Abstract
Context
Objectives
Methods
Results
Conclusion
Key Words
Introduction
Methods
Study Population
Characteristics | Frequency % (n) |
---|---|
State: | N = 98 |
California | 59.0 (58) |
Arizona | 4.1 (4) |
Hawaii | 1.0 (1) |
Kentucky | 2.0 (2) |
Louisiana | 4.1 (4) |
Massachusetts | 3.1 (3) |
Michigan | 5.1 (5) |
Missouri | 1.0 (1) |
Montana | 1.0 (1) |
New Mexico | 1.0 (1) |
Oregon | 4.1 (4) |
South Carolina | 1.0 (1) |
Texas | 8.2 (8) |
Washington | 4.1 (4) |
Wisconsin | 1.0 (1) |
Size: | N = 73 |
Mean | 348 |
Median | 286 |
Range: | 26 – 1,120 |
N = 73 | |
1 – 149 beds | 10 (13.7) |
150 – 299 beds | 27 (37.0) |
300 – 499 beds | 19 (26.0) |
500+ beds | 17 (23.3) |
Hospital Status | N = 97 |
Not for profit | 68.1 (66) |
Academic | 17.5 (17) |
Public | 11.3 (11) |
For profit | 1.0 (1) |
Other | 2.1 (2) |
Team composition: | % (n) |
Nurse (NP/RN) | 92.2 (83/90) |
Physician | 98.8 (84/85) |
Social Worker | 87.1 (74/85) |
Chaplain | 69.9 (58/83) |
Number of members in the team: | N = 90 |
1 | 3.3 (3) |
2 | 12.2 (11) |
3 | 33.3 (30) |
4 | 51.1 (46) |
Credentialed b :Credentialling includes American Board of Hospice and Palliative Nursing certification for nurses, Amercian Board of Medical Specialties certification for physicians; Advanced Palliative Hospice and Social Work Certification credentialling for Social Workers and Palliative Care & Hospice Advanced Certification or Hospice and Palliative Care Specialty Certification credentialling for Chaplains. | |
Registered Nurse | 44.3 (27/61) |
Nurse Practitioner | 57.7 (41/71) |
Physician | 94.7 (72/76) |
Social Worker | 33.3 (21/63) |
Chaplain | 18.6 (11/59) |
Dataset
POLST: Portable medical orders for seriously ill or frail individuals. [cited 2021 Jan 11]. Available at: https://polst.org. Accessed April 3, 2022.
Statistical Analysis
Results
Patient Characteristics
Patient Characteristics | Referral Location | P-value | |
---|---|---|---|
ICU | Med/Surg | ||
N = 39,462 | N = 63,056 | ||
Mean (95%CI) | Mean (95%CI) | ||
Age (Years) | 68.43(68.27,68.59) | 72.04 (71.91,72.17) | <0.001 |
Median (SD) | 70.0 (16.0) | 74.0 (16.3) | |
%(n) | %(n) | ||
N = 39,501 | N = 63,047 | ||
Gender (Female) | 45.4 (17,919) | 52.0 (32,815) | <0.001 |
Primary Diagnosis: | N = 38,750 | N = 62,012 | |
Cancer | 15.0 (5,819) | 40.9 (25,355) | <0.001 |
Cardiovascular | 20.3 (7,864) | 7.2 (4,483) | |
Pulmonary | 16.5 (6,405) | 7.2 (4,439) | |
Neurologic/Stroke | 15.9 (6,146) | 7.6 (4,713) | |
Other | 32.3 (12,516) | 37.1 (23,022) | |
Reason for referral: | N = 39,012 | N = 62,590 | |
GoC/ACP | 80.6 (31,434) | 75.0 (46,913) | <0.001 |
Pain management | 6.1 (2,393) | 21.8 (13,665) | <0.001 |
