Inpatient Palliative Care Program Research Articles

Systemic inflammatory markers may predict survival in advanced cancer patients admitted to an acute palliative care unit.

134 Background: The Acute Palliative Care Unit (APCU) is an inpatient palliative care program that provides intensive symptom management and facilitates the transition from hospital discharge to hospice. Often patients are admitted to the APCU very late at the end of their disease trajectory. The purpose of this study was to investigate whether systemic inflammatory markers can predict remaining survival in these patients. Methods: Advanced cancer patients admitted to the APCU at a tertiary cancer center in Korea between April 2015 and March 2016 were included in this retrospective study. Of the 405 consecutive APCU admissions during this time period, there were 312 individual patients. Within this cohort, 267 patients were eligible for this study. Systemic inflammatory markers including albumin level, neutrophil to lymphocyte ratio (NLR), and Advanced Lung cancer Inflammation index (ALI = BMI x Albumin / NLR) were analyzed. Results: Of the 267 patients analyzed, the median age of patients was 66 (range, 23-97), and 45% were female. Primary cancer types were lung cancer (21%), gastric cancer (17%), colorectal cancer (15%), and pancreatobiliary cancer (14%). Overall survival after admission to the APCU was 21 days. Patients with low albumin level ( < 3.3g/dL) showed shorter survival compared with those with normal albumin level (16 days vs 32 days, hazard ratio [HR] 1.79, 95% CI 1.37-2.33, P < 0.001). Median NLR was 8.7, and patients with high NLR (≥8.7) exhibited poorer survival (HR 1.32, 95% CI 1.03-1.68, P = 0.028). Patients with low ALI ( < 18) had poor prognosis compared with those with high ALI (≥18) (HR 1.54, 95% CI 1.15-2.08, P = 0.004). Conclusions: Low albumin level ( < 3.3), high NLR (≥8.7), and low ALI ( < 18) may indicate poor prognosis in advanced cancer patients admitted to the APCU. A prospective cohort studies are necessary to validate these results.

Economic Impact of Early Inpatient Palliative Care Intervention in a Community Hospital Setting.

Inpatient palliative care programs have demonstrated financial benefit for the hospital and improved quality of care for patients with advanced disease. Previous studies on this subject have focused on comparisons between palliative and traditional care. The financial and clinical effects of early versus late palliative care intervention are less well documented. The aims of this study are to review the financial and quality outcomes that early palliative care intervention has on appropriate inpatients in the community hospital setting. This retrospective study analyzed 449 palliative care patients. The independent variable was days to palliative care consultation, characterized as early palliative care (≤3 days) and late palliative care (>3 days). Dependent variables included length of stay (LOS) and financial considerations. The two groups were further stratified according to case mix index, medical versus surgical, as well as certain disease groups, such as sepsis, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) exacerbation. The patient's functional status, measured by the Victoria Palliative Performance Scale (PPSv2) was calculated to determine if this variable independently influenced the timing of consultation. Patients in the early intervention group realized a reduction in LOS and a significant cost reduction. In the analysis of the entire group, the average LOS with early intervention was 6.09 days versus 16.5 days with late intervention (p < 0.001). The early intervention group demonstrated an earlier transition to comfort care, earlier referral to outpatient hospice, and did not have a negative effect on mortality. The patient's PPSv2 score did not influence the timing of intervention (p 0.25). Early intervention with inpatient palliative care consultation correlated with financial benefit as well as earlier referral to more appropriate levels of care. These effects were achieved with minimal expense in a medium-sized community hospital.

