Critical Illness, End of Life, Quality of Life
Conditions
Keywords
Palliative Care, Hospice, Medical ICU
Brief summary
The goal of this study is to investigate whether embedding a hospice and palliative care practitioner within a medical intensive care unit will improve patient outcomes and healthcare usage. The practitioner will work solely within the medical intensive care units and offer timely as well as proactive consultations based on clinical criteria and estimated mortality risk. The study team will compare patients seen by the practitioner to patients in an adjacent ICU and historical patients to determine whether patient care is improved by this intervention.
Detailed description
The study goal is to determine whether an embedded palliative care practitioner in the medical ICU improves patient outcomes, palliative care/hospice utilization, and healthcare quality metrics. The medical ICUs included in this study are comprised of two geographically co-located units that provide care for medically complex patients from a large tertiary referral area. Palliative care services are currently available as a consultative service at the ICU clinicians' discretion for patients with palliative needs such as complex goals of care, advanced symptom management, or chronic critical illness. Under the current consultation model, palliative care consultation is requested in a minority of critically ill patients and consults occur on average 5-14 days after a patient's admission. Hospice services are similarly available on a consultative basis for patients that the primary team has determined are suitable for hospice, however, logistical limitations of hospice consultation may lead to delays in inpatient hospice transfers and home hospice discharges. This study's intervention is to embed a palliative care/hospice practitioner within the medical ICUs as a dedicated palliative care and hospice consultant who will offer proactively triggered palliative care consultations early in a patient's ICU stay as well as immediate availability for standard-of-care palliative care and hospice consultations.
Interventions
OTHEREmbedded Hospice and Palliative Care Practitioner
The hospice and palliative care practitioner will be embedded in one medical intensive care unit for the first half of the study timeframe, after which the practitioner will expand to both medical intensive care units. While active in a medical intensive care unit, the practitioner will proactively trigger palliative care consultations based on clinical criteria and estimated mortality risk, in addition to providing immediate availability for standard-of-care hospice or palliative care consultations.
OTHEREmbedded Hospice and Palliative Care Practitioner (Group Effect)
While the hospice and palliative care practitioner is active in one medical intensive care unit with respect to triggering consultations, the other medical intensive care unit can still utilize the practitioner's services for standard-of-care hospice or palliative care consultations.
OTHERNone (Historical)
This control arm includes historical patients admitted to the medical intensive care units prior to the study's enrollment timeframe.
Sponsors
Washington University School of Medicine
Study design
Allocation
RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Intervention model description
Stepped Wedge Intervention
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients admitted to the medical intensive care units at a tertiary referral center * Patients must be at least 18 years of age
Exclusion criteria
* None
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| ICU Length of Stay | From date of enrollment until hospital discharge, assessed up to 1 year | Length of stay in any intensive care unit during the hospitalization |
| Code Status De-escalation | From date of enrollment until hospital discharge, assessed up to 1 year | Frequency of changes in code status to limited code or comfort measures only |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Length of Stay Index (Vizient) | From date of enrollment until hospital discharge, assessed up to 1 year | Length of stay index as calculated by Vizient |
| Vasopressor Utilization | From date of enrollment until hospital discharge, assessed up to 1 year | Days on vasopressors |
| Hospital Mortality | From date of enrollment until hospital discharge, assessed up to 1 year | Inpatient all-cause mortality |
| Operating cost in dollars, including departmental breakdown | Assessed six months following discharge | Hospital operating cost for each patient, including departmental breakdown such as ICU, pharmacy, procedural, operating room, etc. |
| Hospital Length of Stay | From date of enrollment until hospital discharge, assessed up to 1 year | Length of hospital stay in days |
| Presence of Advance Care Planning Documentation during Current Admission | From date of enrollment until hospital discharge, assessed up to 1 year | Documentation of advance directives, limitations in life-sustaining treatments, or code status that is newly created during the active hospital admission |
| Hospice Consultation | From date of enrollment until hospital discharge, assessed up to 1 year | Frequency of Hospice consultations |
| Mortality Index (Vizient) | From date of enrollment until hospital discharge, assessed up to 1 year | Mortality index as calculated by Vizient |
| Palliative Care Consultation | From date of enrollment until hospital discharge, assessed up to 1 year | Frequency of Palliative Care consultations |
| Time to change in code status, advance care planning documentation, palliative care consultation, and hospice consultation | From date of enrollment until hospital discharge, assessed up to 1 year | Time in days to the first occurrence of the above outcomes |
| Inpatient Hospice Duration | From date of enrollment until hospital or hospice discharge, assessed up to 1 year | Days while patients are enrolled in inpatient hospice (GIP) |
| Location of discharge disposition | From date of enrollment until hospital discharge, assessed up to 1 year | Discharge disposition to home, skilled nursing facility, long term acute care facility, inpatient rehabilitation, etc. |
| 30-Day Mortality | Assessed 30 days after hospital admission | All-cause mortality within 30 days of hospital admission |
| 30-day Emergency Room Visit | Assessed 30 days after hospital discharge | Emergency Room encounter in the same healthcare system within 30 days of discharge |
| 30-day Readmission | Assessed 30 days after hospital discharge | Hospital readmission in the same healthcare system within 30 days of discharge |
| Hospice Enrollment | From date of enrollment until hospital discharge, assessed up to 1 year | Frequency of discharge or transition to hospice during or immediately following the hospital stay |
| Mechanical Ventilation Duration | From date of enrollment until hospital discharge, assessed up to 1 year | Days on mechanical ventilation |
Countries
United States
Contacts
Primary ContactStephen Chi, MD
Outcome results
None listed