An Analysis of the Role of Palliative Care Involvement on Inter-hospital Transfers to the Intensive Care Unit

From the 2021 HVPAA National Conference

Keneil Shah (University of Maryland School of Medicine), Safanah Siddiqui, Sonika Patel, Kathryn Robinett

Background

Tertiary care hospitals serve as referral centers for the larger community in which they reside. Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of these hospitals for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care (PC) involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays.

Objective

To identify the frequency of hospice referral, rate and timing to PC consultation, and overall impact towards patient outcome, disposition, and cost amongst inter-hospital transfers within a single institution’s medical intensive care unit (MICU) and cardiac critical care unit (CCU).

Methods

This is a single-center, retrospective cohort study of 848 patients transferred from local community hospitals to the MICU and CCU of a large tertiary care hospital between 2016-2018. Data extracted from the electronic medical record included 475 MICU patients and 373 CCU patients for the duration of their hospitalizations. Primary data endpoints collected were length of stay, hospitalization cost, disposition (expired, hospice, other discharge), presence of PC consultation, and time to PC consultation. An independent t-test was conducted to compare mortality rate, percentage of hospice referrals, mean length of stay, and mean cost of hospitalization between patients with and without PC consultation. Pearson correlation coefficient was calculated to analyze relationship between time to PC consultation with length of hospitalization as well as PC consultation with length of stay.

Results

Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. PC consult was placed for 201 (23.7%) patients. Of the transfers, 49 (5.78%) were referred to hospice. Patients with PC consult were statistically more likely to be referred to hospice (p<0.001). The majority of PC consults were placed later than 7 days after transfer. Time to PC consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to PC consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86).

Conclusions

There is a high mortality rate, cost, and length of stay associated with patients transferred from community hospitals to tertiary care hospitals, yet there was a low rate of PC consultation in this cohort. Furthermore, there was a delay in PC consultation, with the majority of consults placed over 7 days into admission. Patients with palliative care consults were significantly more likely to be referred to hospice, but still had high mortality rates, suggesting a missed potential to facilitate timely goals of care discussions.

Clinical Implications

Our findings demonstrate that inter-hospital transfers represent a resource-intensive population with which increased, rapid PC involvement may allow an opportunity for improving optimization of resources and patient outcomes in ICUs.