In-hospital Palliative Care Research Articles

Health-related quality of life predicts prognosis in individuals with COPD hospitalized with community-acquired pneumonia – a prospective cohort study

Community-acquired pneumonia (CAP) in chronic obstructive pulmonary disease (COPD) often result in sudden and persistent reduction in health-related quality of life (HRQoL), which may be alleviated with palliative care. Among individuals with COPD, we aimed to investigate potential associations between HRQoL at admission with CAP and the risk of re-hospitalization and mortality and potential associations between specific HRQoL domains and CAP treatment outcomes. HRQoL was assessed at admission and the participants were grouped into tertiles based on the HRQoL utility index and specific domains. The results revealed that participants in the middle and highest tertiles of HRQoL had a lower 90-day re-hospitalization risk compared to those in the lowest tertile, whereas no differences in re-hospitalization risk were observed 30 and 180 days after discharge. Almost one in four had severe pain or discomfort at admission and the domain pain or discomfort emerged as a predictor of re-hospitalization. In addition, participants in the middle and highest tertiles had lower risk of 180-day mortality compared to those in the lowest, while no differences were observed in 30-day or 90-day mortality risk. An increased focus on in-hospital palliative care could alleviate the pain and discomfort reported by many participants with potential to reduce re-hospitalization rates.

Evaluating Outcomes for Women with Metastatic Breast Cancer: Palliative Care Consultations, Hospital Charges, and Length of Stay.

Introduction: Women with late-stage metastatic breast cancer are at an increased risk of pain and distress from symptoms and often struggle with associated emotional and financial burden of their disease. Palliative care is known to alleviate symptom burden in patients with end-stage, terminal diseases but is often underutilized in both inpatient and outpatient settings. The current study aims to investigate the prevalence of palliative care consultation on inpatients with metastatic breast cancer and examine the association between palliative care consultation and length of hospital stay and total hospital charges. Methods: Patients diagnosed with metastatic breast cancer between 1998-2017 were abstracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Database (NIS). The primary outcome was the presence of a palliative care consultation (PCC) during the inpatient stay. Secondary outcomes were hospital length of stay and total hospital charges. Multivariable logistic regression was used to examine factors associated with the presence of a PCC. The relationship between PCC and hospital length of stay and total hospital charges were investigated using linear regression. Results: 513,509 cases of metastatic breast cancer were identified, 5.7% had a documented in-hospital palliative care encounter. Of those who received PCC, total hospital charges were about USD 5452 less than those who did not receive consultation. Women who received PCC had higher odds of a longer hospital stay. Predictors of PCC were older age, non-White race, and residing in a lower-income ZIP code. Conclusions: Palliative care remains to be an underutilized resource among patients with end-stage metastatic breast cancer.

In-Hospital vs 30-Day Sepsis Mortality at US Safety-Net and Non–Safety-Net Hospitals