Timing of Inpatient Pediatric Palliative Care Services and Hospital Length of Stay (S803)

•Understand the support for earlier palliative care consultations.•Understand demographic differences. Extended hospital stays for children with life limiting conditions are costly to families and disrupt children’s social/emotional development and quality of life. Engagement in pediatric palliative care services may reduce lengthy hospital stays when provided early in children’s disease trajectory. To examine the influence of timing of a palliative consult on inpatient length of and demographics (race/ethnicity, gender, insurance) as moderators of this association. Using program data from an inpatient palliative care program (N=935), this study examines 1) the stage at which initial consults are made, 2) associations between stage and length of stay, and 3) associations between time from admit to consult and from consult to discharge. Study aims were examined using descriptives, analysis of variance, and correlations in SPSS. Patients were evenly split by gender (52% male), predominantly public insurance (70%), and ethnically diverse (41% White, 38% Latino, 11% Native American, 7% African American, 3% Asian/Pacific Islander). Consults frequently occurred at new diagnosis and patients in the new diagnosis and stable chronic stages had longer stays than patients more advanced in their conditions. Consults that occurred closer to admit were associated with shorter times from consult to discharge. These effects were consistent across gender and insurance coverage, but were moderated by race/ethnicity with no association between time to admit and time to discharge for Native Americans. This study provides evidence that consults should occur closer to admission. The limited findings for Native Americans may be due to the fact that Native Americans often live far from the hospital and have no palliative services available in their communities. There may also be cultural differences in use of palliative care services.

Self-Reported California Hospital Palliative Care Program Composition, Certification, and Staffing Level Are Associated with Lower End-of-Life Medicare Utilization.

California hospitals report palliative care (PC) program characteristics to the California Office of Statewide Health Planning and Development (OSHPD), but the significance of this information is unknown. Our objective was to determine whether self-reported California hospital PC program characteristics are associated with lower end-of-life (EoL) Medicare utilization. We performed a cross-sectional study of hospitals submitting 2012 data to OSHPD and included in the 2012 Dartmouth Atlas of Healthcare (DAHC) dataset, using statistical hypothesis testing, multivariate regression, and fuzzy set qualitative comparative analysis. Our analysis included 203 hospitals primarily providing general medical-surgical (GMS) care. The following measures were available for each hospital: licensed GMS beds; type of control; presence of an inpatient or outpatient PC program; number of physicians, nurses, social workers, and chaplains on the PC team; number of PC-certified staff; percentage of Medicare decedents dying as inpatients; and average total hospital days, ICU days, and physician visits per Medicare decedent in the last six months of life. Investor-owned hospitals have fewer PC programs and higher EoL utilization than do nonprofit hospitals. Among nonprofit hospitals, small size (substantially fewer than 150 medical-surgical beds), or large size and having an inpatient PC program with more than three PC staff per 100 GMS beds, or an interdisciplinary PC-certified team, is associated with significantly lower EoL hospital utilization and percentage of deaths occurring in the inpatient setting. Improved program performance associated with higher staffing levels may be mediated by increased access to and earlier PC interventions. California hospital-reported PC program characteristics are associated with significantly lower inpatient utilization by Medicare decedents.

Abstract W MP107: Palliative Care Referrals are Under-used

Introduction: The National Institutes of Health Stroke Scale (NIHSS) is a well-validated predictor of 90-day functional outcomes. A score of ≥16 forecasts a high probability of death or severe disability. The palliative care (PC) needs of patients with serious or life-threatening stroke are enormous. Per PC standards and the American Stroke Association’s position statement on PC after stroke, customized PC should be available to patients and their families throughout the entire course of illness. Palliative care can be initiated in the hospital setting without limitations on life expectancy. The purpose of this project was to quantify NIHSS scores on admission compared to the percent of PC referrals made at 3 urban hospitals that use neurological pre-formatted orders, and have in-patient PC programs. Hypothesis: We hypothesized that In-patient PC referrals for stroke patients with NIHSS scores of ≥16 are low, in the context of pre-formatted orders that set the referral trigger at ≥ to 25. Methodology: Ischemic and hemorrhagic stroke cases discharged from Nov. 1, 2013-May 31, 2014 were reviewed retrospectively (674 total). NIHSS assessments were scored by stroke-certified RN staff on admission. Excluded were patients whose full NIHSS score was not documented, patients referred directly to hospice, and patients who left Against Medical Advice. Cases were examined for NIHSS score, and whether or not they were referred to PC. Results: Of 615 qualifying patients, 51 (8.3%) were referred for PC during their in-patient stay. The percentage with a NIHSS score on admission &lt;/= 6, was 3.5% (11/313). At a score of 7-15, 7.8% (15/188) received referrals. At scores ≥ 16, 21.9% (25/114) were referred. Conclusion: While the poor 90-day outcomes for patients with NIHSS scores ≥ 16 have been well-validated, just under 22% of the patients in this study received in-patient referrals to palliative care. Previously conducted studies relating NIHSS scores and 90-day outcomes suggest that there is an opportunity to improve the quality of life for more of these patients and their families through increased palliative care referrals.

