Clinical Outcomes of Patients Hospitalized with Coronavirus Disease 2019 (COVID-19) in Boston.

BACKGROUND: Outcomes of hospitalized patients with COVID-19 have been described in health systems overwhelmed with a surge of cases. However, studies examining outcomes of patients admitted to hospitals not in crisis are lacking. OBJECTIVE: To describe clinical characteristic and outcomes of all patients with COVID-19 who are admitted to hospitals not in crisis, and factors associated with mortality in this population. DESIGN: A retrospective analysis PARTICIPANTS: In total, 470 consecutive patients with COVID-19 requiring hospitalization in one health system in Boston from January 1, 2020 to April 15, 2020. MAIN MEASURES: We collected clinical outcomes during hospitalization including intensive care unit (ICU) admission, receipt of mechanical ventilation, and vasopressors. We utilized multivariable logistic regression models to examine factors associated with mortality. KEY RESULTS: A total of 470 patients (median age 66 [range 23-98], 54.0% male) were included. The most common comorbidities were diabetes (38.5%, 181/470) and obesity (41.3%, 194/470). On admission, 41.9% (197/470) of patients were febrile and 60.6% (285/470) required supplemental oxygen. During hospitalization, 37.9% (178/470) were admitted to the ICU, 33.6% (158/470) received mechanical ventilation, 29.4% (138/470) received vasopressors, 16.4% (77/470) reported limitations on their desire for life-sustaining therapies such as intubation and cardiopulmonary resuscitation, and 25.1% (118/470) died. Among those admitted to the ICU (N=178), the median number of days on the ventilator was 10 days (IQR 1-29), and 58.4% (104/178) were discharged alive. Older age (OR=1.04, P<0.001), male sex (OR=2.14, P=0.007), higher comorbidities (OR=1.20, P=0.001), higher lactate dehydrogenase on admission (2nd tertile: OR=4.07, P<0.001; 3rd tertile: OR=8.04, P<0.001), and the need for supplemental oxygen on admission (OR=2.17, P=0.014) were all associated with higher mortality. CONCLUSIONS: The majority of hospitalized patients with COVID-19 and those who received mechanical ventilation survived. These data highlight the need to examine public health and system factors that contribute to improved outcomes for this population.

Quality Indicators in Surgical Palliative Care: A Systematic Review.

CONTEXT: Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs. OBJECTIVES: To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality. METHODS: A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality. RESULTS: There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators. CONCLUSION: This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.

Older Adult Perspectives on Medical Decision Making and Emergency General Surgery: "It had to be Done."

CONTEXT: Optimal surgical care for older adults with life-threatening conditions, with high risk of poor perioperative outcomes and morality in the months after surgery, should incorporate an understanding of the patient's treatment goals and preferences. However, little research has explored the patient perspective of decision making and advanced care planning during an emergency surgery episode. OBJECTIVES: We sought to better understand older patients' lived experience making decisions to undergo emergency general surgery (EGS) and perceptions of perioperative advance care planning (ACP). METHODS: Adults aged 65 and older who underwent one of seven common EGS procedures with lengths of stay more than five days at three Boston-area hospitals were included. Semistructured phone interviews were conducted three months postdischarge. Transcripts were reviewed and coded independently by surgeons and palliative care physicians to identify themes. RESULTS: About 31 patients were interviewed. Patients viewed the decision for surgery as a choice of life over death and valued prolonging life. They felt there was no choice but to proceed with surgery but reported that participation in decision making was limited because of severe symptoms, time constraints, and confused thinking. Despite recently surviving a life-threatening illness, patients had not reconsidered their wishes for the future and preferred to avoid future ACP. CONCLUSION: Older patients who survived a life-threatening illness and EGS report receiving goal-concordant care in the moment that relieved symptoms and prolonged life but had not considered future care. Interventions to facilitate postoperative ACP should be targeted to this vulnerable group of older adults.

Association Between Patient-Reported Frailty and Non-Home Discharge Among Older Adults Undergoing Surgery.

BACKGROUND/OBJECTIVES: Identifying surgical patients at risk for discharge to a post-acute facility has the potential to reduce hospital length of stay, improve postoperative planning, and increase patient satisfaction. We sought to examine the association between a positive response to a preoperative patient-reported frailty screen and non-home discharge (NHD). DESIGN: Prospective cohort. SETTING: Urban tertiary academic preoperative evaluation center. PARTICIPANTS: Convenience sample of patients aged 60 and older evaluated from November 2018 to August 2019) undergoing one of 14 major elective general and vascular operations with an expected length of stay of 3 days or longer. METHODS: Items from the previously validated Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL) screen were modified, and patients were queried on fatigue, activity against resistance, ambulation, and weight loss. Multivariable logistic regression adjusting for age and sex was used to determine the association between patient-reported items and NHD. RESULTS: A total of 230 patients were included for analysis. The average age of the cohort was 70.1 (standard deviation = 7.1); 91.7% were White, and 52.4% were female. There were 24 patients (10.4%) who were not discharged home. They were more likely to report fatigue (54% vs 29%; P = .01), weight loss (58% vs 21%; P < .01), and difficulty with activity against resistance (33% vs 7%; P < .01) before surgery. In adjusted analysis, patients who self-reported frailty (FRAIL screen ≥2) were significantly more likely to have an NHD (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 1.7-11.7; P < .01), as were patients who responded "yes" to any question from the FRAIL screen (OR = 2.5; 95% CI = 1.7-3.5; P < .01). A positive response to difficulty with activity against resistance or recent weight loss showed similar odds of NHD (OR = 7.6; 95% CI = 2.6-23.9; P < .01; and OR = 7.9; 95% CI = 2.9-21.6; P < .01, respectively). CONCLUSION: Patient response to screening questions on the FRAIL screen identified those at highest risk of NHD. The FRAIL screening tool is practical, easy to apply, and could be used during preoperative counseling to identify patients likely to have increased discharge planning needs.