Nausheen Ahmed, MD

Background: Mortality rates in critically ill patients remain in excess of 20% in many institutions. In the last 2 decades, palliative care has become a core component of ICU care. Current literature recommends a palliative care consult in the ICU setting; however, implementing this recommendation in a meaningful way has been challenging. The purpose of this study is to evaluate whether consulting palliative care in ICU earlier improves patient outcomes.

Study design: Single-center cluster randomized crossover trial.

Setting: Two medical ICUs at Barnes Jewish Hospital, St. Louis.

Synopsis: 199 patients were enrolled using palliative care criteria to identify patients at high risk for morbidity and mortality. In the intervention arm patients received a palliative care consultation from an inter-professional team led by board-certified palliative care providers within 48 hours of ICU admission.

The primary outcome of this study was a change in code status to Do Not Resuscitate/Do Not Intubate (DNR/DNI), which was significantly higher in the intervention group (50.5% vs. 23.4%; P less than .0001). The intervention group also had more hospice discharges, fewer ventilated days, a lower rate of tracheostomy, and fewer hospital readmissions. However, mortality and ICU/hospital length of stay were not significantly different between the two arms. Limitations of this study include using a single academic center and the fact that establishing a DNR/DNI may not measure quality of life or patient/family satisfaction. Further studies are needed to focus on clinical outcomes as well as patient and family satisfaction.

Bottom line: Early goal-directed palliative care consults with experienced clinicians board certified in palliative care influences goals of care, code status, and discharge plans for the critically ill and can improve medical resource utilization.

Citation: Ma J et al. Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Crit Care Med. 2019 Dec;47: 1707-15.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Mortality rates in critically ill patients remain in excess of 20% in many institutions. In the last 2 decades, palliative care has become a core component of ICU care. Current literature recommends a palliative care consult in the ICU setting; however, implementing this recommendation in a meaningful way has been challenging. The purpose of this study is to evaluate whether consulting palliative care in ICU earlier improves patient outcomes.

Study design: Single-center cluster randomized crossover trial.

Setting: Two medical ICUs at Barnes Jewish Hospital, St. Louis.

Synopsis: 199 patients were enrolled using palliative care criteria to identify patients at high risk for morbidity and mortality. In the intervention arm patients received a palliative care consultation from an inter-professional team led by board-certified palliative care providers within 48 hours of ICU admission.

The primary outcome of this study was a change in code status to Do Not Resuscitate/Do Not Intubate (DNR/DNI), which was significantly higher in the intervention group (50.5% vs. 23.4%; P less than .0001). The intervention group also had more hospice discharges, fewer ventilated days, a lower rate of tracheostomy, and fewer hospital readmissions. However, mortality and ICU/hospital length of stay were not significantly different between the two arms. Limitations of this study include using a single academic center and the fact that establishing a DNR/DNI may not measure quality of life or patient/family satisfaction. Further studies are needed to focus on clinical outcomes as well as patient and family satisfaction.

Bottom line: Early goal-directed palliative care consults with experienced clinicians board certified in palliative care influences goals of care, code status, and discharge plans for the critically ill and can improve medical resource utilization.

Citation: Ma J et al. Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Crit Care Med. 2019 Dec;47: 1707-15.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Mortality rates in critically ill patients remain in excess of 20% in many institutions. In the last 2 decades, palliative care has become a core component of ICU care. Current literature recommends a palliative care consult in the ICU setting; however, implementing this recommendation in a meaningful way has been challenging. The purpose of this study is to evaluate whether consulting palliative care in ICU earlier improves patient outcomes.

Study design: Single-center cluster randomized crossover trial.

Setting: Two medical ICUs at Barnes Jewish Hospital, St. Louis.

Synopsis: 199 patients were enrolled using palliative care criteria to identify patients at high risk for morbidity and mortality. In the intervention arm patients received a palliative care consultation from an inter-professional team led by board-certified palliative care providers within 48 hours of ICU admission.

The primary outcome of this study was a change in code status to Do Not Resuscitate/Do Not Intubate (DNR/DNI), which was significantly higher in the intervention group (50.5% vs. 23.4%; P less than .0001). The intervention group also had more hospice discharges, fewer ventilated days, a lower rate of tracheostomy, and fewer hospital readmissions. However, mortality and ICU/hospital length of stay were not significantly different between the two arms. Limitations of this study include using a single academic center and the fact that establishing a DNR/DNI may not measure quality of life or patient/family satisfaction. Further studies are needed to focus on clinical outcomes as well as patient and family satisfaction.

Bottom line: Early goal-directed palliative care consults with experienced clinicians board certified in palliative care influences goals of care, code status, and discharge plans for the critically ill and can improve medical resource utilization.