In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Prior studies have reported higher in-hospital mortality among patients with sepsis at safety-net hospitals compared with non-safety-net hospitals; however, in critically ill patients, in-hospital mortality rates are known to be associated with hospital discharge practices, which may differ between safety-net hospitals and non-safety-net hospitals. To assess how admission to safety-net hospitals is associated with 2 metrics of short-term mortality (in-hospital mortality and 30-day mortality) and discharge practices among patients with sepsis. Retrospective, national cohort study of Medicare fee-for-service beneficiaries aged 66 years and older, admitted with sepsis to an intensive care unit from January 2011 to December 2019 based on information from the Medicare Provider Analysis and Review File. Data were analyzed from October 2022 to September 2023. Admission to a safety-net hospital (hospitals with a Medicare disproportionate share index in the top quartile per US region). Coprimary outcomes: in-hospital mortality and 30-day mortality. Secondary outcomes: (1) in-hospital do-not-resuscitate orders, (2) in-hospital palliative care delivery, (3) discharge to a postacute facility (skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital), and (4) discharge to hospice. Between 2011 and 2019, 2 551 743 patients with sepsis (mean [SD] age, 78.8 [8.2] years; 1 324 109 [51.9%] female; 262 496 [10.3%] Black, 2 137 493 [83.8%] White, and 151 754 [5.9%] other) were admitted to 666 safety-net hospitals and 1924 non-safety-net hospitals. Admission to safety-net hospitals was associated with higher in-hospital mortality (odds ratio [OR], 1.09; 95% CI, 1.06-1.13) but not 30-day mortality (OR, 1.01; 95% CI, 0.99-1.04). Admission to safety-net hospitals was associated with lower do-not-resuscitate rates (OR, 0.86; 95% CI, 0.81-0.91), palliative care delivery rates (OR, 0.66; 95% CI, 0.60-0.73), and hospice discharge (OR, 0.82; 95% CI, 0.78-0.87) but not with discharge to postacute facilities (OR, 0.98; 95% CI, 0.95-1.01). In this cohort study, among patients with sepsis, admission to safety-net hospitals was associated with higher in-hospital mortality but not with 30-day mortality. Differences in in-hospital mortality may partially be explained by greater use of hospice at non-safety-net hospitals, which shifts attribution of death from the index hospitalization to hospice. Future investigations and publicly reported quality measures should consider time-delimited rather than hospital-delimited measures of short-term mortality to avoid undue penalty to safety-net hospitals with similar short-term mortality.

A multicentre survey on the perception of palliative care among health professionals working in haematology

PurposePatients with haematologic malignancies have less access to palliative care and are referred later than patients with solid tumours. We developed a survey to investigate this phenomenon, with the intention of analysing palliative care perceptions among health professionals who treat haematology patients and identifying barriers and facilitators to referrals to palliative care services.MethodsThis was a multicentre exploratory descriptive web-based survey. A questionnaire was administered to 320 medical and nursing staff members from five Italian haematological units and San Marino’s hospital to investigate their perception of palliative care. Quantitative and qualitative analyses were performed.ResultsA total of 142/320 healthcare professionals completed the survey, achieving a 44% response rate. Most of the respondents supported the integration of haematology and palliative care and were aware of the role of palliative care. Despite this, only half had an in-hospital palliative care team, and only a few had previously attended a specific training course. The majority agreed with palliative care referral when the prognosis was less than 3 months or when the symptoms were incoercible and with blood transfusions even in the last stages of the disease. Many considered the presence of an in-hospital palliative care team or a case manager, as well as structured palliative care training, as fundamental facilitators of palliative care referrals.ConclusionThese results showed that healthcare professionals in haematology generally hold a favourable attitude and a high interest in integrating palliative care into their patients’ care. The low referral rate could depend on clinical, cultural, and organisational issues.

Embracing family presence: exploring the reasons for family decision-making dependence on in-hospital palliative care for cancer patients

The implementation of home-based palliative care is widely recognized as a commendable and effective model of care provision. However, it is noteworthy that families residing in Indonesia exhibit a propensity to predominantly seek palliative care services within hospital environments for their family members afflicted with palliative-stage cancer. Therefore, the aim of this research was to investigate the perceptions of family members in their decision-making process regarding the care of palliative-stage cancer patients at home. This qualitative study employed a descriptive phenomenological approach. Data were obtained through in-depth interviews with ten Indonesian family members of palliative-stage cancer patients refusing discharge, and were analyzed using the Colaizzi method. Furthermore, the inclusion criteria were that the dominant family member who cares for the patient lives with the patient and is involved in the decision-making process. Two themes emerged from this study: i) a lack of support in decision-making, and ii) pain and chronic sorrow. Home-based palliative care for cancer patients presents significant decision-making challenges and persistent grief for families, necessitating robust support and education from healthcare professionals such as nurses and policymakers. Additionally, a national health insurance system that enables effective palliative care is crucial.

