What is the in-hospital mortality rate of older adults after undergoing emergency intubation?

The author conducted a retrospective cohort study using Vizient’s database, which included 226 hospitals (total 35,036 patients) data of patients aged 65 and older who were intubated in the ED from January 1, 2008 to December 31, 2015.

The outcomes of patients aged 65 and older who were intubated in the ED were categorized into 3 groups; survived and discharged to home (27%), survived and discharged to a location other than home (40%), and died in hospital (33%). The factors associated with a higher in-hospital mortality rate were older than 89 years old (OR=2.6), transferred from another hospital (OR=1.7), had CCI>4 (OR=1.5), admission diagnoses of cerebrovascular disease and sepsis (OR=2.4, OR=1.5). The factors associated with a lower odds were black patients (OR=0.8), patients came from the Midwestern Region (OR=0.9), admission diagnoses of congestive heart failure (CHF, OR=0.5), respiratory failure (OR=0.5), and altered mental status/seizure (OR=0.7). To improve shared decision making between clinicians and patients/surrogates this study can help clinicians and patients/surrogates make decisions regarding intubation for their patients/their loved ones.

This study shows the factors associated with both higher and lower odds of in-hospital mortality for the adults aged 65 and older who meet intubation criteria in the ED. As we know from prior studies, intubations can lead to prolonged mechanical intubation, ventilator-associated pneumonia, and a high probability of living in a long-term care facility. These factors can help emergency physicians counsel patients/surrogates in the shared decision-making regarding ED intubation for older adults. Furthermore, this would help surrogates understand and prepare loved ones after the patients have been discharged to a location other than home. However, this study did not show post-hospitalization outcomes, compare patients who refused intubation and intubated patients, or pre-post intubation status. These data would help in shared decision-making and should be further explored in future studies.

What are ED patients’ and providers’ perceptions of barriers to outpatient palliative care consultations and referrals from the ED?

At a single academic ED, the authors conducted a written survey with a convenience sample of 51 ED patients deemed at risk of functional decline by clinician gestalt or a scoring system (the Elderly Risk Assessment) (67% response rate). The authors also conducted a web-based survey with a convenience sample of 48 emergency clinician respondents from the same department (47% response rate).

Nearly half of patients reported needing more resources and care at home to prevent hospital visits (44%) and had visited the ED at least once due to lack of resources at home (49%). Almost all providers reported caring for patients who would benefit from palliative care consultation (98%). Patients and providers alike perceived patient understanding of palliative care and access to appointments as barriers to consultation. About half of emergency providers additionally cited emergency provider understanding of palliative care as a barrier (52%). From these findings, the authors highlighted lack of understanding of palliative care and lack of access to appointments as contributors to underutilization of ED referral to outpatient palliative care.

This study suggests a role for increased education of patients and EM providers about palliative care as well as increased referral of ED patients to outpatient palliative care consultations. Further training or continuing medical education opportunities could address providers’ self-identified lack of comfort with palliative care and goals-of-care discussions. However, results from this single academic site may not be generalizable to community EDs. The absence of demographic information about patient and provider respondents raises questions about how patients’ sociocultural identities and providers’ training backgrounds affect understandings of and acceptance of referrals to palliative care; these attributes may also vary significantly by ED site. As understanding of palliative care is cited as a barrier to consultation, qualitative research could better characterize patients’ and providers’ perceptions and meanings associated with palliative care.

Does early ED consultation of palliative care have direct effects on hospital length of stay, direct hospital costs, and effect on workflow for both emergency medicine and palliative care end-users of the system?

This study was a quasi-experimental prospective cohort design, conducted over an 18-month period in a community academic center with over 70,000 annual ED visits. Patients screened in if 3 of 3 inclusion criteria were met: presence of an end stage illness as determined by the treating emergency physician, functional limitation to mostly bed or chair, and the physician would not be surprised if the patient died during this admission. There were no exclusion criteria. Workflow impacts for both emergency medicine and palliative care clinicians were carefully considered to minimize added work or disruption in patient flow, with a goal to identify patients who would likely later receive palliative care consultation and initiate that process earlier. Subjects were matched for financial analysis by gender, age (within 5 years), and case mix index within 0.25.

Over 18 months, total palliative care consult volume increased 2.9%, consistent with prior annualized growth. The percentage of consults initiated in the ED increased from 7% to 19% of total, and floor decreased from 76% to 57%. ICU-initiated consults remained unchanged. For patients discharged alive, median hospital LOS was 3 days for ED-initiated consults vs 7 days for floor -initiated (p<0.001) and 7 days for ICU (P<0.001). For inpatient deaths, median LOS was 1.5 days for ED consults vs 8 for floor (p<0.001) and 7 for ICU (p<0.001).  Median direct hospital costs were $5,578 for ED consults vs $14,660 for floor (p<0.001) and $20,716 for ICU (p<0.001). Mean direct costs were $9,725 for ED vs $21,779 for floor (p<0.001) and $28,577 for ICU (p<0.001).

The authors concluded that over the 18-month study period palliative care consult volume grew sustainably at the previous annualized rate, indicating that ED-initiated consult shifted timing earlier for appropriate consults, without adding overall volume.  ED-initiated consult decreased LOS, and direct costs, by 50-75%. All stakeholder goals were met, without reported grievances. Limitations included the lack of inclusion of a third matched arm who received no palliative care consultation, that direct costs represent hospital savings in a value-based care model but not necessarily in a fee for service model, and that there was a fairly high rate of data loss for financial analysis due to inadequate matching (9% of ED patients, 26% of floor patients, 45% of ICU patients), that the sensitivity and specificity of the ED consult trigger criteria could not be determined, and that generalizability of results to centers with less integration of palliative care services is unclear. Overall, this was a thoughtful and pragmatic study that prioritized ED and palliative care end-user considerations and showed a convincing reduction in hospital LOS and cost, while adding little burden to end-users.