Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project.

CONTEXT: There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). OBJECTIVE: To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. METHODS: In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to "do not resuscitate" (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. RESULTS: In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR-adjusted odds ratio (AOR) = 7.5; 95% CI 5.6-9.9) and hospice referrals-(AOR = 7.6; 95% CI 5.0-11.7). They had slightly lower 30-day readmissions-(AOR = 0.7; 95% CI 0.5-1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation-by Day 4 of admission-was associated with reductions in LOS (1.7 days [95% CI -3.1, -1.2]) and average direct variable costs (-$1815 [95% CI -$3322, -$803]) compared to those who received no PCC. CONCLUSION: Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.

Can regulation improve safety in critical care?

This article examines national and state safety practice initiatives, including the Centers for Medicare and Medicaid Services quality focus, federal and state outcomes reporting, and consumer access to outcomes data. The efforts of national and regional legislators and health care institutions to create regulations for staffing and technology to reduce medical errors is reviewed. The potential of a unified cooperative effort from all stakeholders to implement the above initiatives to improve intensive care unit safety practices is discussed.

Pulmonary embolism.

Pulmonary embolism is a commonly suspected but underdiagnosed condition of clinical significance. Preventable deaths continue to occur. We begin this article with an overview of prognosis, clinical evidence, signs and symptoms, and risk factors, followed by an in-depth evaluation of diagnostic techniques and treatment modalities. The greatest improvement in mortality from pulmonary embolism is likely to come from improved and aggressive prevention and prophylaxis by the critical care team.