title: Integrating Palliative Care into Critical Care: A Quality Improvement Study.
abstract: BACKGROUND
  Many terminally ill patients experience an increasing intensity of medical care, an escalation frequently not consistent with their preferences. In 2009, formal palliative care consultation (PCC) was integrated into our medical intensive care unit (ICU). We hypothesized that significant differences in clinical and economic outcomes exist between ICU patients who received PCC and those who did not.
  
  
  METHODS
  We reviewed ICU admissions between July and October 2010, identified 41 patients who received PCC, and randomly selected 80 patients who did not. We measured clinical outcomes and economic variables associated with patients' ICU courses.
  
  
  RESULTS
  Patients in the PCC group were older (average 64 years, standard deviation [SD] 19.2 vs 55.6 years, SD 14.5; P = .021) and sicker (median Acute Physiology and Chronic Health Evaluation IV score 85.5, interquartile range [IQR] 60.5-107.5 vs 60, IQR 39.2-74.75; P < .001) than the non-PCC controls. PCC patients received significantly more total days of ICU care on average (8 days, IQR 4-15 vs 4 days, IQR 2-7; P < .001), had more ICU admissions, and were more likely to die during their ICU stay (64.3% vs 12.5%, P < .001). Median total hospital charges per patient attributable to ICU care were higher in the PCC group than in the controls (US$315,493, IQR US$156,470-US$486,740 vs US$116,934, IQR US$54,750-US$288,660; P < .001). After we adjusted for ICU length of stay, we found that median ICU charges per day per patient did not differ significantly between the groups (US$37,463, IQR US$27,429-US$56,230 vs US$41,332, IQR US$30,149-US$63,288; P = .884). Median time to PCC during the ICU stay was 7 days (IQR 2-14.5 days).
  
  
  CONCLUSIONS
  Patients who received PCC had higher disease acuity, longer ICU lengths of stay, and higher ICU mortality than controls. "Trigger" programs in the ICU may improve utilization of PCC services, improve patient comfort, and reduce invasive, often futile end-of-life care.
authors.affiliation: Department of Medicine, Division of Internal Medicine, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Hsu-Kim
authors.affiliation: Vitas Palliative Care Solutions, Philadelphia, PA, USA.
authors.forename: Tara
authors.initials: T
authors.lastname: Friedman
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Philadelphia, PA, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Gracely
authors.affiliation: Department of Medicine, Section of Critical Care Medicine, Drexel University College of Medicine, Philadelphia, PA, USA Department of Environmental and Occupational Health, School of Public Health, Drexel University, Philadelphia, PA, USA james.gasperino@drexelmed.edu.
authors.forename: James
authors.initials: J
authors.lastname: Gasperino
mesh_terms: D018806:APACHE; D000368:Aged; D003422:Critical Care / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D003695:Delivery of Health Care / Q000191:economics / Q000379:methods* / Q000592:standards; D005260:Female; D017722:Hospital Charges / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D058996:Quality Improvement
keywords: end-of-life care; hospice and palliative care medicine; intensive care unit; palliative care