Early Advanced Care Research Articles

Fatal Paraquat Poisoning: A Case Report

Abstract: Paraquat, a widely used herbicide, is notorious for its high toxicity and limited antidotal options. This case report details the clinical presentation, management strategies, and outcomes of a patient with paraquat poisoning. A 32-year-old male presented to the emergency department with a history of intentional ingestion of paraquat. The patient exhibited signs of acute toxicity, including gastrointestinal distress, respiratory distress, and multi-organ failure. Prompt recognition and initiation of treatment were crucial in navigating the complex clinical course. The treatment protocol involved aggressive decontamination, administration of activated charcoal, and utilization of specific antidotes such as cyclophosphamide and methylprednisolone. The patient received supportive care, including mechanical ventilation and hemodynamic support. Continuous monitoring of renal and hepatic functions was implemented to detect and manage complications promptly. Despite the aggressive therapeutic approach, the patient faced significant challenges, with progressive deterioration of respiratory and renal functions. The case highlights the limited efficacy of current treatment modalities in severe paraquat poisoning. The patient eventually succumbed to multi-organ failure, underscoring the need for further research to explore alternative interventions. Paraquat poisoning remains a significant clinical challenge with high mortality rates. This case report emphasizes the importance of early recognition, aggressive decontamination, and advanced supportive care in managing paraquat toxicity. Further research is imperative to explore novel treatment strategies and improve outcomes in cases of severe paraquat poisoning.

‘ALERT’, a machine learning predictive model to identify six-month mortality in patients with advanced cancer: Perception of the utility and acceptability among patients.

189 Background: Machine learning (ML) models can predict mortality and guide end-of-life (EOL) care for patients with advanced solid cancers. Early advanced care planning (ACP) leads to more goal-concordant care, yet many patients, especially from minoritized groups, do not engage in serious illness conversations (SIC). Reasons for delay include inability of oncologists to identify patients at high short-term mortality risk, and uncertainties about prognosis. While ML may improve prognosis accuracy, research on its use and impact on racial biases affecting SIC is limited. This study aims to evaluate the acceptability of deploying a ML model to predict 6-month mortality among patients with advanced solid cancers. Methods: In order to inform the implementation of ‘ALERT,’ a predictive mortality model into a clinical alert system, we conducted one-on-one semi-structured interviews with patients with advanced solid cancer receiving care at a single institution (N=26). Interviews were recorded, transcribed verbatim, coded, and themes were reviewed by a team of interdisciplinary investigators. Results: Benefits and challenges to guide the future implementation of ALERT were identified. Patient-perceived benefits were: 1) EOL Planning: preparing family members (e.g., financial, emotional); 2) Emotional Freedom: knowledge would give freedom to live out life more carefree due to limited time left; 3) Medical Autonomy: the treatment could be worse than the actual disease, if at any point it was not helping, knowing allows individuals to make the decision to stop. Challenges identified were: 1) Loss of Control: “when you don’t know [the outcome], you just keep moving, you just keep pushing”- knowing can result in a loss of control patients may desire for their course of treatment 2) Emotional Impact: knowledge of mortality could lead to grief among patients and families leading to distress around acceptability; 3) Faith: mortality prediction can be seen “playing God,” many patients believed when their time comes, it will happen and a ML tool cannot accurately predict when that time will be. Conclusions: Patients expressed equal balance of acceptability and resistance of ALERT for themselves and their families. This resulted in the difference of preferences regarding whether or not the knowledge this tool could provide would be helpful. This could lead to clinicians taking a patient-centered approach where the delivery of results using ALERT can be based on patient preference. The findings underscore the complexity of implementing ALERT, balancing significant benefits with notable challenges. These insights will guide the refinement of ALERT, ensuring it supports patient care while ensuring ALERT’s benefits are maximized and challenges are overcome.