Feasibility of a physical exercise intervention for patients on a palliative care unit: a critical analysis

BackgroundRecent exercise intervention studies have shown promising results in improving quality of life (QoL) and physical function (PF) in diverse chronic disease and advanced cancer patients. However, the effects of structured exercise in palliative care patients, having different therapeutic needs, lower life expectancies and PFs remain unknown. This study primarily aimed to assess the feasibility of an exercise intervention with follow-up by analysing recruitment numbers, screening procedures, acceptability, preferences, and safety of the exercise intervention as well as retention in follow-up. Our secondary aims related to changes in QoL and PF.MethodsThis study comprised of a one-arm design without a control group. Over 6 months, every in-hospital palliative care unit (PCU) patient was screened for eligibility. Eligible patients were asked to participate in a 2-week exercise intervention consisting of resistance training and/or endurance training with moderate or high intensity based on personal preferences and a 4-week follow-up. Before and after the exercise intervention, QoL and PF were assessed and a qualitative interview after the intervention addressed expectations and experiences of the exercise intervention. For follow-up, patients were provided with information on independent training and after 1 and 4 weeks a QoL assessment and qualitative interview were conducted.ResultsOf 124 patients screened, 10 completed the intervention with an adherence rate of (80 ± 25%), of which 6 patients completed follow-up. Endurance training was the most performed training type and only a few minor adverse events occurred in certain or likely connection to the exercise intervention. While physical QoL and PF measured by arm curl strength and time up and go performance improved, mental QoL and the other PF tests remained unchanged.ConclusionDespite the challenges that were faced in our screening and testing process, that are specific to the palliative patient population with their unique therapeutic requirements and varying mental-/ physical capabilities, we discovered the 2-week exercise intervention to be feasible, safe, and well tolerated by palliative care patients. Moreover, it seems that short-term improvements in QoL and PF are possible. Further full scale studies are required to confirm our findings.Trial registrationThe study was retrospectively registered on 25.01.2022 in the German Clinical Trials Register (DRKS00027861)

Association of patient sex with use of palliative care in Ontario, Canada: a population-based study.

It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use. We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient-physician sex concordance. There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69-87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08-1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14-1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17-1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19-1.21) to have had a male referring physician. After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.

More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study

BackgroundTo improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway.MethodsWe conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands.ResultsThe palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84–5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49–6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation.ConclusionsThe pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.

The perspectives of in-hospital healthcare professionals on the timing and collaboration in advance care planning: A survey study

BackgroundHospital admissions are common in the last phase of life. However, palliative care and advance care planning (ACP) are provided late or not at all during hospital admission. AimTo provide insight into the perceptions of in-hospital healthcare professionals concerning current and ideal practice and roles of in-hospital palliative care and advance care planning. MethodsAn electronic cross-sectional survey was send 398 in-hospital healthcare professionals in five hospitals in the Netherlands. The survey contained 48 items on perceptions of palliative care and ACP. ResultsWe included non-specialists who completed the questions of interest, resulting in analysis of 96 questionnaires. Most respondents were nurses (74%). We found that current practice for initiating palliative care and ACP was different to what is considered ideal practice. Ideally, ACP should be initiated for almost every patient for whom no treatment options are available (96.2%), and in case of progression and severe symptoms (94.2%). The largest differences between current and ideal practice were found for patients with functional decline (Current 15.2% versus Ideal 78.5%), and patients with an estimated life expectancy <1 year (Current 32.6% versus ideal 86.1%). Respondents noted that providing palliative care requires collaboration, however, especially nurses noted barriers like a lack of inter-professional consensus. ConclusionsThe differences between current and ideal practice demonstrate that healthcare professionals are willing to improve palliative care. To do this, nurses need to increase their voice, a shared vision of palliative care and recognition of the added value of working together is needed.