Citation: Ma J et al. Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Crit Care Med. 2019 Dec;47: 1707-15.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Studies show better outcomes, decreased length of stay, increased patient satisfaction, improved quality, and decreased readmission rates when hospitalist services are used. This study looks at how hospitalist schedules affect these outcomes.

Study design: Retrospective cohort study.

Setting: 229 hospitals in Texas.

Synopsis: This cohort study used 3 years of Medicare data from 229 hospitals in Texas. It included 114,777 medical admissions of patients with a 3- to 6-day length of stay. The study used the percentage of hospitalist working days that were blocks of 7 days or longer. ICU stays and patients requiring two or more E&M codes were excluded since they are associated with greater illness severity.

The primary outcome was mortality within 30 days of discharge and secondary outcomes were 30-day readmission rates, discharge destination, and 30-day postdischarge costs.

Patients receiving care from hospitalists working several days in a row had better outcomes. It is postulated that continuity of care by one hospitalist is important for several reasons. Most importantly, the development of rapport with patient and family is key to deciding the plan of care and destination post discharge as it is quite challenging to effectively transfer all important information during verbal or written handoffs.

Bottom line: Care provided by hospitalists working more days in a row improved patient outcomes. A variety of hospitalist schedules are being practiced currently; however, these findings must be taken into account as schedules are designed.

Citation: Goodwin JS et al. Association of the work schedules of hospitalists with patient outcomes of hospitalization. JAMA Intern Med. 2020;180(2):215-22. doi: 10.1001/jamainternmed.2019.5193.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Studies show better outcomes, decreased length of stay, increased patient satisfaction, improved quality, and decreased readmission rates when hospitalist services are used. This study looks at how hospitalist schedules affect these outcomes.

Study design: Retrospective cohort study.

Setting: 229 hospitals in Texas.

Synopsis: This cohort study used 3 years of Medicare data from 229 hospitals in Texas. It included 114,777 medical admissions of patients with a 3- to 6-day length of stay. The study used the percentage of hospitalist working days that were blocks of 7 days or longer. ICU stays and patients requiring two or more E&M codes were excluded since they are associated with greater illness severity.

The primary outcome was mortality within 30 days of discharge and secondary outcomes were 30-day readmission rates, discharge destination, and 30-day postdischarge costs.

Patients receiving care from hospitalists working several days in a row had better outcomes. It is postulated that continuity of care by one hospitalist is important for several reasons. Most importantly, the development of rapport with patient and family is key to deciding the plan of care and destination post discharge as it is quite challenging to effectively transfer all important information during verbal or written handoffs.

Bottom line: Care provided by hospitalists working more days in a row improved patient outcomes. A variety of hospitalist schedules are being practiced currently; however, these findings must be taken into account as schedules are designed.

Citation: Goodwin JS et al. Association of the work schedules of hospitalists with patient outcomes of hospitalization. JAMA Intern Med. 2020;180(2):215-22. doi: 10.1001/jamainternmed.2019.5193.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.

Background: Studies show better outcomes, decreased length of stay, increased patient satisfaction, improved quality, and decreased readmission rates when hospitalist services are used. This study looks at how hospitalist schedules affect these outcomes.

Study design: Retrospective cohort study.

Setting: 229 hospitals in Texas.

Synopsis: This cohort study used 3 years of Medicare data from 229 hospitals in Texas. It included 114,777 medical admissions of patients with a 3- to 6-day length of stay. The study used the percentage of hospitalist working days that were blocks of 7 days or longer. ICU stays and patients requiring two or more E&M codes were excluded since they are associated with greater illness severity.

The primary outcome was mortality within 30 days of discharge and secondary outcomes were 30-day readmission rates, discharge destination, and 30-day postdischarge costs.

Patients receiving care from hospitalists working several days in a row had better outcomes. It is postulated that continuity of care by one hospitalist is important for several reasons. Most importantly, the development of rapport with patient and family is key to deciding the plan of care and destination post discharge as it is quite challenging to effectively transfer all important information during verbal or written handoffs.

Bottom line: Care provided by hospitalists working more days in a row improved patient outcomes. A variety of hospitalist schedules are being practiced currently; however, these findings must be taken into account as schedules are designed.

Citation: Goodwin JS et al. Association of the work schedules of hospitalists with patient outcomes of hospitalization. JAMA Intern Med. 2020;180(2):215-22. doi: 10.1001/jamainternmed.2019.5193.

Dr. Ahmed is assistant professor in the division of hospital medicine, Loyola University Medical Center, Maywood, Ill.