End of life and palliative care decisions in advanced head neck cancer

The complexity of care for patients with advanced head and neck cancer is a significant issue, and current healthcare systems must focus on appropriate referral criteria, increased integration and coordination of care, and robust evaluation of specific care components. Linkage between research and service design delivery across teams, disciplines, and care settings is also important. Palliative care needs of patients with advanced head and neck cancer pose unique complexities due to the impact the illness has on eating, speaking, appearance, and breathing. Specialty palliative care consultation by trained experts helps primary teams facilitate goals of care discussions, symptom management, and medical resource navigation for the terminally ill patient. Early initiation of palliative care results in less invasive and more cost-effective patient-centered care. There is little literature on care practices in this population, and hospital-based care may increase towards the end of life to address potentially reversible conditions or uncertain prognosis. Early advanced care planning and end-of-life care options should be supported alongside continuation of therapy lines.

Structured Early Advanced Care Planning Outcomes for Patients with High Grade Glioma (S17.006)

<h3>Objective:</h3> To assess the impact of integrating structured early advanced care planning (SEACP) into care for patients with malignant glioma (MG). <h3>Background:</h3> SEACP is under-utilized in cancer and critical in MG due to prognosis, progressive cognitive impairment and patient autonomy. <h3>Design/Methods:</h3> Providers underwent training and used checklists to conduct SEACP visits that included patients and caregivers. We performed an IRB-approved retrospective analysis of 40 SEACP visits over 2 years. We reviewed documentation of SEACP and evaluated impact on adherence to end-of-life quality measures (EOLQM) and advanced care planning (ACP) documentation. Chi-square and t-tests were used to compare outcomes to a published pre-SEACP cohort from our institution. Qualitative data regarding patient and provider experience was analyzed using thematic content analysis. <h3>Results:</h3> All SEACP visits were conducted by advanced practice providers or registered nurses. 54% were tele-visits. Topics discussed included: existential concerns (85%), ACP documents (81%), clinical concerns (77%), and patient values (74%). Patients who completed SEACP (n=40) were more likely to have ACP documented than patients in pre-SEACP cohort (85% vs. 44%; p&lt;0.05), to have completed ACP documents themselves rather than by a proxy (81% vs. 55.0%; p&lt;.01) and higher hospice enrollment &gt; 7 days before death (89% vs. 70.0%; p&lt;.05). Evaluation of qualitative data revealed that 100% of patients found SEACP to be helpful in decision making. 75% of caregivers agreed that “I understand my loved one’s illness better after this visit” and 100% of providers agreed SEACP “improved understanding of patient wishes.” <h3>Conclusions:</h3> Our findings suggest that SEACP is effectively performed by non-physician providers and by telemedicine. SEACP improved ACP documentation, patient involvement in ACP decisions and EOLQM while creating a forum to discuss end of life concerns. Patients, caregivers and providers all viewed SEACP positively. <b>Disclosure:</b> Mrs. Pescatello has nothing to disclose. Dr. Mohile has nothing to disclose. Ms. Serventi has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Novocure. Mrs. Sayers has nothing to disclose. Mrs. Behr has nothing to disclose. Dr. Hemminger has nothing to disclose. Dr. Hardy has received research support from Del Monte Institute for Neuroscience.

Development of the PREDS score to predict in-hospital mortality of patients with Ebola virus disease under advanced supportive care: Results from the EVISTA cohort in the Democratic Republic of the Congo.

SummaryBackgroundAs mortality remains high for patients with Ebola virus disease (EVD) despite new treatment options, the ability to level up the provided supportive care and to predict the risk of death is of major importance. This analysis of the EVISTA cohort aims to describe advanced supportive care provided to EVD patients in the Democratic Republic of the Congo (DRC) and to develop a simple risk score for predicting in-hospital death, called PREDS.MethodsIn this prospective cohort (NCT04815175), patients were recruited during the 10th EVD outbreak in the DRC across three Ebola Treatment Centers (ETCs). Demographic, clinical, biological, virological and treatment data were collected. We evaluated factors known to affect the risk of in-hospital death and applied univariate and multivariate Cox proportional-hazards analyses to derive the risk score in a training dataset. We validated the score in an internal-validation dataset, applying C-statistics as a measure of discrimination.FindingsBetween August 1st 2018 and December 31th 2019, 711 patients were enrolled in the study. Regarding supportive care, patients received vasopressive drug (n = 111), blood transfusion (n = 101), oxygen therapy (n = 250) and cardio-pulmonary ultrasound (n = 15). Overall, 323 (45%) patients died before day 28. Six independent prognostic factors were identified (ALT, creatinine, modified NEWS2 score, viral load, age and symptom duration). The final score range from 0 to 13 points, with a good concordance (C = 86.24%) and calibration with the Hosmer-Lemeshow test (p = 0.12).InterpretationThe implementation of advanced supportive care is possible for EVD patients in emergency settings. PREDS is a simple, accurate tool that could help in orienting early advanced care for at-risk patients after external validation.FundingThis study was funded by ALIMA.