Other symptom management | 9.0 (3,500) | 15.1 (9,472) | <0.001 |
Hospice referral/discussion | 9.8 (3,806) | 17.7 (11,059) | <0.001 |
Comfort care | 9.7 (3,780) | 5.1 (3,172) | <0.001 |
Withdrawal of interventions | 7.7 (3,014) | 1.3 (787) | <0.001 |
Support for patient/family | 36.6 (14,271) | 25.9 (16,189) | <0.001 |
N = 34,321 | N = 54,558 | ||
Mean (95%CI) | Mean (95%CI) | ||
PPS score | 25.7 (25.5,25.9) | 41.6 (41.5,41.8) | <0.001 |
Median (SD) | 20.0 (17.5) | 40.0 (18.3) | |
%(n) | %(n) | ||
Code Status: | N = 38,366 | N = 61,543 | |
Full | 64.4 (24,720) | 55.9 (34,402) | <0.0001 |
Partial | 6.7 (2,564) | 2.3 (1,441) | |
DNR/DNI | 28.9 (11,082) | 41.8 (25,700) | |
N = 39,496 | N = 63,025 | ||
Mean (95%CI) | Mean (95%CI) | ||
Time between admission and PC consult in days | 5.90 (5.73,6.07) Median (SD) 3.0 (17.1) | 5.04 (4.87,5.20) Median (SD) 2.0 (20.9) | <0.001 |
%(n) | %(n) | ||
N = 39,496 | N = 63,025 | ||
PC referral within 24 hours of admission: | 35.5 (14,015) | 39.8 (25,075) | <0.001 |
Symptoms at time of consult: | |||
Pain: | N = 32,762 | N = 53,209 | |
Able to report | 42.8 (14,048) | 73.8 (39,266) | <0.001 |
N = 14,048 | N = 39,266 | ||
Severity – Mod./Severe | 18.0 (2,527) | 31.5 (12,364) | <0.001 |
Anxiety: | N = 32,666 | N = 53,049 | |
Able to report | 40.0 (13,066) | 68.5 (36,342) | <0.001 |
N = 13,066 | N = 36,342 | ||
Severity – Mod./Severe | 11.8 (1,537) | 11.6 (4,214) | 0.61 |
Nausea: | N = 32,692 | N = 53,059 | |
Able to report | 41.2 (13,465) | 72.0 (38,215) | <0.001 |
N = 13,465 | N = 38,215 | ||
Severity – Mod./Severe | 2.3 (310) | 5.7 (2,185) | <0.001 |
Dyspnea: | N = 32,685 | N = 52,951 | |
Able to report | 41.5 (13,571) | 72.4 (38,335) | <0.001 |
N = 13,571 | N = 38,335 | ||
Severity – Mod./Severe | 16.8 (2,276) | 7.8 (3,002) | <0.001 |
Processes of Care | OR 95%CI | P-value |
---|---|---|
Reason for referral | N = 64,682 | |
GoC/ACP | 1.70 (1.64,1.77) | <0.001 |
Pain management | 0.26 (0.24,0.27) | <0.001 |
Other symptom management | 0.57 (0.54,0.60) | <0.001 |
Hospice referral/discussion | 0.59 (0.56,0.61) | <0.001 |
Comfort care | 1.82 (1.72,1.92) | <0.001 |
Withdrawal of interventions | 6.47 (5.91,7.08) | <0.001 |
Support for patient/family | 1.56 (1.51,1.62) | <0.001 |
N = 61,528 | ||
POLST at time of consult | 0.66 (0.62,0.69) | <0.001 |
N = 62,599 | ||
Advance Directives documented at time of consult | 0.87 (0.84,0.91) | <0.001 |
Code status at time of consult: | N = 63,932 | |
Full | 1.0 | |
Partial | 3.01 (2.79,3.25) | <0.001 |
DNR/DNI | 0.71 (0.69,0.74) | <0.001 |
N = 65,121 | ||
PC referral within 24 hours of admission: | 0.88 (0.84, 0.91) | <0.001 |
PPS by tertile | ||
N = 57,050 | ||
70% – 100% | 1.0 | |
