The Association of Symptom Severity and Functional Status Among Patients Who Received Palliative Consults (Sch476)

1. Describe the association of functional status and symptom severity for 10 common symptoms among patients who receive palliative care consultation. 2. Consider the interaction of functional status and different symptoms when managing symptoms of patients who receive palliative care consultations. The interaction of functional status and individual symptoms has never been comprehensively investigated in palliative care (PC) populations. Therefore, we studied the relationship between the Karnofsky Performance Status (KPS) and the prevalence and severity of 10 common symptoms among hospitalized patients at the time of PC consult. Weretrospectively analyzed data from a registry of PC consults across five hospitals within the Mount Sinai Health System between January 1, 2020, and December 31, 2021. Demographics and ICD-10 codes were extracted from electronic medical and billing records. During consult, PC clinicians assessed functional status using the KPS at the time of consult (0%-100%) and symptom burden using the 10-item Edmonton Symptom Assessment Scale (ESAS), which rates each symptom as none, mild, moderate, or severe. The association of KPS and ESAS symptom severity was assessed using ordinal logistic regression models, adjusting for age, gender, Elixhauser comorbidity index, and the underlying serious illness (cancer, sepsis, dementia, COVID-19). The study population included 6,065 patients (mean age 70±16 years, 50.9% male). The most frequent underlying serious illnesses were sepsis (36.6%), cancer (32.9%), and dementia (22.8%). In regression analysis, KPS was significantly associated with symptom severity for all ESAS symptoms (p<0.001). However, symptoms separated into two different groups. Drowsiness (β=-0.85), inactivity (β=-0.71), dyspnea (β=-0.21), anorexia (β=-0.19), and agitation (β=-0.06) were negatively associated with KPS (ie, lower functional status was associated with more severe symptoms), whereas nausea (β=0.2), anxiety (β=0.15), physical discomfort (β=0.13), depression (β=0.13), and constipation (β=0.06) were positively associated with KPS (ie, lower functional status was associated with milder symptoms). These associations remained statistically significant after adjusting for baseline characteristics. While some symptoms were more severe, other symptoms were less severe among patients with poor functional status. This observation can inform symptom management and warrants further investigation. [ FROM AUTHOR] Copyright of Journal of Pain & Symptom Management is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Functional Status Changes in Patients Receiving Palliative Care Consult During COVID-19 Pandemic.

CONTEXT: Hospitalized patients with functional impairment have higher symptom burden and mortality. Little is known about how increased patient volume and acuity during the coronavirus disease 2019 (COVID-19) pandemic affected access to palliative care among patients with functional impairment. OBJECTIVES: To examine changes in functional status and hospital outcomes among patients receiving inpatient palliative care consultation before, during and after the COVID-19 pandemic. METHODS: We conducted a retrospective, multisite cohort study of all adult patients (≥ 18 years) admitted to four hospitals in New York City, USA, who received inpatient palliative care consultation between March 1, 2019 and February 28, 2022 with documented functional status at the time of consultation measured by Karnofsky Performance Status scale. RESULTS: Among 13,180 eligible patients identified, patients' functional status at the time of consultation decreased as palliative care consult volume increased with the onset of the pandemic. Compared to pre-pandemic, there was a statistically significant trend of lower functional status (P < 0.001) and higher in-hospital mortality (P < 0.001) among patients with noncancer and non-COVID-19 diagnoses two years after the pandemic. In contrast, patients with cancer had a statistically significant trend of higher functional status (P < 0.001) and no significant changes in in-hospital mortality over time. CONCLUSION: As the healthcare system was stressed with high demand and limited resources, palliative care consultation prioritized highest acuity patients by shifting towards those with lower functional status and higher in-hospital mortality. This shift disproportionately affected noncancer patients. Innovative approaches to ensure upstream palliative care consultation during increased resource constraints are needed.

Lessons Learned from an Embedded Palliative Care Model in the Medical Intensive Care Unit

Outcomes 1. Examine impact of an embedded model of palliative care delivery in the ICU 2. Brainstorm how to adapt this model of delivery into other ICU settings Background When palliative care is embedded in the medical intensive care unit (MICU), more critically ill patients with unmet palliative care needs can receive an earlier consultation and more value-aligned medical care. Aim Statement To describe an embedded physician (MD) + registered nurse (RN)-led palliative care consultation team in the MICU. To compare timing of consultation, goals of care documentation, and in-ICU mortality before and after the embedded team is implemented. Methods In a retrospective cohort study, we compared patients who received a referral-based MICU consult (pre-embedded) from 01/01/2019 to 06/30/2019, an MD/RN consult (embedded) from 09/01/2019 to 02/28/2020 and an adapted COVID MICU consult from 03/1/2020 to 8/31/2020. Using the electronic health record, we collected sociodemographic and clinical data to compare the consultation volume, patient sociodemographics, rates of documentation of medical decision makers and goals of care, and in-ICU deaths. Results The number of patients who received a MICU palliative care consult increased by 2.4 times (63 patients [pre] vs 169 patients [embedded]) As compared to pre-embedded, there was a significant increase in the documentation of medical decision makers (39% vs 90%, p < .001) and goals of care (34% vs. 90%, p < .001) during the embedded period. Patients were seen earlier in the hospitalization (median 9 days [pre-embedded] vs 3 days [embedded], p < .001);the rate of in-ICU death decreased (75% vs 43%, p < .001). During COVID, there was no change in documentation of decision makers (90% [embedded] vs 93% [COVID], p = .24), goals of care (98% vs 99%, p = 0.63), or time to consult (3 days vs 4 days, p = .08), yet, the rate of in-ICU death increased (43% vs 58%, p = .01). Conclusions and Implications The embedded model provided earlier consultation, increased medical decision maker and goals of care documentation, and decreased in-ICU mortality for MICU patients. Future work will examine how to adapt this model to other ICUs to improve palliative care access for critically ill patients.