Obstacles in the Practice of Palliative Care Consultation Services in Grade A Tertiary Hospitals

Objective To explore the obstacles in palliative care consultation services and put forward the suggestions for improving the services in grade A tertiary hospitals. Methods A semi-structured interview was conducted with 17 medical workers who had requested palliative care consultation services in Peking Union Medical College Hospital. Results The palliative care consultation services were hindered by five obstacle factors including insufficient knowledge of patients and their families about palliative care,unsound understanding of medical workers about palliative care,poor implementation of consultation opinions,limited labor of palliative care team,and poor economic benefits from palliative care.In view of such obstacles,the following suggestions were put forward,which included increasing the acceptance of palliative care by patients and their families,enriching the knowledge of medical staff on palliative care,establishing a new cooperation model between consultation team and medical staff,strengthening the institutional guarantee for the development of palliative care,and establishing and perfecting the laws and policies related to palliative care. Conclusion Although there are many difficulties in the in-hospital palliative care consultation services in grade A tertiary hospitals,the demand and expectation of medical staff for palliative care are still increasing.

P09.07.A Signs and Symptoms in the last days of life of the glioblastoma patients - A Descriptive and Retrospective Study

Abstract Background Despite scientific advances to develop techniques for early diagnosis and treatment of glioblastoma, the disease continues to have a remarkably poor prognosis. Studies have shown that in patients with glioblastoma, not only the presence of end-of-life signs and symptoms but also their frequency differs from those in the rest of cancer patients. The complexity of glioblastoma symptoms makes the integration of a palliative care philosophy essential. Objective To identify the main signs and symptoms that occur in patients with glioblastoma in their last seven days of life in a neuro-oncology ward. Material and Methods This was a descriptive and retrospective study regarding the signs and symptoms in the last seven days of life of patients with glioblastoma who were admitted to the neurology ward of a national oncology reference center. The patients were admitted after neuro-oncologist consultations between 2019 and 2020. The data collection instrument used was based on the document “The Last Hours of Living”. Confidentiality of the participants was guaranteed, and authorization was obtained from the institution’s ethics committee. Results The sample had 17 patients (13 men and 4 women), with an average hospital stay of 17.3 days. The men and women had average ages of 61.8 and 63 years, respectively. Clinical and nursing records revealed that the most prevalent signs and symptoms were “decreased level of consciousness” (94%); “rare and unexpected events” (94%); “respiratory dysfunction” (88%); and “loss of ability to swallow” (76%). In the last seven days of life, the approximate times of presentation for these signs and symptoms were: decreased level of consciousness, 6 days; rare and unexpected events, 2 days; respiratory dysfunction, 3 days; and loss of ability to swallow, 6 days. Support was requested from the in-hospital palliative care support team for 76.4% of patients. Conclusion The identification of reduced level of consciousness and alterations in swallowing as the most prevalent symptoms is consistent with the findings of previous studies. The prevalence of rare and unexpected events (such as fever, myoclonus and seizures) aligns with previous studies that indicated a difference in the signs and symptoms presented by patients with glioblastoma in the last days of life and patients with other oncological diseases. In this sense, the instrument used for data collection may not be the most appropriate for the population with primary central nervous system tumors. The decreased level of consciousness and impaired communication can complicate the assessment of signs and symptoms, such as pain, nausea, anxiety and depression. It is essential to conduct research studies with more representative samples. The recording of the signs and symptoms presented, as well as interventions and the evaluation of their effectiveness, are essential to ensure the quality of end-of-life.

Integration of Specialist Palliative Care into Tertiary Hospitals: A Multicenter Point Prevalence Survey from Thailand.

