Clinical Investigations
Feasibility and Economic Impact of Dedicated Hospice Inpatient Units for Terminally Ill ICU Patients* Zachary O. Binney, MPH1; Tammie E. Quest, MD2; Paul L. Feingold, MD3; Timothy Buchman, MD, PhD3,4, Alyssa A. Majesko, MD, MS1,4
Objectives: End-of-life care is frequently provided in the ICU because patients receiving life-sustaining treatments are often unsuitable for transfer to home or community hospices. In-hospital dedicated hospice inpatient units are a novel option. This study was designed to 1) demonstrate the feasibility of ICU to dedicated hospice inpatient unit transfer in critically ill terminal patients; 2) describe the clinical characteristics of those transferred and compare them to similar patients who were not transferred; and 3) assess the operational and economic impact of dedicated hospice inpatient units. Design: Retrospective chart review. Setting: ICUs and dedicated hospice inpatient units at two southeast urban university hospitals. Interventions: Charts of ICU and dedicated hospice inpatient unit deaths over a 6-month period were reviewed. Patients: Dedicated hospice inpatient unit transfers were identified from hospice administrator records. Missed opportunities were patients admitted to the hospital for more than 48 hours who either adopted a comfort care course or had a planned termination of life-sustaining therapy. Patients were excluded if they were declared brain dead, were organ donors, required high-frequency ventilation, or if there was insufficient information in the medical record to make a determination. Measurements and Main Results: We identified 167 transfers and 99 missed opportunities; 37% of appropriate patients were not *See also p. 1288. 1 Emory Palliative Care Center, Emory University, Atlanta, GA. 2 U.S. Department of Veterans Affairs Medical Center and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA. 3 Department of Surgery, Emory University School of Medicine, Atlanta, GA. 4 Emory Center for Critical Care Medicine, Emory University, Atlanta, GA. This work was performed at Emory University Hospital, Atlanta, GA, and Emory University Hospital Midtown, Atlanta, GA. Dr. Quest is employed by Gentiva Hospice. Dr. Buchman’s institution received grant support from the James S. McDonnell Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000120
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transferred. Transfers were older (66.9 vs 60.4 yr; p < 0.05), less likely to use mechanical ventilation (71.9% vs 90.9%) and vasopressors (70.9% vs 95.0%; p < 0.05), and less likely to receive a palliative care consult (70.4% vs 43.4%; p < 0.05) than missed opportunities. Transfers saved 585 ICU bed days. Conclusions: Dedicated hospice inpatient units are a feasible way to provide care for terminal ICU patients, but barriers including lack of knowledge of the units and provider or family comfort with leaving the ICU remain. Dedicated hospice inpatient units are potentially significant sources of bed days and cost savings for hospitals and the healthcare system overall. (Crit Care Med 2014; 42:1074–1080) Key Words: critical care; healthcare costs; hospice care; palliative care; terminal care
O
f Medicare beneficiaries with a severe chronic illness who died in 2007, nearly one fifth (17.6%) did so in the ICU (1). This figure varies geographically, with the proportion approaching one third in some areas (31.1% in Brunswick, NJ) (1). Nationally, 10–20% of patients admitted to the ICU will die in the ICU (1–4). Providing quality end-of-life care with spiritual, psychosocial support and bereavement care is challenging in the critical care setting (5–8). Several studies have documented the negative psychologic impacts including depression and posttraumatic stress disorder on family members who have experienced the death of a loved one in the ICU (6–8). Communication interventions to mitigate these have had modest success (9, 10). In 2008, the American College of Critical Care Medicine issued a consensus statement outlining the importance of palliative and end-of-life care—ranging from symptom management to caregiver support and bereavement follow-up—in the ICU (5). Although end-of-life care is an integral part of ICU care, several studies over time have demonstrated considerable shortfalls and variability in the quality of end-of-life care in the ICU (11, 12). One recent analysis found that 10–40% of patients did not have a pain assessment in the last 24 hours of May 2014 • Volume 42 • Number 5
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life; 20–40% did not have a family meeting within 72 hours of admission; and 50–80% did not have a prognostic discussion within 72 hours of admission (12). As ICUs strive to continue improving patient-centered care (13), the use of hospital-based palliative care units or hospice partnerships is rising: in 2001, 19% of 100 teaching hospitals surveyed had an inpatient palliative care unit and 22% reported a hospice affiliation (14), and recent growth in the prevalence of palliative care teams suggests that these figures are higher today (15). Furthermore, these palliative teams have demonstrated their ability to improve care quality when integrated into the ICU (16, 17). Our study seeks to describe an alternative to variable end-of-life care in an ICU. In the outpatient setting, when a patient has a prognosis of 6 months or less and the patient/surrogate elects a comfort care course, hospice is appropriate. However, critically ill patients, especially those on mechanical ventilation and infusions, have not traditionally been suitable for hospice. Some hospice models for critically ill patients with invasive support exist, such as a “swing bed” model where critical care staff provides end-of-life care in the critical care unit under the direction of hospice (18). Such models may deliver fractured, nonspecialized and nonstandardized care, however (19). Some hospitals use a dedicated palliative care unit with critical care capabilities (20), but these units have variable bereavement support. A more comprehensive approach is a dedicated hospice unit within the hospital. These units have expertise in end-of-life care and the flexibility to accept critical care patients on invasive support. These units help shift the focus to comfort care and provide access to a multidisciplinary hospice team that works with families as they plan for discontinuation of life-sustaining therapies. This same team provides a number of ancillary benefits such as spiritual and caregiver support and continues providing bereavement support months after the patient’s death. The three objectives of this study were 1) to demonstrate the feasibility of ICU to dedicated hospice inpatient unit (DHIPU) transfer in the university hospital setting; 2) to describe the clinical characteristics of those transferred and compare them with critically ill terminal patients who were not transferred (“missed opportunities”); and 3) to assess the operational and economic impact of DHIPUs.
