Venous thromboembolism (VTE) is increasingly diagnosed among individuals with hematologic malignancies. However, the risk of VTE among patients undergoing hematopoietic stem cell transplantation (HSCT) is unclear. We examined the incidence and risk factors for VTE and bleeding among 1514 patients undergoing in-patient HSCT. No protocolized VTE prophylaxis was used. By HSCT day 180, 75 symptomatic VTE occurred in 70 patients (4.6%; 95% confidence interval [CI], 3.6%-5.8%). Fifty-five (3.6%) were catheterassociated, 11 (0.7%) were non-catheterassociated deep venous thromboses, and 9 (0.6%) were pulmonary emboli. Thirtyfour percent of VTE occurred at a platelet count less than 50 ؋10 9 /L; 13% occurred at a platelet count less than 20 ؋10 9 /L. In multivariate analysis, VTE was associated with prior VTE (odds ratio [OR], 2.9; 95% CI, 1.3-6.6) and with graft-versushost disease (GVHD; OR, 2.4; 95% CI, 1.4-4.0). Clinically significant bleeding occurred in 230 patients (15.2%; 95% CI, 13.4%-17.1%); 55 patients (3.6%; 95% CI, 2.7%-4.7%) had fatal bleeding. Bleeding was associated with anticoagulation (OR, 3.1; 95% CI, 1.8-5.5), GVHD (OR, 2.4; 95% CI, 1.8-3.3), and veno-occlusive disease (OR, 2.2; 95% CI, 1.4-3.6). In HSCT patients, VTE is primarily catheter-related and 3-fold less common than clinically significant bleeding. These findings warrant consideration when selecting VTE prophylaxis in HSCT patients. (Blood. 2008;112:504-510)
Evaluation of implementation of the protocol showed improved timeliness and adherence to sepsis practice guidelines. Postintervention adherence to threshold times for obtaining blood cultures and blood lactate and start of antibiotics showed improvement. All recommended interventions were completed within the target time frame for the majority of patients.
PURPOSE: Immunotherapy has rapidly become the mainstream treatment of multiple cancer types. Since the first drug approval in 2011, we have noted a decline in referrals from inpatient oncology to hospice and an increase in referrals to subacute rehabilitation (SAR) facilities, possibly with the aim of getting strong enough for immunotherapy and other promising drugs. This study explores outcomes after discharge to SAR, including rates of cancer-directed therapy after SAR, overall survival, and hospice use. METHODS: We performed an electronic chart review of patients discharged from our inpatient oncology units to SAR facilities from 2009 to 2017. Demographics, admission statistics, and post-discharge outcomes were gathered from discharge summaries and targeted chart searches. RESULTS: Three hundred fifty-eight patients were referred to SAR 413 times. One hundred seventy-four patients (49%) returned to the oncology clinic before readmission or death, and only 117 (33%) ever received additional cancer-directed treatment (chemotherapy, radiation, or immunotherapy). Among all discharges, 28% led to readmissions within 30 days. Seventy-four patients (21%) were deceased within 30 days, only 31% of whom were referred to hospice. Palliative care involvement resulted in more frequent do not resuscitate code status, documented goals of care discussions, and electronic advance directives. CONCLUSION: A growing number of oncology inpatients are being discharged to SAR, but two thirds do not receive additional cancer therapy at any point, including a substantial fraction who are readmitted or deceased within 1 month. These data can help guide decision making and hospital discharge planning that aligns with patients’ goals of care. More clinical data are needed to predict who is most likely to benefit from SAR and proceed to further cancer therapy.
1 Background: Advanced life support resources are required for optimal care of patients undergoing curative therapy, but their use in patients with terminal disease does not improve patient outcomes. In 2007, our cancer center established the Duffey Pain and Palliative Care team, and one important goal was to help our physicians improve at discussing end-of-life issues with patients. We hypothesized that if this effort was effective, it would result in less utilization of intensive care unit (ICU) management among patients who die in the center. Methods: All inpatient deaths were systematically tabulated and code status displayed at the multidisciplinary Morbidity and Mortality review twice per quarter, beginning in July 2006. Utilization of ICU care, defined as ventilator or dialysis support, was identified from billing data and confirmed by chart review. Survival to discharge among patients who received ICU care was monitored as a component of our patient safety dashboard. Results: From 2008 through 2011, 525 oncology patients died while hospitalized in the cancer center. During this period, among patients who died, there was a gradual increase in no-code status, election of comfort care, or withdrawal of ICU support, from 81% to 95% (OR 1.14 per quarter, p<0.0001). Although the proportion of patients who received any ICU care during their terminal hospitalization did not change, the duration of such care decreased: the proportion with mechanical ventilation for over 14 days decreased from 10% to 5% (OR 0.93 per quarter, p<0.05). There was no decrease in the survival-to-discharge of patients who received ICU care. Conclusions: A multidisciplinary team approach to improve discussion of end-of-life issues, combined with regular feedback to cancer center staff regarding code status at death, resulted in significant changes in patient and family decisions about management at the end of life over a four-year interval. These changes have reduced utilization of ICU care during terminal hospitalizations with no reduction in the survival-to-discharge of all patients who receive ICU care. We propose appropriate establishment of code status and survival-to-discharge of ICU patients as measures of quality oncology care.
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