Background: Accessibility and quality of hospital-based palliative care in Thailand have received scant attention.Objective: To determine the prevalence of inpatients who require in-hospital palliative care, to identify the proportion with access to specialist palliative care, and to define the factors associated with accessibility to specialist palliative care.Design: A cross-sectional analysis of a multicenter survey.Setting/Subjects: We surveyed all hospitalized patients from Thailand's four regions admitted to 14 tertiary care hospitals.Measurements: We used the Supportive and Palliative Care Indicators Tool to identify palliative care patients then reviewed their medical records. We categorized hospitalized palliative care patients into a palliative care consultation group and a nonconsultation group. The odds ratio (OR) between patient characteristics and patient groups was estimated using binary logistic regression.Results: One-fifth (18.7%) of hospitalized patients were palliative care patients, whereas only 17.3% received a specialist palliative care consult. Of these, one-third (28.4%) received advance care planning (ACP) documentation. One-quarter of patients in pain were not prescribed analgesics. The logistic regression analysis revealed that palliative care consultations were associated with patients >65 years (OR = 1.830, 95% confidence interval [CI]: 1.122−2.987), a cancer diagnosis (OR = 2.640, 95% CI: 1.478−4.718), strong opioids prescription (OR = 5.519, 95% CI: 3.217−9.469), and ACP documentation (OR = 50.149, 95% CI: 28.239−89.059).Conclusions: The prevalence of hospitalized palliative care patients in Thailand is comparable with that in developed countries; however, accessibility remains a significant gap, as specialist palliative care is associated with the quality of palliative care service.

Decision-Making by Emergency Medicine Personnel in Prehospital Treatment of Patients Receiving Palliative Care: A Questionnaire, Comparative Cohort Study.

ObjectivePalliative care is an approach to improve quality of life in patients with life-limiting diseases. The sudden nature of such conditions involves emergency providers as the first responders, who have roles in delivering appropriate care to meet patients’ needs. In this study, we evaluated whether previous experience in palliative care among paramedic students could affect their decision-making skills in prehospital work.MethodsThis questionnaire-based prospective cross-sectional study was conducted from October 2019 to November 2020. We compared two groups of paramedic students in a tertiary hospital in Bangkok, Thailand. The class of 2019 did not attend palliative care courses and the class of 2020 completed a 2-week course regarding in-hospital palliative care services. Questionnaires including rating scales and checklists and involving cases with and without malignancy were completed via a web-based data collection form. The reliability of the questionnaire was tested. Decision-making skills were categorized into seven domains comprising life-sustaining treatment, withholding or withdrawing life-sustaining treatment, advance care planning, self-autonomy, decision-making capacity and surrogate decision-makers, prehospital dyspnea management, and communication skills.ResultsAmong 57 paramedics, 52 (91%) completed the questionnaire. There was no significant difference in decision-making between the two groups in all seven domains (p>0.050). Overall, participants more often recognized patients who were eligible for palliative care and made more decisions to withhold or withdraw life-sustaining treatment when patients had advanced malignancy than in cases of non-malignancy (100% and 84.6% respectively, p=0.006).ConclusionOur findings showed that the decision-making process for patients regarding prehospital palliative care was not significantly different between two groups of emergency personnel with and without in-hospital palliative care experience.

Verification of administrative data to measure palliative care at terminal hospital stays.

Administrative data and clinician documentation have not been directly compared for reporting palliative care, despite concerns about under-reporting. The aim of this study was to verify the use of routinely collected administrative data for reporting in-hospital palliation and to examine factors associated with coded palliative care in hospital administrative data. Hospital administrative data and inpatient palliative care activity documented in medical records were compared for patients dying in hospital between 1 July 2017 and 31 December 2017. Coding of palliative care in administrative data is based on hospital care type coded as "palliative care" and/or assignment of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) palliative care diagnosis code Z51.5. Medical records were searched for specified keywords, which, read in context, indicated a palliative approach to care. The list of keywords (palliative, end of life, comfort care, cease observations, crisis medications, comfort medications, syringe driver, pain or symptom management, no cardiopulmonary resuscitation, advance medical plan/resuscitation plan, deteriorating, agitation, restless and delirium) was developed in consultation with seven local clinicians specialising in palliative care or geriatric medicine. Of the 576 patients who died in hospital, 246 were coded as having received palliative care, either solely by the ICD-10-AM diagnosis code Z51.5 (42%) or in combination with a "palliative care" care type (58%). Just over one-third of dying patients had a palliative care specialist involved in their hospital care. Involvement of a palliative care specialist and a cancer diagnosis substantially increased the odds of a Z51.5 code (odds ratio = 11 and 4, respectively). The majority of patients with a "syringe driver" or identified as being at the "end of life" were assigned a Z51.5 code (73.5% and 70.5%, respectively), compared to 53.8% and 54.7%, respectively, for "palliative" or "comfort care." For each keyword indicating a palliative approach to care, the Z51.5 code was more likely to be assigned if the patient had specialist palliative care input or if they had cancer. Our results suggest administrative data under-represented in-hospital palliative care, at least partly due to medical record documentation that failed to meet ICD-10-AM coding criteria. Collaboration between clinicians and coders can enhance the quality of records and, consequently, administrative data.