Too little, too late: Palliation and end-stage liver disease.

End-stage liver disease is a leading cause of mortality. Fewer than 60% of patients with decompensated cirrhosis survive after 2years, with patients often experiencing distressing symptoms impairing quality of life. Early advanced care planning and timely palliative care referral can improve quality of life and the end of life experience. We aimed to determine palliative care referral rates and patterns for patients admitted with decompensated cirrhosis, and to identify the factors associated with referral. This was a retrospective, single-center study undertaken at a metropolitan tertiary referral hospital. Patients admitted between the 1 June 2016 and 31 January 2019 with a Child-Pugh score of B or C, and a model for end-stage liver disease score ≥15 were included. We assessed survival and compared those referred and not referred to palliative care, adjusting for lag-time to referral (Kaplan-Meier analysis). One-hundred and sixteen admissions met eligibility criteria for referral. The median age at admission was 59years, with 76% male participants. Only a fifth of eligible patients (25/116) were referred to palliative care. The median survival (from referral) for those referred to palliative care was 20days, versus 148days for those not referred. Despite benefits from timely referral, less than one quarter of palliative care eligible patients was referred. Referral appears reserved for those facing imminent death-surviving just under 3weeks postreferral, yet mortality in nonreferred patients remained high (148-day median). Low rates and late referral are a missed opportunity to improve the end of life care for patients with end-stage liver disease.

Clinical Features, Inpatient Trajectories and Frailty in Older Inpatients with COVID-19: A Retrospective Observational Study.

Introduction: We describe the clinical features and inpatient trajectories of older adults hospitalized with COVID-19 and explore relationships with frailty. Methods: This retrospective observational study included older adults admitted as an emergency to a University Hospital who were diagnosed with COVID-19. Patient characteristics and hospital outcomes, primarily inpatient death or death within 14 days of discharge, were described for the whole cohort and by frailty status. Associations with mortality were further evaluated using Cox Proportional Hazards Regression (Hazard Ratio (HR), 95% Confidence Interval). Results: 214 patients (94 women) were included of whom 142 (66.4%) were frail with a median Clinical Frailty Scale (CFS) score of 6. Frail compared to nonfrail patients were more likely to present with atypical symptoms including new or worsening confusion (45.1% vs. 20.8%, p < 0.001) and were more likely to die (66% vs. 16%, p = 0.001). Older age, being male, presenting with high illness acuity and high frailty were independent predictors of death and a dose–response association between frailty and mortality was observed (CFS 1–4: reference; CFS 5–6: HR 1.78, 95% CI 0.90, 3.53; CFS 7–8: HR 2.57, 95% CI 1.26, 5.24). Conclusions: Clinicians should have a low threshold for testing for COVID-19 in older and frail patients during periods of community viral transmission, and diagnosis should prompt early advanced care planning.