MATERIALS AND METHODS Setting The study included patients dying in the ICUs or DHIPUs of two academic medical centers (AMCs) in the same healthcare system in the southeast. AMC-1 is strictly an academic faculty practice hospital. AMC-2 is a blended university/community practice hospital. The units are a partnership between the academic health system and a third-party hospice provider with independent medical staff that administers both units. Each inpatient hospice unit, eight beds at AMC-1 and six beds at AMC-2, is staffed by two registered nurses and one nursing aide for each 12-hour period; a palliative care physician is on call as the hospice attending 24 hours a day. All DHIPU physicians are board-certified in Hospice and Palliative Medicine and supervise nurses in comfort care management of patients Critical Care Medicine
on mechanical ventilation. The Emory University Institutional Review Board approved this study. Sample We analyzed ICU and DHIPU records of patients 18 years old and older with an ICU admission who died in the hospital or DHIPU from January to June 2011. To identify DHIPU patients, a list of 358 DHIPU patient admissions during this period was obtained from the hospice administrator’s inpatient census. These were matched in the hospitals’ decision support system (DSS) on full name, Social Security number, and DHIPU admission date (± 1 d) to hospital encounter numbers immediately prior to the DHIPU admission. Of these 358 patients, 31 (8.7%) transferred from the emergency department and 117 (32.7%) from floor units were excluded; 208 (58.1%) transferred from an ICU were considered for further analysis. Of these 208, we further excluded 34 patients (16.3%) who were discharged alive from the DHIPU because these would be less comparable to ICU deaths. Finally, we also excluded seven patients (3.4%) with an ICU length of stay (LOS) of less than 24 hours because transferring ICU patients to a DHIPU that quickly may be infeasible. Deaths were confirmed in hospice and hospital records. We identified 167 eligible inpatient unit transfers. To identify missed opportunities for transfer from the ICU to the DHIPUs, we undertook a retrospective chart review on 395 deaths at the two AMCs between January 1, 2011, and June 30, 2011. We excluded 102 patients (25.8%) who died outside an ICU, were brain dead, organ donors, on high-frequency ventilation, or in the hospital for less than 48 hours prior to death. Any of these criteria would have made patients ineligible for DHIPU transfer from the ICU. Of these 293, we identified 99 missed opportunities (33.8%) for DHIPU transfer who were admitted to the hospital for at least 48 hours and who either: 1) adopted a comfort care course or 2) had a planned termination of life-sustaining therapy (Fig. 1). We excluded cases where there was insufficient information in the medical record to make a determination. Variable Definitions Hospital LOS is discharge day minus admit day. ICU LOS is the total ICU days from the hospitals’ DSS. DHIPU LOS is billable DHIPU days. DHIPU LOS was assumed to equal the number of ICU days avoided for transferred patients. We used primary and secondary International Classification of Diseases, 9th Edition, diagnosis codes grouped into ICUrelevant categories. For patients with multiple comorbidities, we developed a hierarchy to assign them a single category. Cancer was at the top of the hierarchy; if a patient had a diagnosis code for cancer their diagnosis was cancer despite any other codes. The hierarchy proceeded with heart failure, chronic obstructive pulmonary disease, sepsis, aortic aneurysm, endocarditis, acute respiratory infection (including influenza and pneumonia), gastrointestinal bleed, ischemic heart disease, acute kidney failure, and acute respiratory failure. Patients without codes in any of these categories were given a diagnosis of “other.” www.ccmjournal.org
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age of 66.6 years (sd, 13.7) and were predominantly white (54.7%). Approximately two thirds of these patients had either heart failure (32.1%) or cancer (33.0%). Most patients were on a ventilator and at least one vasopressor. Almost two thirds received a consult from the hospital’s inpatient palliative care service (Table 1). Also in Table 1, missed opportunities were significantly younger (mean, 59.6 [sd, 15.4] vs 66.6 [sd, 13.7] yr; p < 0.05) and more likely to be on both a ventilator (88.4% vs 74.5%; p < 0.05) and vasopressor (94.2% vs 70.8%; p 0.05) (Table 1). Similar to AMC-1, they were more likely to require mechanical ventilation (96.7% Data Analysis vs 75.4%; p < 0.05) and at least one vasopressor (96.7% vs Descriptive statistics are reported for patients who die in the 73.8%; p 0.05). As at AMC-1, missed opportunities were less likely reported for categorical variables. To compare DHIPU transfers with missed opportunities, to get a palliative care consult (50.0% vs 80.3%; p < 0.05). we used Fisher exact test for categorical variables and twoEconomic Impact of DHIPU Transfers sample t tests for continuous variables. LOS was normalized The mean DHIPU LOS was 3.5 days (sd, 3.2), translating to 585 using log transformation. Statistical tests are two-sided, with a ICU days avoided at an average cost of $4,882 per day (Table 2). p value of less than 0.05 considered significant. The daily estimated cost of a DHIPU day was $2,118, translating to a cost savings of approximately $1,384,110 (Table 2).