Inequalities in end-of-life palliative care by country of birth in New South Wales, Australia: a cohort study.

Objective This study investigated variation in in-hospital palliative care according to the decedent's country of birth. Methods A retrospective cohort study was performed of 73469 patients who died in a New South Wales public hospital between July 2010 and June 2015 and were diagnosed with a palliative care-amenable condition. Differences in receipt of palliative care by country of birth were examined using multilevel logistic regression models adjusted for confounding. Results In this cohort, 26444 decedents received palliative care during their last hospital stay. In the adjusted analysis, 40% rate differences (median odds ratio 1.39; 95% confidence interval 1.31-1.51) were observed in receipt of palliative care between country of birth groups. Conclusions There are differences in in-hospital palliative care at the end of life between population groups born in different countries living in Australia. The implementation of culturally sensitive palliative care programs may help reduce these inequalities. Further studies are needed to identify the determinants of the differences observed in this study and to investigate whether these differences persist in the community setting. What is known about the topic? International studies have reported inequities in access to palliative care between ethnic groups. What does this paper add? We observed differences in in-hospital palliative care between decedents from different countries of birth in New South Wales, Australia. These differences remained after adjusting for individual, area and hospital characteristics. What are the implications for practitioners? Implementation of culturally sensitive palliative care services and targeting groups with low rates of palliative care can reduce these inequalities and improve a patient's quality of life.

Palliative Care Consultation Reduces 30-Day Readmission Rates for Hospitalized Patients with End-Stage Chronic Obstructive Pulmonary Disease (FR440C)

•List the rates and causes for hospital readmission in patients with end-stage chronic obstructive disease, with and without palliative care services.•Provide the outcomes in end-stage chronic obstructive disease patients, with and without palliative care consultation. End-stage chronic obstructive disease (COPD) has a high level of symptom burden, requirement for long-term oxygen therapy and frequent exacerbations that require hospitalization. Research to date is limited regarding the delivery and impact of palliative care services in patients with end-stage COPD. Determine the relationship between in-hospital palliative consultation on hospital readmission in patients with end-stage COPD in the United States. A retrospective study was conducted using the AHRQ-HCUP Nationwide Readmission Database for 2014. Adults (≥ 18 years) with a diagnosis of end-stage COPD that received an in-hospital palliative consultation were identified using ICD-9 codes described in literature. The primary outcome was rate of readmission within 30-days of discharge. Secondary outcomes were reasons for readmission, and mortality and morbidity rates. Propensity score (PS) using the next neighbor method without replacement with 1:1 matching was utilized to adjust for confounders. Independent risk factors for readmission were identified using Cox's proportional hazards model. In total, 233,184 hospital admissions with a diagnosis of end-stage COPD were identified, of which 6.87% (16,038) received in-hospital palliative care consultation. PS matching was performed based on age, gender, hospital status, and Charlson comorbidity score. The overall 30-day rate of readmission in patients with end-stage COPD was 16.9%. Palliative care consultation was an independent predictor associated with a lower risk of readmission (Hazard Ratio 0.521, CI 0.398-0.682, p <0.001). The most common cause for readmission was sepsis (8.46%), followed by COPD (7.29%). Those readmitted had a significantly higher rate of death in hospital than those for index admissions (8.44% vs 5.52 %, p < 0.001). In-hospital palliative care consultation in patients with end-stage COPD reduces hospital readmission.

What Do We Do After the Pilot Is Done? Implementation of a Hospital Early Warning System at Scale

Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals. How can one deploy an RRS using an automated EWS at scale? EWS displays were removed from frontline clinicians' hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards. The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care.