Blood Product Supply for a Helicopter Emergency Medical Service

Background: Long patient transport times to trauma centers are a well-known problem in sparsely populated regions with a low hospital density. Transfusion of red blood cell concentrates (RBC) and plasma improves outcome of trauma patients with severe bleeding. Helicopter emergency services (HEMS) are frequently employed to provide early advanced medical care and to reduce time to hospital admission. Supplying HEMS with blood products allows prehospital transfusion and may help to prevent exsanguination or prolonged hemorrhagic shock. We have investigated the maintenance of blood product quality under air transport conditions and the logistical steps to introduce a HEMS blood depot into routine practice. Methods: A risk analysis was performed and a validation plan developed. A special, commercially available transport container for blood products was identified. Maintenance of temperature conditions between 2 and 6°C in the box were monitored at ambient temperatures up to 35°C over 48 h. Quality of blood products before and after helicopter air transport were evaluated including (1) for RBCs: hemoglobin, hematocrit, hemolysis rate; (2) for thawed plasma: aPTT, INR, single clotting factor activities. The logistics for blood supply of the regional HEMS were developed by the transfusion service of the Greifswald University Hospital in collaboration with the in-hospital transport team, the HEMS team, and the HEMS operator. Results: The transport container maintained a temperature below 6°C up to 36 h at 35°C ambient temperature. Vibration during helicopter operation did not impair quality of RBC and thawed plasma. To provide blood products for HEMS at least two transport containers and an additional set of cooling tiles is needed as the cooling tiles need a special temperature priming over 20 h. The two boxes were used at alternate days. To reduce wastage, RBCs and thawed plasmas were exchanged every fourth day and reintegrated into the blood bank inventory for further in-hospital use. Conclusions: Supplying HEMS with RBCs and plasma is feasible. Helicopter transport has no negative impact on blood product quality. The logistic challenges require close collaboration between the HEMS team and the blood transfusion service.

Clinical and Laboratory Profile of Fatal Dengue Cases at a Tertiary Care Private Hospital in Mumbai, India.

Dengue-related mortality has significantly reduced with early and appropriate fluid resuscitation. However, we continue to see dengue-related fatalities in patients despite early intervention and advanced critical care support. This was a retrospective study conducted at a tertiary care private hospital in Mumbai, India. All patients dying of dengue in the calendar year 2017 were studied. Details related to age, gender, condition at presentation, laboratory parameters, treatment administered, and time to death were abstracted from case records. A total of 575 patients with a diagnosis of dengue were admitted to the hospital in 2017, of which 15 died (mortality rate 2.6%). Four patients died in the emergency medical unit; 11 patients who died after admission to the inpatient unit had multi-organ dysfunction at the time of presentation, with shock, severe liver dysfunction, and severe metabolic acidosis. Only 4/11 patients had hemoconcentration, and 10/11 patients had high white cell counts. In five patients where serum ferritin was performed, it was more than 40,000 ng/mL. Death occurred at a median time of 2 days after hospitalization despite good supportive care. Although there is scope for improvement of supportive care in these patients, it appears that other interventions are urgently needed to improve outcomes in severe dengue. This calls for more research into the immunopathology of dengue, evaluation of anti-inflammatory drugs, intravenous immunoglobulins, antivirals, and improved vaccines.

Chain of Survival in Industrial Emergencies and Industrial Disasters.

The Chain of Survival in Industrial Emergencies and Disasters is similar to the cardiac arrest chain of survival of the American Heart Association (AHA) and the trauma chain of survival. It is a sequence of five inter-linked rings, which when practiced, decreases the mortality and morbidity in the concerned population. The first ring is Early Prevention, which should be a combined effort of healthcare professionals and industrial authorities. The second ring is Early Recognition. Industrial workers and surrounding communities should be equally trained in hazard and risk analysis along with vulnerability assessment. The third ring is Access to Care by the Early Response System, involving a universal emergency response number and early intervention by on-site trained medical professionals. This ring emphasizes the importance of a link with the surrounding communities, as they are the first responders and the front-line victims. The fourth ring is Early Advanced Care by EMS for transportation to hospitals or by Emergency Department personnel in referral hospitals. The fifth and the last ring is Early Rehabilitation, which includes integrated post emergency care, overall rehabilitation and early return to work. The key to successful implementation of Chain of Survival is to have identified components of care, training and quality monitoring. When practiced diligently, this could help prevent industrial disasters, and mitigate their harmful effects on occurrence.

What older adults do with the results of dementia screening programs.