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life.

Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life. We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6months of life for patients with chronic illness. Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service. For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use. We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

Comprehensive Analyses for Planning and Evaluating Palliative Care Programs (P5)

Objectives 1. Discover the established approaches for measuring inpatient palliative care program impact, and the emerging approaches for planning and evaluating outpatient programs. 2. Identify and access specific data elements necessary for measuring reach and outcomes. 3. Initiate or expand analyses to measure the reach and impact of your own palliative care program. In this workshop, participants will learn about a comprehensive suite of data analyses to aid in planning and evaluating both inpatient and outpatient specialist palliative care (SPC) programs. Concrete directions will be given for conducting these analyses, with examples of results from Virginia Commonwealth University and descriptions of how these results were presented and received. 1. The ‘‘3-bucket’’ analysis. All adult hospitalizations are stratified into two categories of SPC-relevant cases comprising 10% of admissions. Metrics include length of stay (LOS), costs, margin, and use of SPC. Results reveal the imperative for expanding your SPC program’s reach. 2. LOS reduction and cost avoidance. Between-patient analyses of early engagement of inpatient SPC are used to assess SPC impact on intensive care unit days, total hospital length of stay, and costs avoided among survivors. This analysis is critical for evaluating cases with no ‘‘pre-SPC’’days. 3. Classic cost-reduction. Within-patient analyses are conducted to demonstrate the direct cost impact of before and after inpatient SPC involvement. This is the analysis used in studies conducted by Smith (2003), Morrison (2008), and (Albanese) 2013. 4. Analyses of care for chronic, life-limiting disease patients. We will describe novel analyses assessing quality, quantity, and costs of care over the last 6 months of life for patients with chronic, life-limiting diseases. This provides the context and imperative for health systems to invest in outpatient SPC integrated earlier with disease-focused treatments, and a baseline against which to measure the impact of those programs. 5. The ‘‘supportive care calculator.’’ We will demonstrate an interactive calculator to plan a supportive care program that is the right size for your target population, providing information on the potential reach, staffing, costs, revenues, and impact of your program. All of these analyses are feasible for most hospitals in the United States.

Intensive Care Unit Nurses and Palliative Care: Perceptions and Recommendations (S706)

3. Review the essential elements and components of an inpatient palliative program implemented in a rural community safety net hospital in an era of cost containment. Background. There is a plethora of data detailing the utilization of inpatient palliative care programs (IPCPs). However, the data is dominated by academic centers including urban/suburban facilities. There is a lack of data regarding rural safety net facilities (RSNF) primarily serving the medically indigent. The medically indigent represent a vulnerable population that historically has been ignored regarding access to palliative care. Research Objectives. To assess the impact of an IPCP in a RSNF in south Louisiana regarding hospital/ICU deaths, palliative care and withdrawal of life support order set utilization, ICU codes, and patient days and hospice referrals. Method. An IPCP was implemented in July 2008 and consisted of providers, nursing staff, social workers, and others formed a palliative care team in 2007 at Chabert Medical Center in Houma, LA. Other components included a consult service, an evidence-based palliative care and withdrawal of care order set, an educational campaign for patients and employees including medical students and residents that includes a lecture series, updated end of life facility policies, a dedicated palliative care suite, and pamphlets and printed literature available for patients and family members in high utilization areas. A quality of care palliative care registry was created and data was tracked from 2005 (3 years prior to program inception) to early 2012. Result. Hospital deaths were reduced by 1518% and ICU deaths by 12.5-15%. Palliative care order set utilization increased from 28% in 2008 to 55% in 2010/2011, ICU deaths were reduced 10%, withdrawal of life support order set use increased from 28% in 2008 to 50% in 2011, ICU codes remained unchanged, ICU patient days fell 20%, and hospice referrals have increased 40-45%. Conclusion. An IPCP implemented at an RSNF may successfully reduce resource utilization and increase hospice referrals. Implications for Research, Policy, or Practice. IPCPs can be implemented successfully at rural safety net facilities primarily serving the medically indigent. Intensive Care Unit Nurses and Palliative Care: Perceptions and Recommendations (S706) Rebecca Aslakson, MDMSci, The Johns Hopkins University School of Medicine, Baltimore, MD. Erica Koegler, MA, Johns Hopkins School of Public Health, Baltimore, MD. Rita Moldovan, RN DNP ACHPN, Johns Hopkins Hospital, Baltimore, MD. Kerry Shannon, MPH, Johns Hopkins University, Baltimore, MD. Jessica Peters Johns Hopkins University, Baltimore, MD. Lauren Redstone, MA, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Selena An, BA, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Jeffrey Duong, MHS, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Erica Koegler, MA, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Maya Nadison Johns Hopkins University, Baltimore, MD. Peter Pronovost, MD PhD FCCM, Johns Hopkins Medicine, Baltimore, MD. (All authors listed above had no relevant financial relationships to disclose.)