40% – 60% | 2.02 (1.87,2.19) | <0.001 |
10% – 30% | 8.90 (8.20,9.65) | <0.001 |
Symptoms at time of consult | ||
Pain: | N = 55,586 | |
Able to report | 0.27 (0.26,0.28) | <0.001 |
N = 35,962 | ||
Severity – Mod./Severe b Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate. | 0.53 (0.50,0.56) | <0.001 |
Anxiety: | N = 55,378 | |
Able to report | 0.29 (0.28,0.30) | <0.001 |
N = 33,399 | ||
Severity – Mod./Severe b Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate. | 0.96 (0.89,1.03) | 0.26 |
Nausea: | N = 55,425 | |
Able to report | 0.27 (0.25,0.28) | <0.001 |
N = 34,968 | ||
Severity – Mod./Severe b Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate. | 0.53 (0.47,0.61) | <0.001 |
Dyspnea: | N = 55,370 | |
Able to report | 0.27 (0.26,0.28) | <0.001 |
N = 35,085 | ||
Severity – Mod./Severe b Of patients that were able to report symptoms. Abbreviations: PC = palliative care; ICU = intensive care unit; OR = odds ratio; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate. | 1.98 (1.85,2.13) | <0.001 |
Treatment Outcomes
Treatment Outcomes | Referral Location | P-value | |
---|---|---|---|
ICU | Med/Surg | ||
%(n) | %(n) | ||
N = 19,588 | N = 31,203 | ||
2nd PC assessment within 72 hours after 1st assessment | 11.6 (2,268) | 6.8 (2,136) | <0.001 |
Symptom improvement from 1st to 2nd assessment a Of patients reporting moderate to severe symptom distress at initial assessment. Abbreviations: PC = palliative care; ICU = intensive care unit; GoC = goals of care; ACP = advance care planning; POLST = Physician Order for Life-Sustaining Treatments; DNR = do-not-resuscitate; DNI = do-not-intubate; PPS = Palliative Performance Scale; Mod = moderate. | N = 1,634 | N = 9,086 | |
Pain | 72.9 (1,191) | 67.0 (6,087) | <0.001 |
N = 947 | N = 2,812 | ||
Anxiety | 72.3 (685) | 69.3 (1,949) | 0.08 |
N = 182 | N = 1,624 | ||
Nausea | 83.0 (151) | 76.6 (1,244) | 0.05 |
N = 1,312 | N = 1,831 | ||
Dyspnea | 63.4 (832) | 64.7 (1,184) | 0.47 |
N = 36,266 | N = 58,027 | ||
Mean (95%CI) | Mean (95%CI) | ||
Mean number of family meetings | 1.67 (1.65,1.68) | 1.23 (1.22,1.24) | <0.001 |
Median (SD) | 1.0 (1.6) | 1.0 (1.3 | |
%(n) | %(n) | ||
Surrogate decision maker at time of discharge: | N = 24,420 | N = 40,290 | |
Not Identified | 3.7 (907) | 4.9 (1,994) | <0.001 |
Identified | 92.0 (22,471) | 88.0 (35,456) | |
Not Addressed | 4.3 (1,042) | 7.0 (2,840) | |
Code status at discharge: | N = 27,293 | N = 42,821 | |
Full | 30.5 (8,336) | 32.8 (14,050) | <0.001 |
Partial | 5.6 (1,517) | 2.1 (886) | |
DNR/DNI | 63.9 (17,440) | 65.1 (27,885) | |
N = 35,452 | N = 56,087 | ||
POLST Completed during PC consultation | 8.5 (3,002) | 16.9 (9,487) | <0.001 |