IntroductionAlzheimer’s disease and related dementias (ADRD) and mild cognitive impairment (MCI) are often under-recognized in the community. MCI/ADRD screening could offer benefits such as early treatment, research participation, lifestyle modification, and advanced care planning. To date, there are no clear guidelines regarding the benefits vs. harms of dementia screening or whether a dementia screening program could be successful.MethodsA community-based study was conducted to evaluate an MCI/ADRD screening program and determine what older adults would do with the information. Measures of cognition, physical health, functionality, and mood were collected. Participants met with a health professional, were given screening results with recommendations, and then contacted 60 days later to determine what was done with the results. Logistic regression models were used to build predictive models.ResultsParticipants (n = 288) had a mean age of 71.5±8.3y, mean education of 13.3±4.8y, and were 70% female, 67% White, 26% African American, and 48% Hispanic. After 60 days, 75% of participants were re-contacted; 54% shared results with family, 33% shared results with health care providers (HCPs), and 52% initiated behavioral change. Among participants sharing results with HCPs, 51% reported HCPs did not follow-up on the results, and 18% that HCPs did not show any interest in the screening visit or its results. Predictors of sharing results with HCPs were elevated hemoglobin A1C (OR = 1.85;95%CI:1.19–2.88), uncontrolled hypertension (OR = 2.73;95%CI:1.09–6.83), and mobility issues (OR = 2.43;95%CI: 1.93–5.54). Participant behavioral changes included lifestyle modification (58%), social engagement (10%), cognitive stimulation (5%), and advanced care planning (4%). The most significant predictors of sharing with family were better overall mental health (OR = 0.19; 95%CI: 0.06–0.59) and better physical function (OR = 0.38; 95%CI: 0.17–0.81).DiscussionMCI/ADRD screening was well-received by a diverse community sample. Participants showed interest in sharing the results with their family and HCPs and many attempted behavioral change. While HCPs did not always act on screening results, 25% ordered further testing and evaluation. Efforts need to be directed toward (1) increasing self-efficacy of older adults to discuss screening results with their HCPs, and (2) educating HCPs on the value of early detection of MCI/ADRD. Community dementia screening programs can increase MCI/ADRD detection and improve patient-centered outcomes and medical decision-making.

Improving the quality of CPR in the Community

An out of hospital cardiac arrest (OHCA) is defined as cessation of cardiac mechanical activity, confirmed by the absence of signs of circulation and that which occurs outside the hospital setting (Roger VL, 2011) About 70–85% of these events have a cardiac cause. Published literature identifies acute coronary syndrome (ACS) as the most frequent cause of OHCA, particularly among elderly and coronary vasospasm as a considerable cause among young healthy individuals. It can also occur from non-cardiac causes such as trauma, drowning, drug overdose, asphyxia, electrocution and primary respiratory arrests. (Sasson C, Kellermann AL. 2010). Early cardiopulmonary resuscitation (CPR), therapeutic hypothermia and early advanced care have a crucial role in management of OHCA. Every minute lost in initiating CPR leads to 10% decrease in survival rates of the victim (Go AS, Mozaffarian D-2013) since members of the community are the first to witness OHCA, there is an increasing recognition of the need to coordinate with the community in providing emergency medical care to optimize patient survival after an OHCA. American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care describes a “chain of survival” to reduce mortality and improve survival. The “chain of survival” comprises of five elements, namely, immediate recognition and rapid access, rapid CPR, rapid defibrillation, effective advanced care and integrated post cardiac arrest care. (Travers AH-: 2010)

Understanding the challenges for oncologists in predicting the end-of-life phase of care in cancer patients with advanced solid tumor diagnoses.

