Research Article
The Impact of a Dedicated Palliative Care Unit on a Busy Medical Intensive Care Unit in an Academic Setting; a Retrospective Review
Campbell J1, Wang L2 and Karlekar M3*
1Department of Medicine, Vanderbilt University Medical Center, USA
2Department of Biostatistics, Vanderbilt University Medical Center, USA
3Division of General Medicine, Vanderbilt University Medical Center, USA
*Corresponding author: Mohana Karlekar, Division of General Medicine, Vanderbilt University Medical Center Nashville, TN, 37232, USA
Published: 26 Aug, 2016
Cite this article as: Campbell J, Wang L, Karlekar M.
The Impact of a Dedicated Palliative
Care Unit on a Busy Medical Intensive
Care Unit in an Academic Setting; a
Retrospective Review. Clin Oncol.
2016; 1: 1059.
Abstract
Introduction: Palliative care aims to maximize quality of life for those patients facing serious illness.
There is growing evidence to demonstrate that palliative care (PC) consultation teams have been
associated with improvement in quality markers such as reduction in intensive care unit length of
stay (LOS) and mortality. Palliative care units (PCUs) are geographically designated units where
patients are cared for by specially trained staff. PCUs are less prevalent nationally and so there are
fewer studies exist examining the impact of PCUs in institutions that already have a PC consultation
team. The aim of this study was to examine the impact of establishing a PCU on a medical intensive
care unit (MICU) that often runs at maximum capacity specifically focusing on MICU LOS, and
mortality and indirectly capacity.
Methods: Retrospective chart review was performed on patients receiving a PC consultation in the
MICU one year before and after the establishment of a PCU in an academic university hospital. The
primary outcome variables include time to MICU discharge, MICU length of stay, and mortality at
MICU discharge. Clinical factors were compared between two time periods using wilcoxon rank
sum test or Pearson chi-square test where appropriate.
Results: MICU LOS was shorter in the group after the establishment of a PCU compared to that
before establishment of PCU (median 4.2 vs. 5.1 days, p=0.015). The MICU mortality rate was 11%
after the PCU and 34% before the PCU (p<0.001).
Conclusion: The addition of a PCU can significantly reduce MICU LOS and mortality, thereby
adding needed capacity for patients who need intensive care.
Introduction
Palliative care (PC) is relatively a new specialty in medicine that has rapidly grown over the
last decade that aims to relieve the suffering of patients facing serious illness utilizing a patient and
family centered approach [1]. Integration of PC into various medical specialties has demonstrated
important benefits to patients, clinicians and health care institutions [2,3]. As a result, there has
been a national trend among hospitals to develop PC programs [4].
The mainstay of PC is delivered in hospitals through consultation teams. There are however
a growing number of dedicated inpatient palliative care units (PCUs) being developed across
institutions. PCUs are geographically designated units where patients and families are cared for
by staff trained in the principals of PC. Although the approach to care is much like that of hospice,
PCUs can accommodate a much greater scope of patients.
The current evidence describing the many benefits of PC supports the consultative model of
care [5-7]. In the MICU, there is considerable published data that demonstrates the integration
of PC improves multiple quality markers including length of stay, better alignment of treatment
goals with patient care plans and more appropriate utilization of health care resources [8-12].
The evidence documenting benefits of PCUs, though less robust, seems to indicate a benefit to
PCUs within institutions that have PC consultation teams [13,14]. Still there remains insufficient
guidance for institutions to determine if investment in a PCU is worthwhile. This decision may
be further challenged by the fact that dedicated PCUs require considerable more financial, spatial
and personnel resources than that required by PC consultation teams
[15].
Our institution developed a PCU five years after establishing a PC
consultative team with the goal of improving end of life care within
our institution. Specifically, leadership hoped to improve the quality
of death for our dying patients unable to be discharged to hospice. We
hypothesized that the creation of a PCU would facilitate patient flow
throughout the institution, allowing patients to receive appropriate
care in the appropriate place. This was especially important given that
our institution frequently runs at or beyond capacity, and ICU beds
are often in high demand. The aim of this study was to examine the
impact of the establishment of the PCU on quality markers in the
MICU, specifically LOS and MICU mortality.
Table 1
Methods
A retrospective review was performed on both patient charts
and through an already existing database of MICU patients. We
studied patients one year before and one year after the PCU opened
in September 2012. Using the palliative care consult service records,
patients who received a palliative care consult from the MICU
between September 2011- August 2012 and January 2013-December
2013 were identified. We did not include patients from September to
December 2012 in order to allow time for the PCU to become fully
functional. After the two patient groups were identified, desired data
were obtained from an existing MICU database. Chart review was
also performed for any information missing from database.