RESULTS
AMC-1 We identified 106 DHIPU transfers and 69 missed opportunities. As outlined in Table 1, DHIPU transfers had a mean 1076
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DISCUSSION DHIPU transfer is feasible for critically ill patients and families seeking to transition from life-sustaining treatments to May 2014 • Volume 42 • Number 5
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Table 1. Characteristics of ICU Patients Successfully Transferred to Dedicated Hospice Inpatient Unit (n = 167) and Missed Opportunities for Transfer (n = 99), January–June 2011 Combined Hospitals
Characteristic
DHIPU Deaths—ICU Transfers (n = 167)
ICU Deaths— Missed Opportunities (n = 99)
AMC-1 DHIPU Deaths—ICU Transfers (n = 106)
AMC-2
ICU Deaths—Missed Opportunities (n = 69)
DHIPU Deaths—ICU Transfers (n = 61)
ICU Deaths— Missed Opportunities (n = 30)
Patient demographics Age, yr; mean (sd)
66.9 (13.8)
60.4 (16.7)a
66.6 (13.7)
59.6 (15.4)a
67.3 (14.0)
62.2 (19.6)
Gender Female, %
55.1
46.5
52.8
45.0
59.0
50.0
White, %
41.5
49.4
54.7
53.3
23.0
41.4
Black, %
51.0
49.4
38.4
45.0
68.9
58.6
Other, %
7.5
1.1
7.0
1.7
8.2
0.0
Heart failure
34.7
28.3
32.1
23.2a
39.3
40.0
Cancer
27.5
29.3
33.0
33.3
18.0
20.0
Acute respiratory failure or infection
13.2
10.1
16.0
8.7
8.2
13.3
Sepsis
10.2
12.1
7.6
15.9
14.8
3.3
Chronic obstructive pulmonary disease
9.6
5.1
8.5
2.9
11.5
10.0
Ischemic heart disease
1.2
5.1
0.0
4.4
3.3
6.7
Other
3.6
10.1
2.8
11.6
4.9
6.7
Ventilator, %
74.9
90.9a
74.5
88.4a
75.4
96.7a
Vasopressor, %
71.9
95.0a
70.8
94.2a
73.8
96.7a
Palliative care consult, % Yes
70.7
43.4a
65.1
40.6a
80.3
50.0a
10.3 (2.0, 51.0)
13.6 (3.0, 6.0)a
9.8 (2.0, 40.0)
14.7 (3.0, 6.0)a
Race
b
Health information Diagnosis
c
Critical care interventions
Admission data LOS Hospital, d; mean (range) ICU, d; mean (range)
9.8 (1.0, 58.0)
Inpatient unit, d; mean (range)
3.5 (1.0, 18.0)
7.2 (1.0, 45.0)a 6.8 (1.0, 39.0) —
3.0 (1.0, 16.0)
11.1 (2.0, 51.0) 11.0 (3.0, 29.0)
10.7 (1.0, 58.0)a
7.8 (1.0, 48.0)
7.8 (1.0, 25.0)
—
4.5 (1.0, 18.0)
—
Total LOSd, d; mean (range) 12.8 (2.0, 54.0) 13.6 (3.0, 6.0) 11.8 (2.0, 41.0) 14.7 (3.0, 67.0)
14.6 (2.0, 54.0) 11.0 (3.0, 29.0)
AMC = academic medical center, DHIPU = dedicated hospice inpatient unit, LOS = length of stay. a p < 0.05. b Race missing for n = 30 subjects. c Includes acute kidney failure, aortic aneurysm, gastrointestinal bleed, endocarditis, and other. d Total LOS = hospital LOS for missed opportunities or hospital LOS + DHIPU LOS for successful DHIPU transfers.
