%) were white and 1,056 (16.70%) were black. Three hundred fifty of 6,324 (5.53%) were discharged with an Adult Comfort Care order set. Two hundred seventy-one White patients (5.62%) with one night in an ICU were discharged with an Adult Comfort Care order set, whereas 54 Black patients (5.11%) with one night in an ICU had the order set (p = 0.516). This study suggests that Black patients may be less likely to withdraw life-supportive measures than whites, but that this disparity may be absent in patients who spend time in the ICU during their hospitalization.

A New Generation of Comfort Care Order Sets: Aligning Protocols with Current Principles.

There are few published comfort care order sets for end-of-life symptom management, contributing to variability in treatment of common symptoms. At our academic medical centers, we have observed that rapid titration of opioid infusions using our original comfort care order set's titration algorithm causes increased discomfort from opioid toxicity. The aim of this study was to describe the process and outcomes of a multiyear revision of a standardized comfort care order set for clinicians to treat end-of-life symptoms in hospitalized patients. Our revision process included interdisciplinary group meetings, literature review and expert consultation, beta testing protocols with end users, and soliciting feedback from key committees at our institutions. We focused on opioid dosing and embedding treatment algorithms and guidelines within the order set for clinicians. The study was conducted at two large academic medical centers. We developed and implemented a comfort care order set with opioid dosing that reflects current pharmacologic principles and expert recommendations. Educational tools and reference materials are embedded within the order set in the electronic medical record. There are prompts for improved collaboration between ordering clinicians, nurses, and palliative care. We successfully developed a new comfort care order set at our institutions that can serve as a resource for others. Further evaluation of this order set is needed.

Abstract WP299: Patients Transferred to Tertiary Care Centers with Fatal Ischemic Strokes Increase Center Specific Mortality Rates

Background: The Center for Medicare and Medicaid Services (CMS) tracks annualized 30 day mortality data for patients with ischemic stroke across hospitals. Due to the increased complexity and severity of stroke patients transferred to tertiary centers, mortality rates would be expected to be higher than at institutions which transfer these patients. Publicly available mortality data may not adequately account for this referral pattern, making tertiary care centers appear to provide inferior care. Methods: We retrospectively analyzed all recorded deaths within 30 days of ischemic stroke from 2009-2011 at our Comprehensive Stroke Center. Data was abstracted from patient charts, including the NIHSS as recorded or calculated retrospectively based on documented exam, admission time, time of first palliative care consult, time of comfort care orders and time of death. Descriptive and nonparametric statistics were used. Results: There were 42 CMS patient deaths reviewed, median age (interquartile range, IQR) was 82 (75-87), median NIHSS = 22.5 (IQR 19-27), 55% were transferred in, 24% received IV tPA, 36% died within 72 hours of admission, 36% had Palliative Care consults and 90% were placed on comfort care. Transfer patients that died did not differ from direct admit deaths by age, NIHSS or death within 72 hours; NIHSS scores averaged 21 in the transferred group vs. 23 in the direct admits, death within 72 hours was 39% for transfers vs 31% for direct admits. There was a trend toward increased use of tPA (35% transfers vs. 11% direct admits, P = 0.07). Patients that died within 72 hours of admission had significantly higher NIHSS scores (26 (IQR 24-31) vs. 20 (IQR 13-25), P = 0.0025) and were less likely to have received a Palliative Care consult (13% vs. 48%, P = 0.024); there were no differences in age or other factors. Conclusions: Over half of the deaths counted in our institutions 30 day ischemic stroke mortality rate were from transfers. Almost all of these patients were placed on comfort care. Many passed away within 72 hours of admission. Early withdrawal of care for severe ischemic strokes in elderly patients may reflect higher, rather than lower, quality of care. Including early deaths with comfort care may bias the CMS mortality measure against tertiary referral centers.

Antimicrobial Use in Patients on a Comfort Care Protocol: A Retrospective Cohort Study.

Antimicrobials are commonly used in patients near the end of life, but the percentage and predictors of patients prescribed antibiotics while hospitalized on a comfort care protocol are unknown. To determine how often patients in the acute care setting are continued on antimicrobials when they are transitioned to comfort-focused care and to describe patient characteristics correlated with antimicrobial use. Retrospective cohort study conducted from June 2012 to August 2014. Two interrelated academic medical centers. Inpatients >18 years old transitioned to a comfort care protocol. Administration of antimicrobials to patients on the comfort care protocol. We generated descriptive statistics and used a modified Poisson regression to estimate unadjusted and adjusted associations along with 95% confidence intervals (CIs) and p-values. There were 1881 patients included in the study; 77% of patients ultimately transitioned to a comfort care protocol received antimicrobials during their admission and 82% died in hospital. Of the 711 alive at ≥24 hours after comfort care orders, 111 (15.6%) were still on antimicrobials. After adjusting for age, a documented infection was positively associated with being on antibiotics (adjusted relative risk [ARR] = 1.46, 95% CI: 1.00-2.12, p = 0.05). Patients in the medical and surgical intensive care units (ICUs) were less likely than those on medicine to receive antimicrobials (MICU ARR = 0.32, 95% CI: 0.14-0.72, p = 0.01; SICU/Neuro ARR = 0.32, 95% CI: 0.12-0.85, p = 0.02). Antimicrobial use is relatively high in hospitalized patients near the end of life, even when the goal is comfort.

Abstract WP402: Performance Measurement of Blood Pressure Management in the Acute Phase of Intracerebral Hemorrhage

Background: Patients with intracerebral hemorrhage (ICH) frequently present with elevated blood pressure (BP) requiring treatment. We conducted an exploratory analysis to examine BP management during the acute phase of ICH. We hypothesized that BP management and time to achieve goal BP would be variable. Our aim was to identify areas for improvement in BP management. Methods: We performed a retrospective chart review on consecutive patients with spontaneous ICH admitted to our neurosurgical intensive care unit (NSICU) from February-March 2015. Exclusions included secondary causes of ICH or comfort care orders placed within 72 hours of arrival. Demographic and clinical characteristics were collected as well as times for BP treatment order placement, IV treatment initiation and discontinuation. We recorded hourly BPs for the first 72 hours of hospitalization. Primary outcome measure was the time to achieve institutional guideline recommended BP control defined as SBP &lt;150 mmHg, maintained for &gt;6 hours. Secondary outcome included the proportion of patients who achieved SBP target &gt;85% of the time. Results: We screened 37 patients and 29 met criteria. Baseline information is summarized in Table 1. Documented BP goals for 25 of 29 patients targeted a SBP goal &lt;150 mmHg. Documentation of BP goals, orders for treatment and initiation of IV medication for BP treatment all happened concurrently about 1 hour after admission (Figure 1). SBP control was achieved at a median of 9.3 hours after admission. Only 46.4% of patients achieved target SBP &gt;85% of the time. Conclusions: In our population, there is variability in the time it takes to achieve and maintain goal SBP with less than half of patients maintaining BP control. We identified targeted areas for improvement. Our data is limited by its retrospective nature and small size. Since aggressive BP management limits hematoma growth and may improve outcomes, we propose development of benchmarks to guide BP management in ICH patients.