281 Background: Early advanced care planning and palliative care improves outcomes during the end-of-life phase of care (EOL) for metastatic cancer patients. Identifying patients who are likely to transition to EOL is a necessary step to prioritize limited palliative care resources and is integral to success in value-based payment models. We analyzed whether physician documentation of prognosis in a clinical pathways system (CPS) could reliably predict when patients are nearing EOL for a large community oncology practice of more than 70 medical oncologists. Methods: Tennessee Oncology (TO) requires physicians to use CPS for all Medicare patients. CPS prompts physicians to answer the “prognostic question” “would you be surprised if this patient died in the next year?” for all OCM patients with advanced solid tumors at the beginning of treatment or at the time of a change in treatment plan. Prognostic question responses were compared to actual dates of death documented in the practice management system. Results: A total of 5,266 distinct patients were expected to trigger an OCM episode during 2017. The CPS prompted a response to the prognostic question for 1,228 (23%) of these OCM patients. There were 665 (54%) positive prognoses (expect patient to live more than 1 year) and 563 (46%) negative prognoses (expect patient to die within 1 year). Physicians documented accurate prognoses in 712 (58%) of cases. For patients with positive prognosis 557 (84%) were accurate. For patients with negative prognosis 155 (21.8%) were accurate. Conclusions: We found that for patients with terminal cancer, it is difficult for physicians to accurately predict prognosis. These findings support the importance of ASCO guidelines pertaining to patient access to palliative care during the entirety of cancer treatment for all patients with metastatic cancer. [Table: see text]

Potential new approaches to the management of the Hb Bart's hydrops fetalis syndrome: the most severe form of α-thalassemia.

The α-thalassemia trait, associated with deletions removing both α-globin genes from 1 chromosome (genotype ζ αα/ζ--), is common throughout Southeast Asia. Consequently, many pregnancies in couples of Southeast Asian origin carry a 1 in 4 risk of producing a fetus inheriting no functional α-globin genes (ζ--/ζ--), leading to hemoglobin (Hb) Bart's hydrops fetalis syndrome (BHFS). Expression of the embryonic α-globin genes (ζ-globin) is normally limited to the early stages of primitive erythropoiesis, and so when the ζ-globin genes are silenced, at ∼6 weeks of gestation, there should be no α-like globin chains to pair with the fetal γ-globin chains of Hb, which consequently form nonfunctional tetramers (γ4) known as Hb Bart's. When deletions leave the ζ-globin gene intact, a low level of ζ-globin gene expression continues in definitive erythroid cells, producing small amounts of Hb Portland (ζ2γ2), a functional form of Hb that allows the fetus to survive up to the second or third trimester. Untreated, all affected individuals die at these stages of development. Prevention is therefore of paramount importance. With improvements in early diagnosis, intrauterine transfusion, and advanced perinatal care, there are now a small number of individuals with BHFS who have survived, with variable outcomes. A deeper understanding of the mechanism underlying the switch from ζ- to α-globin expression could enable persistence or reactivation of embryonic globin synthesis in definitive cells, thereby providing new therapeutic options for such patients.

Using Best Practice Advisory alert to increase early advanced care planning discussion and palliative care referral in advanced cancer patients.

320 Background: Patients with advanced cancer can benefit from early initiation of palliative care (PC) and advanced care planning (ACP). In theory, the Medical Order for Life-Sustaining Treatments (MOLST), which provides a vehicle for end-of-life discussion, could lead to improved uptake of ACP and PC. In order for MOLST forms to influence these care process outcomes, methods are needed to help clinicians introduce the forms to patients in a compassionate manner. The objective of this study is to develop a best practice advisory (BPA) alert in the electronic medical record (EMR) to help oncologists identify appropriate patients for ACP and PC referral and evaluate its impact on improving MOLST form and palliative referral order documentation in EMR for these patients. Methods: BPA alert criteria included Lung and GI cancer patients with stage IV disease or undergoing treatment with palliative intent. The oncologists could act on the alert by either acknowledging it with action statement (I have already discussed ACP, I intend to discuss ACP in this or next visit, Patient unlikely to die in next 12 months, other) or dismiss it. We examined the rates of MOLST form and PC referral orders in the EMR 12-months before and after the BPA was implemented in 03/2018. Results: The BPA fired in 424 patients who met the criteria over a period of 9 weeks. It was acknowledged in 409 and cancelled in 15 patients. Following the alert, 40 (9%) patients had a MOLST form added to the chart compared to only 9 (2%) patients before the alert and 17 (4%) patients had palliative care referral order placed vs. 10 (2%) patients before the alert. Physicians acknowledged discussing ACP in 145 patients, most of whom (25/30) initiated these conversations after the BPA was implemented. Data collection is ongoing to capture BPA effect for longer follow-up. Conclusions: The BPA alert intervention resulted in significant increase in documentation of ACP and palliative referral order suggesting the potential of this tool in improving adherence to national guidelines calling for early initiation of palliative care and advance care planning in patients with advanced cancers.

