Friday, June 8, 2007

2 year anniversary; Medical blogging; Palliative consultation decreases ICU LOS

Well this is the 2 year anniversary of Pallimed and the 360ish post (my God that means we've posted nearly every other day for 2 years). Hooray. I want to thank all the readers and commenters on the blog and all the people over the last 2 years who have given Christian and me encouraging feedback on Pallimed.

Not wanting to wallow in self-congratulation too much here...but I'd also like to thank Christian for his contributions to Pallimed - for the reformat to be sure - but also his unique voice and perspective.

It's not the happiest time to be a medical blogger. There have been several bloggers who have recently packed up shop - frequently due to fear of liability (professionally or legally) - this is particularly true of anonymous bloggers. Most notably for us - Hospice Guy at Hospice Blog seems to be bidding adieu due to concerns for being outed and damaging his own organization or others. Frankly I don't really understand how this could be the case - his blog is so mild mannered & well-reasoned &, well, wise - but that, I guess, doesn't make one immune. I'm not sure if I'm naive or not to think that we are immune from such consequences at Pallimed. The blog, however, has never been anonymous, we don't post about patients or really any personal stuff, the tone has (almost) always been civil and constructive, and probably the most controversial things I've said are that I have ethical queasiness about assisted suicide (although firmly believing it shouldn't be criminal) and that I'm an irreligious & well-left-of-center-politically sort of guy, but this isn't anything I'd hide from my patients (if it ever came up), employers, or a court. If this gets me into trouble, then, well, may god have mercy on us all. Hospice Guy - so long and good luck. I guess I'll add that if lawyers or my employers are reading this, I'll refer you to the disclaimer at the very bottom of the Pallimed homepage.

Back to the blogging - an important article for the profession (thanks to Dr. Dana Lustbader for letting me know about this paper). It's a study in the current Critical Care Medicine about the impact of a proactive palliative care consultation project in an MICU . The study was a project at the University of Rochester and involved 'automatic' palliative care consultation in the ICU if patients met certain criteria: "a) ICU admission following a current hospital stay of >=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g.; end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest (usually with other serious co-morbid conditions); or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation." The project involved a 4 month baseline in which patients were screened but received usual care (this group of 65 patients was the control group) and then a 7.5 month phase in which those patients who screened 'positive' were automatically seen by the hospital's palliative care team. (Well, almost - the patient's chart was reviewed and symptom management, goals of care, psychosocial/family issues were discussed with the MICU team but the MICU attending could elect to not actually have the PC team meet the patient/family. This is an interesting aspect of the project; one which makes the final outcome that much more impressive as well as would make similar projects more politically acceptable to many ICU teams.)

In a pattern that will be recognizable to many-a palliative care clinician, in the baseline phase 65 patients screened 'positive,' only 5 of these were referred to PC for consultation, and the average consultation occurred on ICU day 14. That rings true to experience. Some interesting prognostic data: in-hospital mortality rate was similar in the baseline and intervention groups (55-60%) as was the in-ICU mortality (~37%). Regarding their screening criteria, in-hospital mortality was 54% for patients hospitalized >10 days prior to ICU admission; 55% for the >80 year olds; 63% for the cancer patients; 74% for the arrest patients; 54% for the ICH patients.

As far as their major outcomes, 25% of patients received a 'complete' palliative consultation at an average of 5 days after MICU admission. MICU LOS was much shorter (for those who died in the MICU) in the intervention group ( 5.7 vs. 14 days). In addition MICU LOS for all patients was shorter in the intervention group (9 vs 16 days). Hospital LOS was not changed.

The authors' conclusions: 'proactive' PC consultation dramatically decreased MICU LOS in a very sick cohort, did not affect overall hospital LOS, and did not affect mortality (comparing the outcomes of similarly screened groups of patients before-after the intervention). All this despite only 25% of the intervention group actually had full palliative care consultation raising the question of the effect of the 'basic' consultation itself (simply raising symptom and goals of care issues with the MICU team had an effect?). Anyway if anything this underestimates the effects of what PC consultation could do. On the other hand one could argue that the LOS went down dramatically because of a change in practice in the MICU service during the study - e.g. more 'sensitive' to goals of care issues etc. due to the very fact a study was being done. However it's hard to imagine this, itself, would nearly halve a team's average LOS and these results are quite convincing despite the obvious limitations of a study of this kind. In fact one's real wish for this study is that they had gathered more information (symptoms, patient/family satisfaction, bereavement, acceptability to ICU team members, and health care costs although one assumes they were dramatically decreased due to the reduction in ICU LOS) - however this was probably a pragmatic study of a quality improvement project without the means to do such an expensive research endeavor. Which, actually, is part of its strength - it seems very reproducible and they did this without any major research. So I think this will be a very important study - particularly in a political sense - for our profession, insofar as much of our growth in the US has been supported by institutions who believe our services decrease unnecessary health care utilization (see CAPC). It will also seems to be an exemplary example of ICU-PC collaboration that would hopefully acceptable to many ICU services (final decision about full PC consult remains with ICU team; does not seem to lead to more deaths, just faster transfer of patients to presumably a more appropriate level of care - out of the ICU)...a piece of good news to start Pallimed's 3rd year.

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