Division of Palliative Medicine, Scripps Health, San Diego, California, USA.
J Palliat Med. 2021 Apr;24(4):554-560. doi: 10.1089/jpm.2020.0082. Epub 2020 Sep 8.
Emergency department (ED) initiated palliative consultation impacts downstream care utilization. Various admission consult triggers have been proposed without clear best practice or outcomes. This 18-month single-center study evaluated the clinical, operational, and financial impact of simplified admission triggers for ED-initiated palliative consults as compared to downstream Floor and intensive care unit (ICU) palliative consults initiated per usual practice. We distilled ED admission triggers into three criteria to ensure bedside actionability and sustainability: (1) end-stage illness, (2) functional limitation, and (3) clinician would not be surprised if the patient died this hospitalization. Eligible patients met all criteria, and received consultation within 24 hours of admission. We compared ED-initiated consults against Floor and ICU consults from March 1, 2018, to September 30, 2019, with matched cohort analysis to evaluate financial outcomes. While overall palliative consult volume remained intentionally steady, the proportion of ED-initiated consults significantly increased (7% vs. 19%, < 0.001). ED consistently comprised 15-25% of all monthly palliative consults. Compared with Floor, ED had similar ED length of stay (LOS) and inpatient mortality. Among live discharges, ED were more likely to be referred to hospice than Floor (59% vs. 47%, = 0.24) or ICU (59% vs. 34%, = 0.02). In a matched cohort analysis, ED demonstrated median cost avoidance of $9,082 per patient versus Floor ($5,578 vs. $14,660, < 0.001) and $15,138 per patient versus ICU ($5,578 vs. $20,716, < 0.001). ED had significantly shorter median LOS before consult than Floor (0 vs. 3 days, < 0.001) or ICU (0 vs. 3 days, < 0.001), which did not differ between live discharges or inpatient deaths. Overall hospital LOS was disproportionately shorter for ED, with a net difference-in-differences of 1-3.5 days compared to Floor and ICU. Simple ED admission triggers to expedite palliative engagement are associated with a 50-75% reduction in both hospital LOS and costs when compared against usual palliative consultation practice. ED initiation reduces both lead time before consultation and subsequent downstream hospitalization length.
急诊科启动的姑息治疗咨询会影响下游的护理利用情况。已经提出了各种入院咨询触发因素，但没有明确的最佳实践或结果。这项为期 18 个月的单中心研究评估了简化急诊科启动的姑息治疗咨询的临床、运营和财务影响，与按照常规实践启动的 Floor 和重症监护病房（ICU）姑息治疗咨询进行了比较。我们将急诊科入院触发因素提炼为三个标准，以确保床边的可操作性和可持续性：（1）终末期疾病，（2）功能限制，以及（3）如果患者在本次住院期间死亡，临床医生不会感到惊讶。符合条件的患者均符合所有标准，并在入院后 24 小时内接受咨询。我们将急诊科启动的咨询与 2018 年 3 月 1 日至 2019 年 9 月 30 日期间的 Floor 和 ICU 咨询进行了匹配队列分析，以评估财务结果。虽然姑息治疗咨询总量保持稳定，但急诊科启动的咨询比例显著增加（7%对 19%，<0.001）。急诊科始终占每月姑息治疗咨询的 15-25%。与 Floor 相比，急诊科的急诊科留观时间（LOS）和住院死亡率相似。在存活出院患者中，急诊科比 Floor（59%对 47%，=0.24）或 ICU（59%对 34%，=0.02）更有可能被转介到临终关怀。在匹配队列分析中，与 Floor 相比，急诊科的每位患者的中位成本避免额为 9082 美元（5578 美元对 14660 美元，<0.001），与 ICU 相比，每位患者的中位成本避免额为 15138 美元（5578 美元对 20716 美元，<0.001）。急诊科在咨询前的中位 LOS 明显短于 Floor（0 天对 3 天，<0.001）或 ICU（0 天对 3 天，<0.001），而存活出院或住院死亡患者之间没有差异。急诊科的总住院 LOS 明显缩短，与 Floor 和 ICU 相比，差异在 1-3.5 天之间。与常规姑息治疗咨询实践相比，简单的急诊科入院触发因素可以将姑息治疗的参与时间和成本缩短 50-75%。急诊科的启动缩短了咨询前的前置时间和随后的下游住院时间。
