Timing is everything: Early versus late palliative care consults in trauma

Abstract

BACKGROUND:The incorporation of dedicated palliative care (PC) services in the care of the critically injured trauma patient is not yet universal. Preexisting data demonstrate both economic and clinical value of PC consults, yet patient selection and optimal timing of these consults are poorly defined, possibly leading to underutilization of PC services. Prior studies in geriatric patients have shown benefits of PC when PC clinicians are engaged earlier during hospitalization. We aim to compare hospitalization metrics of early versus late PC consultation in trauma patients. METHODS:All patients 18 years or older admitted to the trauma service between January 1, 2019, and March 31, 2021, who received a PC consult were included. Patients were assigned to EARLY (PC consult ≤3 days after admission) and LATE (PC consult >3 days after admission) cohorts. Demographics, injury and underlying disease characteristics, outcomes, and financial data were compared. Length of stay (LOS) in the EARLY group is compared with LOS-3 in the LATE group. RESULTS:A total of 154 patient records met the inclusion criteria (60 EARLYand 94 LATE). Injury Severity Score, head Abbreviated Injury Scale score, and medical comorbidities (congestive heart failure, dementia, previous stroke, chronic obstructive pulmonary disease, malignancy) were similar between the groups. The LATE group was younger (69.9 vs. 75.3, p = 0.04). Patients in the LATE group had significantly longer LOS (17.5 vs. 7.0 days, p < 0.01) and higher median hospital costs ($53,165 vs. $17,654, p < 0.01).Patients in the EARLY group had reduced ventilator days (2.4 vs. 7.0, p < 0.01) and reduced rates of tracheostomies and surgical feeding tubes (1.7% vs. 11.7%, p = 0.03). CONCLUSION:Trauma patients with early PC consultation had shorter LOS, reduced ventilator days, reduced rates of invasive procedures, and lower costs even after correcting for delay to consult in the late group. These findings suggest the need for mechanisms leading to earlier PC consult in critically injured patients.

Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients

“…Both statistically and clinically significant, LOS decreased patients’ stay by half for EPC patients. This is consistent with the recent work by Spencer et al who similarly showed a decrease in the hospital and ICU LOS with EPC consultation ( 10 ), findings echoed in other studies ( 11 , 12 ). Just as important, a shorter LOS is aligned with the patient wishes of having less time within the ICU and hospital ( 13 ).…”

“…Mortality for EPC was 36%, and for LPC, it was 35% ( p = 0.473). Consistent with published work by Spencer et al ( 10 ), our findings suggest that the time of palliative care consultation had no impact on the mortality rates of the two groups. Although there was a slight trend for patients with EPC to have discharge to home, statistical significance was not reached, and there was no difference between other discharge dispositions.…”

“…Although our study did not evaluate cost, predictive model by Khandelwal et al (20) suggested a potential decrease in ICU cost of 11% if palliative care consultation and advance care planning became standard of care. This is further supported by the recent work by Spencer et al (10) which showed an average decrease in median cost of $35,511 per patient with the use of EPC consultation. These beneficial results may help to change the viewpoint of some surgeons toward palliative care consultations and improve utilization (2,8,21).…”

“…Tracheostomy and PEG tube placement was found to be significantly lower when palliative care was consulted early in a patient’s course, with only 4% of EPC patients getting a tracheostomy or PEG compared with LPC, where 14% had tracheostomy and 15% had PEG tube placement. Recent work by Spencer et al ( 10 ) also showed this trend which showed a decrease in tracheostomy and surgical feeding tubes from 11.7% compared to 1.7%, as well as findings published by Kupensky et al ( 14 , 15 ), indicating lower rates of tracheostomy and PEG tubes in patients who had EPC. Conversely, our study did not find any difference in the more acute procedures, including rates of CPR, intubation, or hemodialysis.…”

Optimizing resource utilization: palliative care consultations in critically ill pediatric trauma patients

“…hours) for trauma patients may lead to shorter length of stay, reduced ventilator days, decreased invasive procedures and lower overall costs. 9 There are, however, limited studies on the current practices and outcomes for palliative care in pediatric trauma patients, particularly those who are critically ill. Trauma remains the leading cause of morbidity and mortality in those aged 1-21 years, with traumatic brain injury (TBI) being the most common lethal injury. 10 11 Special issues pertaining to supportive care in children and adolescents include incorporation of healthcare surrogates, state rules regarding consent of minors, need for child life services, and unique challenges for bereaving families facing the loss of a child.…”