N = 35,665 | N = 56,545 | ||
Advanced directives completed during PC consultation | 3.4 (1,199) | 4.3 (2,454) | <0.001 |
N = 38,919 | N = 61,904 | ||
Mean (95%CI) | Mean (95%CI) | ||
Mean days followed by the PC Team | 6.85 (6.70-7.01) | 5.57 (5.40-5.74) | <0.001 |
Median (SD) | 4.0 (15.7) | 3.0 (21.1) | |
%(n) | %(n) | ||
Discharge Disposition: | N = 39,001 | N = 62,355 | |
Discharged alive | 56.7 (22,112) | 87.1 (54,283) | <0.001 |
Discharge Location: | N = 21,728 | N = 53,468 | |
Home | 31.2 (6,774) | 49.5 (26,471) | <0.001 |
Inpatient | 34.6 (7,524) | 17.8 (9,516) | |
Non-Hospital Facility | 29.4 (6,387) | 29.5 (15,791) | |
Other | 4.8 (1,043) | 3.2 (1,690) | |
Service provided if discharged: | N = 19,009 | N = 49,124 | |
None | 44.2 (8,395) | 34.1 (16,764) | <0.001 |
N = 19,004 | N = 49,075 | ||
Nursing Home | 12.2 (2,315) | 15.8 (7,755) | <0.001 |
N = 18,995 | N = 49,061 | ||
Clinic-based PC | 1.4 (274) | 6.0 (2,930) | <0.001 |
N = 18,995 | N = 49,061 | ||
Home-based PC | 3.1 (588) | 6.7 (3,270) | <0.001 |
N = 19,009 | N = 49,124 | ||
Hospice | 31.6 (5,998) | 35.3 (17,355) | <0.001 |
Treatment Outcomes | OR (95%CI) | P-value |
---|---|---|
N = 33,880 | ||
Patients receiving 2nd PC assessment 72 hours after 1st assessment | 1.62 (1.51,1.75) | <0.001 |
Symptom improvement from 1st to 2nd assessment | N = 7,818 | |
Pain | 1.13 (0.99,1.30) | 0.06 |
N = 2,784 | ||
Anxiety | 1.11 (0.91,1.35) | 0.32 |
N = 1,468 | ||
Nausea | 1.37 (0.86,2.17) | 0.19 |
N = 2,638 | ||
Dyspnea | 0.96 (0.81, 1.14) | 0.68 |
Surrogate decision maker at time of discharge: | N = 41,614 | |
Not Identified | 1.0 | |
Identified | 1.35 (1.23,1.48) | <0.001 |
Not Addressed | 0.79 (0.70,0.89) | <0.001 |
Code status at discharge: | N = 44,932 | |
Full | 1.0 | |
Partial | 3.62 (3.27,4.01) | <0.001 |
DNR/DNI | 1.44 (1.38,1.50) | <0.001 |
N = 58,777 | ||
POLST Completed during PC consultation | 0.61 (0.58,0.64) | <0.001 |
N = 59,220 | ||
Advance directives completed during PC consultation | 0.80 (0.73,0.87) | <0.001 |
Discharge Disposition: | N = 64,464 | |
Discharged alive | 0.19 (0.18,0.20) | <0.001 |
Discharge Location | N = 47,323 | |
Home | 0.48 (0.46,0.50) | <0.001 |
Inpatient | 2.4 (2.32,2.53) | <0.001 |
Non-Hospital Facility | 1.0 (0.96,1.05) | 0.85 |
Service provided if discharged | N = 43,219 | |
None | 1.24 (1.19,1.30) | <0.001 |
N = 43,180 | ||
Nursing Home | 0.65 (0.62,0.69) | <0.001 |
N = 43,162 | ||
Clinic-based PC | 0.41 (0.36,0.47) | <0.001 |
N = 43,162 | ||
Home-based PC | 0.48 (0.44,0.54) | <0.001 |
N = 43,219 | ||
Hospice | 1.07 (1.03,1.12) | 0.001 |
Discussion
Disclosures and Acknowledgments
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