Impact of an Inpatient Palliative Care Program in a Rural Safety Net Hospital in South Louisiana (S705)

Impact of an Inpatient Palliative Care Program in a Rural Safety Net Hospital in South Louisiana (S705)

Palliative Care in the Outpatient Cancer Center

Predictions for exponential growth in the incidence and prevalence of cancer will present a significant challenge to the healthcare system. Most of this care will be provided in the outpatient setting. Although inpatient palliative care programs are well established, this is not the case for outpati

Palliative Care Intervention for Choice and Use of Opioids in the Last Hours of Life

The purpose of this study was to evaluate the effects of a multicomponent palliative care intervention on choice and use of opioid pain medications for symptom control for patients dying in an acute care inpatient setting. A preintervention/postintervention trial was conducted between 2001 and 2003. Participants were physician, nursing, and ancillary staff of inpatient services of an urban, tertiary care Veterans Affairs (VA) Medical Center. The intervention included staff education to better identify actively dying patients and a Comfort Care Order Set to guide care in the last hours of life. Data abstracted from computerized medical records of 191 veterans who died during a 6-month period before (N=98) and after (N=93) the intervention were used to examine changes in choice and amount of medication administered in the last 3 days of life. Findings show a significant increase in orders specifically for morphine from 47.4% to 81.7% (p<.001). Orders for hydromorphone or oxycodone did not increase significantly, and no patients had orders for meperidine or codeine. There was an increase in the administration of opioids from 16.7% to 73.0% of patients (p<.001). The amount of opioid administered (in oral morphine equivalents) increased from 31.9 mg/72 hours preintervention to 52.9 mg/72 hours postintervention (p=.12). The results indicate that the availability of morphine as a preferred opioid and the number of patients who received opioid medication during the last 3 days of life increased after introduction of the inpatient palliative care program.

The Economic and Clinical Impact of an Inpatient Palliative Care Consultation Service: A Multifaceted Approach

While there has been a rapid increase of inpatient palliative care (PC) programs, the financial and clinical benefits have not been well established. Determine the effect of an inpatient PC consultation service on costs and clinical outcomes. Multifaceted study included: (1) interrupted time-series design utilizing mean daily costs preintervention and postintervention; (2) matched cohort analysis comparing PC to usual care patients; and (3) analysis of symptom control after consultation. Large private, not-for-profit, academic medical center in San Francisco, California, 2004-2006. Time series analysis included 282 PC patients; matched cohorts included 27 PC with 128 usual care patients; clinical outcome analysis of 48 PC patients. Mean daily patient costs and length of stay (LOS); pain, dyspnea, and secretions assessment scores. Mean daily costs were reduced 33% (p < 0.01) from preintervention to postintervention period. Mean length of stay (LOS) was reduced 30%. Mean daily costs for PC patients were 14.5% lower compared to usual care patients (p < 0.01). Pain, dyspnea, and secretions scores were reduced by 86%, 64%, and 87%, respectively. Over the study period, time to PC referral as well as overall ALOS were reduced by 50%. The large reduction in mean daily costs and LOS resulted in an estimated annual savings of $2.2 million in the study hospital. Our results extend the evidence base of financial and clinical benefits associated with inpatient PC programs. We recommend additional study of best practices for identifying patients and providing consultation services, in addition to progressive management support and reimbursement policy.