Implementation and adoption of advanced care planning in the elderly trauma patient

BackgroundGeriatric trauma has high morbidity and mortality, often requiring extensive hospital stays and interventions. The number of geriatric trauma patients is also increasing significantly and accounts for a large proportion of trauma care. Specific geriatric trauma protocols exist to improve care for this complex patient population, who often have various comorbidities, pre-existing medications, and extensive injury within a trauma perspective. These guidelines for geriatric trauma care often suggest early advanced care planning (ACP) discussions and documentation to guide patient and family-centered care.MethodsA provincial ACP program was implemented in April of 2012, which has since been used by our level 1 trauma center. We applied a before and after study design to assess the documentation of goals of care in elderly trauma patients following implementation of the standardized provincial ACP tool on April 1, 2012.ResultsDocumentation of ACP in elderly major trauma patients following the implementation of this tool increased significantly from 16 to 35%. Additionally, secondary outcomes demonstrated that many more patients received goals of care documentation within 24 h of admission, and 93% of patients had goals of care documented prior to intensive care unit (ICU) admission. The number of trauma patients that were admitted to the ICU also decreased from 17 to 5%.ConclusionEarly advanced care planning is crucial for geriatric trauma patients to improve patient and family-centered care. Here, we have outlined our approach with modest improvements in goals of care documentation for our geriatric population at a level 1 trauma center. We also outline the benefits and drawbacks of this approach and identify the areas for improvement to support improved patient-centered care for the injured geriatric patient. Here, we have provided a framework for others to implement and further develop.

Barriers in treating patients with acute coronary syndrome in Indonesia Primary Health Care: A phenomenological study

Introduction: Acute Coronary Syndrome (ACS) is the leading cause of mortality in the world. Primary prevention strategy focuses on reducing the risk of disease spread. At the same time, curative strategy aims at reducing the risk of disability and mortality. Initial therapy should be considering early stabilization and immediate advanced care to reduce the risk of complication. Therefore, it is important to improve guidelines, the medical referral system, and family consent procedure to save patients with ACS. Aim: This research aimed at exploring the barriers faced by nurses in treating patients with ACS in Primary Health Care (PHC). Method: This research employed a qualitative research method using descriptive phenomenology.This study involving 16 subjects of nurses working in PHC with indepth interview . The data analysis procedure proposed by Clark and Brown 2013. Result: Three main themes were pointed out by 16 participants; 1) Update Guidlines, 2) Inefficient referral process to other health centers, 3) Consent making process by the family. Dicussion: Barriers in performing health care for patients with ACS in the emergency unit of PHC needs updating guidline to be enhanced by engaging the advancement of technology and communication using electronic medical record system, family education, and fulfillment of better medical facilities to make the process more efficient. At the same time, also improves the management service for patients with ACS and making it possible for PHC to provide reliable health care as the first health care provider for the society. Keywords: Barriers to care, Health Care Referral, Acute Coronary Syndrome, Emergency Nursing, Primary Health Care