Characteristics Associated With Disparities Among Older Adults in Coronavirus Disease 2019 Outcomes in an Academic Health Care System.

BACKGROUND: An improved understanding of the coronavirus disease 2019 (COVID-19) pandemic is needed to identify predictors of outcomes among older adults with COVID-19. OBJECTIVE: The objective of this study was to examine patient and health system factors predictive of in-hospital mortality, intensive care unit (ICU) admission, and readmission among patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: A cohort study of patients aged 18 years and older with COVID-19 discharged from 5 New York hospitals within the Mount Sinai Health System (March 1, 2020-June 30, 2020). MEASURES: Patient-level characteristics (age, sex, race/ethnicity, comorbidities/serious illness, transfer from skilled nursing facility, severe acute respiratory syndrome coronavirus 2 viral load, Sequential Organ Failure Assessment score, treatments); hospital characteristics. OUTCOMES: All-cause in-hospital mortality; ICU admission; 30-day readmission. RESULTS: Among 7556 subjects, mean age 61.1 (62.0) years; 1556 (20.6%) died, 949 (12.6%) had an ICU admission, and 227 (9.1%) had a 30-day readmission. Increased age [aged 55-64: odds ratio (OR), 3.28; 95% confidence interval (CI), 2.41-4.46; aged 65-74: OR, 4.67; 95% CI, 3.43-6.35; aged 75-84: OR, 10.73; 95% CI, 7.77-14.81; aged 85 y and older: OR, 20.57; 95% CI, 14.46-29.25] and comorbidities (OR, 1.11; 95% CI, 1.16, 2.13) were independent risk factors for in-hospital mortality. Yet older adults (aged 55-64 y: OR, 0.56; 95% CI, 0.40-0.77; aged 65-74: OR, 0.46; 95% CI, 0.33-0.65; aged 75-84: OR, 0.27; 95% CI, 0.18-0.40; aged above 85 y: OR, 0.21; 95% CI, 0.13-0.34) and those with Medicaid (OR, 0.74; 95% CI, 0.56-0.99) were less likely to be admitted to the ICU. Race/ethnicity, crowding, population density, and health system census were not associated with study outcomes. CONCLUSIONS: Increased age was the single greatest independent risk factor for mortality. Comorbidities and serious illness were independently associated with mortality. Understanding these risk factors can guide medical decision-making for older adults with COVID-19. Older adults and those admitted from a skilled nursing facility were half as likely to be admitted to the ICU. This finding requires further investigation to understand how age and treatment preferences factored into resource allocation.

Access to Palliative Care Consultation for Hospitalized Adults with COVID-19 in an Urban Health System: Were There Disparities at the Peak of the Pandemic?

Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1-June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities.

Expanding the Palliative Care Workforce during the COVID-19 Pandemic: An Evaluation of Core Palliative Care Skills in Health Social Workers.

Background: Meeting the needs of seriously ill SARS-CoV-2 (COVID-19) patients requires novel models of deploying health social workers (SWs) to expand the palliative care workforce. To inform such expansion, understanding the current state of health SWs' core palliative care skills is necessary. Methods: Following minimal training, health SWs in one New York City hospital were surveyed about their frequency, competence, and confidence in using core palliative care skills. Results: Of the 170 health SWs surveyed, 46 (27%) responded, of whom 21 (46%) and 24 (52%) had palliative care training before and during the COVID-19 surge, respectively. Health SWs reported a "moderate improvement" in the use of three skills: "identify a medical decision maker," "assess prognostic understanding," and "coordinate care." There was "minimal decrease" to "no improvement" to "minimal improvement" in competence and confidence of skill use. Conclusion: Our findings suggest that educational initiatives can improve health SWs' use of core palliative care skills.

Palliative Care as Essential to a Hospital System's Pandemic Preparedness Planning: How to Get Ready for the Next Wave.

The sudden and unprecedented increase in seriously ill patients with COVID-19, coupled with both the lack of core palliative care training and expertise among frontline providers and the specialty-trained palliative care workforce shortage, produced immediate challenges to meet the needs of this novel seriously ill patient population. In this article, we describe the rapid expansion and creation of new specialty palliative care services across a health system to meet demands of the COVID-19 surge in New York City. During April 2020, 1019 patients received inpatient specialty palliative care consultations across the Mount Sinai Health System. This overview demonstrates how palliative care services can be titrated up rapidly to meet the acute increase in hospitalized persons with serious illness due to COVID-19, and how these services tailored to the changing needs across a health system.

Creating a Colocation Unit for End-of-Life Care during a Pandemic.

Background: Palliative care seeks to support the physical, psycho-social and spiritual needs of patients and families who are facing life threatening diseases. Advantages of establishing a palliative care unit, or alternatively co-locating patients, include promoting optimal physical and psychological symptom management; increased family satisfaction; and facilitating resource allocation. Objective: To design a stand-alone hospital unit to provide end of life care during a pandemic. Setting: Mount Sinai Hospital (MSH), a 1,144 bed tertiary- and quaternary-care teaching facility and Brookdale Department of Geriatrics and Palliative Medicine of the Icahn School of Medicine at Mt Sinai. Method: Tracking key indicators signaling the need for conversion to a COVID-19 unit, and identifying factors to facilitate a successful conversion. Result/Implementation: Using previously identified key focused action categories as framework, we describe our successful palliative care unit (PCU) conversion into a COVID-19 care unit. Conclusion: We believe that these operational insights gained from transforming our unit during COVID-19 will be helpful to other programs and institutions during a pandemic, or public health emergencies.