Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States of America.
Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
PLoS One. 2021 Aug 11;16(8):e0255989. doi: 10.1371/journal.pone.0255989. eCollection 2021.
Automated specialty palliative care consultation (SPC) has been proposed as an intervention to improve patient-centered care in the intensive care unit (ICU). Existing automated SPC trigger criteria are designed to identify patients at highest risk of in-hospital death. We sought to evaluate common mortality-based SPC triggers and determine whether these triggers reflect actual use of SPC consultation. We additionally aimed to characterize the population of patients who receive SPC without meeting mortality-based triggers.
We conducted a retrospective cohort study of all adult ICU admissions from 2012-2017 at an academic medical center with five subspecialty ICUs to determine the sensitivity and specificity of the five most common SPC triggers for predicting receipt of SPC. Among ICU admissions receiving SPC, we assessed differences in patients who met any SPC trigger compared to those who met none.
Of 48,744 eligible admissions, 1,965 (4.03%) received SPC; 979 (49.82%) of consultations met at least 1 trigger. The sensitivity and specificity for any trigger predicting SPC was 49.82% and 79.61%, respectively. Patients who met no triggers but received SPC were younger (62.71 years vs 66.58 years, mean difference (MD) 3.87 years (95% confidence interval (CI) 2.44-5.30) p<0.001), had longer ICU length of stay (11.43 days vs 8.42 days, MD -3.01 days (95% CI -4.30 --1.72) p<0.001), and had a lower rate of in-hospital death (48.68% vs 58.12%, p<0.001).
Mortality-based triggers for specialty palliative care poorly reflect actual use of SPC in the ICU. Reliance on such triggers may unintentionally overlook an important population of patients with clinician-identified palliative care needs.
自动化专科姑息治疗咨询（SPC）已被提议作为一种干预措施，以改善重症监护病房（ICU）的以患者为中心的护理。现有的自动化 SPC 触发标准旨在识别住院期间死亡风险最高的患者。我们试图评估常见的基于死亡率的 SPC 触发因素，并确定这些触发因素是否反映了 SPC 咨询的实际使用情况。我们还旨在描述不符合基于死亡率的触发因素但接受 SPC 的患者人群。
我们对 2012 年至 2017 年期间在一家学术医疗中心的五个专科 ICU 进行的所有成年 ICU 入院进行了回顾性队列研究，以确定五种最常见的 SPC 触发因素预测接受 SPC 的敏感性和特异性。在接受 SPC 的 ICU 入院中，我们评估了符合任何 SPC 触发因素的患者与不符合任何 SPC 触发因素的患者之间的差异。
在 48744 名合格的入院患者中，有 1965 名（4.03%）接受了 SPC；979 名（49.82%）咨询符合至少 1 个触发因素。任何触发因素预测 SPC 的敏感性和特异性分别为 49.82%和 79.61%。虽然没有触发因素但接受 SPC 的患者更年轻（62.71 岁 vs 66.58 岁，平均差值（MD）为 3.87 岁（95%置信区间（CI）为 2.44-5.30）p<0.001），ICU 住院时间更长（11.43 天 vs 8.42 天，MD-3.01 天（95%CI-4.30-1.72）p<0.001），住院死亡率较低（48.68% vs 58.12%，p<0.001）。
基于死亡率的 SPC 触发因素不能很好地反映 ICU 中 SPC 的实际使用情况。依赖这些触发因素可能会无意中忽略具有临床医生确定的姑息治疗需求的重要患者群体。
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