Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting

Abstract

ObjectiveIn the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients’ wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State.MethodA retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form.ResultThere were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.Significance of resultsCompleting an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.

The influence of POLST on treatment intensity at the end of life: A systematic review

“…We also found consistent evidence across five good quality 14,34,41,47,52 and three poor quality 45,49,50 observational studies that treatment limitations on POLST are associated with reduced incidence of hospitalization and ICU admission among patients in the acute care setting 14,47 . For example, a recent study evaluated the association between POLST order (i.e., comfort measures only, limited interventions, or full treatment) and ICU admission among 1818 decedents who were hospitalized within 6 months of their death.…”

“…Similarly, a 2010 retrospective cohort study of 1711 randomly sampled nursing facility residents in Oregon, Wisconsin, and West Virginia found that residents with POLST comfort measures only orders were 42% less likely to receive life-sustaining medical interventions than residents with POLST limited treatment orders (p = 0.03), and 67% less likely to receive life-sustaining medical interventions than residents with full treatment orders (p = 0.004). 43 We also found consistent evidence across five good quality 14,34,41,47,52 and three poor quality 45,49,50 observational studies that treatment limitations on POLST are associated with reduced incidence of hospitalization and ICU admission among patients in the acute care setting. 14,47 For example, a recent study evaluated the association between POLST order (i.e., comfort measures only, limited interventions, or full treatment) and ICU admission among 1818 decedents who were hospitalized within 6 months of their death.…”

“…Among the 27,092 patients with POLST across all studies, the median sample size was 261 (IQR 145, 830). All studies were observational and included four descriptive studies, 40,44,46,51 15 retrospective cohort studies, 14,17,[32][33][34][35][41][42][43]45,[47][48][49][50]53 and one prospective cohort study. 52 There were no randomized controlled trials of POLST.…”

“…Abbreviations42Odds ratio for receipt of life-sustaining treatment (reference = CMO orders on POLST):• Limited or Full Treatment 3.74 (95% CI, 1.81-7.72) Hickman et al43 Odds ratio for receipt of life-sustaining treatment (reference = CMO orders on POLST):• Limited treatment: 1.73, p = 0.03 • Full treatment: 3.03, p < 0.0150 Care outcomes (eMOLST vs. no eMOLST)• Direct costs: $21,667 versus $18,429, p = 0.10• ICU costs: $7718 versus $6385, p = 0.07 • Time in the hospital: 11.44 versus 9.85 days, p = 0.09 • Time in the ICU: 113 versus 98 days, p = 0.26…”

Characteristics and outcomes of patients with do-not-resuscitate and physician orders for life-sustaining treatment in a medical intensive care unit: a retrospective cohort study

“…A study by Huang et al comprising patients with severe sepsis and septic shock also found that the DNR group was older, had higher sequential organ failure assessment score and APACHE II score, and had higher prevalence of diabetes mellitus and hypertension than the non-DNR group [ 14 ]. A study by Serrano-Eanelli et al found that the group that completed life-sustaining treatment act document was older than the group that did not [ 15 ]. A study by Devanand et al of patients admitted to an intensive care unit after an out-of-hospital cardiac arrest found that patients older than 65 years and those with higher Charlson comorbidity index and APACHE II scores were more likely to have a decision to withdraw life-sustaining therapy [ 16 ].…”