Bringing an Inpatient Palliative Care Program to a Teaching Hospital: Lessons in Leadership

This feature provides a platform for oncology nurses to illustrate the many ways that leadership may be realized and professional practice may transform cancer care. Possible submissions include but are not limited to overviews of projects, interviews with nurse leaders, and accounts of the application of leadership principles or theories to practice. Descriptions of activities, projects, or action plans that are ongoing or completed are welcome. Manuscripts should clearly link the content to the impact on cancer care. Manuscripts should be six to eight doublespaced pages, exclusive of references and tables, and accompanied by a cover letter requesting consideration for this feature. For more information, contact Associate Editor Paula Klemm, PhD, RN, OCN, at klemmpa@udel.edu or Associate Editor Judith K. Payne, PhD, RN, AOCN, at payne031@mc.duke.edu Paula T. Rieger, RN, MSN, AOCN®, FAAN Associate Editor

Clinical pharmacy services in a home-based palliative care program

Palliative care is designed to provide pain relief for and improve the quality of life of patients with a life-threatening illness.1 The number of patients with chronic, slowly debilitating illnesses, such as heart disease and end-stage lung disease, is on the rise, and most Americans with debilitating diseases prefer to die at home rather than in a hospital.2 Health care systems are expanding to accommodate these wishes. The number of formal palliative care programs is growing rapidly, with the most documented growth in the number of inpatient palliative care programs.3 Home-based palliative care programs are less common; however, some programs have been described.4,5 Palliative and hospice care share many similar goals. Both aim to address physical, emotional, and spiritual aspects of the patient’s life. However, several differences are apparent between these two types of patient care programs. Most hospice rules are determined by the regulations set by the federal government under Medicare. Patients must meet specific criteria to qualify for hospice and for hospice agencies to receive payment from the federal government. These criteria may vary depending on the patient’s diagnosis but could include a certain amount of weight loss or a particular functional status. One of the criteria for all patients enrolled in hospice care is a life expectancy of less than six months. Hospice care focuses on providing patient comfort after life-extending interventions are no longer appropriate or desired. On the other hand, palliative care can be provided during any stage of the illness, even while life-extending treatments, such as chemotherapy, are being pursued. Therefore, palliative care applies to a larger patient population, including those who do not desire or are not eligible for hospice services.

Evaluating the California Hospital Initiative in Palliative Services

Inpatient palliative care programs can improve care of patients with serious illness. We developed the California Hospital Initiative in Palliative Services (CHIPS) program to assist hospitals in establishing these programs. CHIPS included an introductory conference followed by 10 months of mentoring with telephone calls, e-mails, on-site consultation at the hospital, and a reunion conference. To evaluate CHIPS and the factors associated with establishing inpatient palliative care programs, we conducted a cross-sectional telephone survey of leaders from the 38 hospitals that participated in CHIPS. We assessed the number of inpatient palliative care consultation services established by hospitals that participated in CHIPS (success) and hospital characteristics associated with success. Participants gave CHIPS high ratings. Six hospitals (16%) had a palliative care consultation service at enrollment in CHIPS and 19 hospitals (60%) established one after participation in CHIPS (P<.001). In bivariable comparisons, successful hospitals were more likely to have a hospitalist program (P = .003) or to be located in an urban setting (P = .03). CHIPS seemed to help many hospitals establish inpatient palliative care programs. Hospitals with hospitalists and those in an urban setting were more likely to succeed in developing palliative care programs. Future studies should focus on the quantity and quality of care provided by these programs.