Factors associated with advanced cardiac care in prehospital chest pain patients

IntroductionMany patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG. MethodsWe performed a retrospective analysis of all adult patients, reporting atraumatic chest pain from a single EMS agency, presenting to a single, urban hospital over a 10-year period. Patients with STEMI on prehospital electrocardiogram were excluded. Patient demographics, chest pain characteristics and prehospital factors were abstracted for all patients. We identified those patients that required advanced cardiac care and performed regression analysis to determine associated factors. ResultsA total of 956 charts were analyzed. Of this total, 193 patients (20.2%) met the primary composite outcome. Of the outcome group, 185 patients (95.9%) had coronary artery disease documented on cardiac catheterization, 22 patients (11.4%) underwent CABG, and seven patients (3.6%) died in the hospital. Most significant variables (multivariable IRR) included age (1.02), male gender (1.65), history of MI (1.47), PCI (1.66), hyperlipidemia (1.40), diaphoresis (1.51), home aspirin (1.53), and improvement with EMS treatment (1.60). ConclusionWe have identified several factors that could be considered when risk stratifying prehospital patients reporting chest pain. While potentially predictive, the factors are broad and support the need for other objective factors that could augment prediction of patients who may benefit from early advanced cardiac care.

What gives your life meaning (WGYLM)? Strategies to encourage advanced care planning.

8 Background: Conversations regarding healthcare decisions are central to patient-and-family-centered care. Early and regular advanced care planning (ACP) conversations benefit the patient, family, multidisciplinary team, and healthcare system. Initiatives targeting employee’s participation in their own ACP may extend to improvement in patients’ ACP utilization. Methods: A social experiment entitled, “What gives your life meaning” (WGYLM?) initially developed at California State University, San Marcos to increase student’s awareness of ACP was adapted to focus health system’s employees’ attention on ACP over the course of a 3-month campaign that culminated during National Healthcare Decisions week. Results: 55 volunteers were involved in the campaign. Over 10,000 workstation screensavers displayed campaign slogans. A system-wide newsletter with 12,500 subscribers included a campaign write-up. The local newspaper featured a front-page color article. Almost 1,700 post-its with comments of what gives their life meaning were collected. More than 1500 ACP packets with ACP resources were distributed with over 1200 people signing a pledge to have an ACP discussion with a loved one within 30 days. Of the 664-successful follow-up email sent to pledge participants: 77 (12%) of respondents responded to the survey; 44% were nurses, and 12% were physicians; 41% reported already having an AD in place, while 21% did not currently have a designated person to make healthcare decisions on their behalf; 66 (85%) reported talking with someone about what gives their own life meaning. Of these, 51% reported it was their spouse they spoke with and 34% reported it was a coworker; 5% created an AD, and 8% edited an AD since the campaign; 73% agreed it helped them think about ACP in a less scary way; 83% agreed it increased their interest in thinking about future healthcare preferences; and 79% agreed it motivated them to talk about healthcare they would want to receive at EOL with a loved one. Conclusions: ACP conversations can be used to prepare anyone regardless of age, sex, culture, or disease. Asking heath care providers, “What gives your life meaning” may familiarize them with the process of ACP and emboldened them to encourage patients to have these same crucial conversations.

The Model of Advanced Care Planning in Catalonia (Spain)

Background: Care models for advanced chronic patients present two key aspects: early identification and advanced care planning (ACP). In 2014, Catalonia arranged the ACP Model (ACPM), addressed to chronic patient’s complex needs, into a public health-social system (HSS).Aims: Describe the implementation process (IP) of an ACPM.Methods: A core group of professionals (n=55) was convened to develop the ACPM with the co-participation of patients, caregivers, social agents and healthy persons. Inclusion criteria included: solid professional trajectory, equal representation as for territory and professional profile.Four work levels were defined: conceptual document (CD) and implementation guide (IG) elaboration; training program (ITP) development; building-up of patients, professionals and healthy persons discussion groups (DG).The CD and IG were written with the agreement of expert professionals in legislation, ethics, medical specialities, nursing, anthropology, social work and psychology. The ITP is being created, as a key aspect of the IP.Results: CD and IG have been published. Simultaneously, DGs are established so as to make the CD a work product of high quality. The ITP is currently being developed, based on CD and IG contents. These documents have been reviewed by around 100 professionals from the Catalan HSS.The ITP contents focus on communication skills; legal and ethical aspects; patient and family needs.Discussion: ACP is a challenge for the model of care towards advanced chronic patients.Conclusions: ACP is a challenge for the model of care towards advanced chronic patients. The Catalan Model of ACP establishes the conceptual and pragmatic foundations of ACP and develops the training of the professionals daily taking care of such type of patients.