MICU length of stay was defined as the total amount of time
spent in the MICU during a hospitalization. Therefore, if a patient
was transferred from the MICU to the floor but “bounced back”
to the MICU, then both MICU admissions were added together to
create a cumulative length of stay in the MICU.
Continuous variables were reported as mean and standard
deviation or median with interquartile range. Categorical variables
were reported as percentage and frequency. Clinical factors were
compared between two time periods using Wilcoxon rank sum test
or Pearson chi-square test where appropriate. The primary outcome
variables include time to MICU discharge, MICU length of stay, and
mortality at MICU discharge. We fit cox proportional hazard model
to assess the association between palliative care and time to MICU
discharge with adjustment of University Health System Consortium
(UHC) length of stay, UHC mortality, UHC cost, and age. We
used proportional odds model to assess the difference in MICU
length of stay before and after palliative care adjusting for same set
of covariates. We used logistic regression to assess the difference in
MICU mortality before and after palliative care adjusting for same set
of covariates. All statistical analyses were performed using statistical
software R version 3.2.5 (www.r-project.org).
Table 2
Results
Demographics are detailed in Table 1.
MICU LOS was shorter in the group after the PCU compared to
that before the PCU (median 4.2 vs. 5.1 days, p=0.015). The MICU
mortality rate was 11% after the PCU and 34% before the PCU
(p<0.001). After adjusting for UHC LOS, mortality, cost, and patient
age, the multivariable cox proportional hazard model indicated that
that hazard of death in the MICU before the PCU was 2.49 times
the hazard of death in the MIUC after the PCU (95% CI 1.57-3.94,
P<0.001). The odds of death in the MICU before the PCU were 4.36
times the odds of death in the MICU after the PCU (95% CI 2.59-7.36,
p<0.001).
Table 2 describes LOS before and after establishment of a PCU.
Figure 1 displays the Kaplan-Meier curve for MICU LOS as
survival from ICU admission to ICU discharge. The primary endpoint
was either death in the ICU or discharge from the ICU.
Discussion
The results of our study indicate that both LOS and mortality
decreased for patients receiving PC consults in the MICU since the
establishment of our PCU. The two groups studied were similar in
terms of age and UHC predicted models for LOS, mortality, and cost.
Our results support the work published by Digwood and
colleagues describing the impact of a 12 bed dedicated PCU. Their
work demonstrated that implementation of a PCU correlated with
a significant decrease in MICU LOS and mortality, as it created
a viable clinical care setting that could provide appropriate end
of life care [16]. Most Americans state their preference is to die at
home; however, the vast majority of Americans die in a facility [12].
Historically ICU patients at the end of life have limited discharge
options. Hospices often lack the resources and expertise to manage
some of the therapies most commonly used in the ICU including
vasoactive drugs and ventilator support, but the PCUs developed
in both this and the Digwood study had the capability of providing
ICU level care. Thus, patients who were unable to go home could be
transferred to the PCU, which was designed to be a quieter, more
home-like setting than an ICU or medical-surgical floor.
Our study demonstrates that the establishment of the PCU
provides an alternate location for end of life care for patients while at
the same time creating needed capacity within our ICU. This benefit
is particularly relevant to institutions like ours that are challenged
with meeting an ever-growing demand for ICU beds that constantly
surpasses supply. Mosenthal and colleagues noted a similar
improvement in capacity following the integration of PC into the usual
care of trauma patients documenting a reduction in both trauma ICU
mortality and LOS [8]. Reduced mortality in Mosenthal’s study was
attributed to more appropriate utilization of resources. Transitioning
comfort care patients out of the ICU facilitated admission of patients
requiring specialty trauma services into their trauma ICU.
Although we did not study the perceptions of end of life care
bereaved families whose loved ones were cared for in our PCU, based
on previous studies we surmise that the PCU has improved family
members’ experience with their loved ones. Cassaret and colleagues
surveyed bereaved family members to see if there was a perceived
difference in care at the end of life for patients being cared for by a
PC consult team vs. in a dedicated PCU. They concluded based on
analyses of their surveys that “care received in a PCU may offer more
improvements than that achieved with PC consultations [13]”.
We note the following limitations to our study. The two cohorts
comparing MICU patients before and after establishment of a PCU
may have some disparities, as they were reviewed from two different
time periods. It is possible that the decreased LOS and mortality may
be the reflection of a population with a lower severity of illness not
captured by the UHC index. Also, since this study reviewed data
one year immediately following the establishment of our PCU, it is
possible that the differences noted in MICU LOS were the result of
increased enthusiasm to transition patients to this novel unit.
Figure 1
Conclusion
Our results indicate that the addition of a PCU in our institution can significantly reduce MICU LOS and mortality, thereby enhancing capacity for to our MICU.
Acknowledgement
The authors would like to acknowledge the contributions of Dr Arthur Wheeler.
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