516 The Impact of In-Hospital Palliative Unit on Percutaneous Gastrostomy Practice, Volume, and Outcomes

INTRODUCTION: Per-cutaneous gastrostomy (PEG) is often preferred for enteral feeding of patients with terminal and critical illness. Implementation of the palliative care often avoids the futile procedures in patients with short life expectancy. Inpatient palliative units have the potential to reduce placement of PEG in terminally ill patients. METHODS: In retrospective review, we analyzed all patients who underwent PEG from 2006 to 2015. The research protocol was approved by Institutional Review Board at our institution. The study population was divided into two groups based on the establishment of in-hospital palliative care unit at our institution in August of 2010. The demographic data including age, gender and ethnicity were reviewed. Endoscopy reports and patient charts were reviewed for the indication of PEG and post-procedural complications. The categorical variables were analyzed with chi-square and continues variable with student t-test. The annual procedural number were extrapolated from our endoscopy EMR. RESULTS: There were 780 PEGS placed on 721 unique patients from 2006 to 2015. Majority of them (62% n = 483) were placed before establishment of in-hospital palliative care unit (August 2010) and the remaining (38% n = 297) were done after Aug 2010. There was no significant difference in total number of hospitalizations or discharges during the study period. After implementation of palliative unit, number of PEGS decreased from 97/year to 52/year (Figure 2). The mean age of patient undergoing PEG was 69 years in both group. There was slight females preponderance (53% vs 50%). African American patients were predominant in both groups. Establishment of in-house palliative care unit led to statically significant decrease (34% to 7%) in number of Hispanic patients and an increase in white Caucasian (from 9% to 42%) undergoing PEGs (Figure 1). There was substantial change noted in the indication of the PEG (Figure 3) after inpatient palliative care unit services, with the predominant decrease for the PEG requirement in patients with dementia (from 42.9% to 24%, P-value &lt; 0.001). There was a statistically significant decrease in the overall mortality (23.3% to 7.4%) and 30-day mortality (9.7% to 4%) for patients undergoing PEGS after the initiation of the palliative unit. However, overall PEG related complications were unaltered. CONCLUSION: The in-house palliative care units impact practice of PEG placement by decreasing procedural volume, lower overall and 30-day mortality after PEG placement.

Variations in hospital inpatient palliative care service use: a retrospective cohort study.

Use of palliative care in hospitals for people at end of life varies. We examined rate and time of in-hospital palliative care use and associated interhospital variations. We used admissions from all hospitals in New South Wales, Australia, within a 12-month period, for a cohort of adults who died in 73 public acute care hospitals between July 2010 and June 2014. Receiving palliative care and its timing were based on recorded use. Among 90 696 adults who died, 27% received palliative care, and the care was initiated 7.6 days (mean; SD: 3.3 days) before death. Over the 5-year period, the palliative care rate rose by 58%, varying extent across chronic conditions. The duration of palliative care before death declined by 7%. Patient (demographics, morbidities and service use) and hospital factors (size, location and availability of palliative care unit) explained half of the interhospital variation in outcomes: adjusted IQR in rate and duration of palliative care among hospitals were 23%-39% and 5.2-8.7 days, respectively. Hospitals with higher rates often initiated palliative care earlier (correlation: 0.39; p<0.01). Despite an increase over time in the palliative care rate, its initiation was late and of brief duration. Palliative care use was associated with patient and hospital characteristics; however, half of the between hospital variation remained unexplained. The observed suboptimal practices and variability indicate the need for expanded and standardised use of palliative care supported by assessment tools, service enhancement and protocols.

Palliative Care in Stroke Patients: Five Years Retrospective Study of Stroke Patients to whom In-Hospital Palliative Care and Support Team Evaluation was Requested

Palliative Care in Stroke Patients: Five Years Retrospective Study of Stroke Patients to whom In-Hospital Palliative Care and Support Team Evaluation was Requested