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Table 2. Cost Impact of ICU Patients Successfully Transferred to Dedicated Hospice Inpatient Unit, January–June 2011 Patients
167
ICU Days Avoided Per Patient
Total ICU Days Avoided
Costs Per ICU Day
Cost Per Dedicated Hospice Inpatient Unit Daya
Cost Savings
3.5
585
$4,484
$2,118
$1,384,110
Estimated as 73% of the average daily hospital cost for patients during the study time frame with a “Hospice–Medical Facility” discharge disposition.
a
comfort care at the end of life. In general, ICU staff supported the use of DHIPUs, with more than 60% of qualifying patients being transferred. Transfer patterns in the two hospitals were similar, as were the characteristics of the missed opportunities. Potential reasons for not using the DHIPU include critical care physician, nurse, or family reluctance to transfer care because of established relationships. Additionally, patient or family reluctance to pursue a palliative course of treatment would preclude DHIPU transfer; the unit’s goal is to provide care in line with the patient’s goals rather than to withdraw intensive life-sustaining interventions a priori. This same reticence may occur among critical care physicians even when families express a desire for palliation; alternatively, clinicians may perceive end-of-life care resources as equivalent in the ICU or DHIPU. Clinician reticence in end of life and treatment withdrawal discussions is a barrier to effective family decision making (24); this likely translates to lower DHIPU use. Finally, some therapies (such as jet or oscillation modes of ventilation) could not be accommodated in the DHIPU and required termination in the traditional ICU setting, but this was a small minority of ICU patients. All of the above are barriers to DHIPU utilization that must be addressed to have a successful unit. That said, we present our DHIPUs as an alternative to ICU-based end-of-life care in patients and families seeking a transition to comfort-focused care; we do not assert that these units are a one-size-fits-all solution appropriate for every ICU death. As Truog et al (5) point out, an ICU admission is a therapeutic trial; if the trial fails, families and medical professionals should consider the transition from restorative to palliative care, which can include DHIPUs. Hospital-based palliative care is on the rise (15) and has been shown to reduce costs and improve quality for a broad array of patients (25, 26), including those dying in the hospital (27, 28). For example, early palliative care consultation decreases the time to comfort-focused care in patients with multisystem organ failure (16). In the ICU, evidence suggests that palliative care improves patient and family understanding of diagnosis, prognosis, and goals of care and provides emotional and spiritual support (29–31). Furthermore, palliative care teams often assist with end-of-life planning and decision making in the ICU (17, 32–34), and palliative care’s involvement in a patient’s care is associated with greater utilization of hospice (35, 36). Hospice care, if available, also provides the patient and family with caregiver support and midterm bereavement support not typically available from ICUs. 1078
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Despite the common concern that hospice accelerates dying, DHIPU transfer, like palliative (36) and hospice (37) care generally, does not appear to shorten life. Although previous data for DHIPUs are limited, one study from Korea found no association with the use of a palliative care facility and survival in cancer patients (38). In our study, ICU plus DHIPU LOS for patients transferred to the DHIPU was no different from that of patients who died in the ICU. While this could be a result of baseline differences in the acuity of patients deemed suitable for transfer that resulted in longer survival, our data refute the oft-raised objection that transfer to DHIPU accelerates dying. There are several limitations to this study. It focuses on AMCs where all ICUs are managed by intensive care physicians with access to palliative care physicians and on-site DHIPUs, limiting its generalizability. The AMCs studied also have high severity of illness scores compared with other AMCs and community hospitals. That said, currently 88% of all hospitals with greater than 300 beds and 66% of those with more than 50 beds have a palliative care service (15). The presence of a palliative care service that can assist with the knowledge and skills is required to provide high quality hospice care, in partnership with hospital-based or community hospice agencies to create a DHIPU, holds great promise for the majority of academic as well as community hospitals. Such a model may be particularly feasible for larger hospitals, but it is capable of being deployed in either an academic or community environment with an existing palliative care infrastructure. Additionally, the study reports initial data beginning 2 months after unit opening; this may not reflect the units’ mature steady-state pattern. Finally, DHIPU costs were unavailable, and we relied on historical data to estimate the units’ economic impact. Several studies suggest that hospice (39–41) reduces costs at the end of life; in our analysis, we used data from three studies that quantified cost differences for inpatient palliative care and hospice units similar to DHIPUs (21–23). All three studies focused on terminal cancer patients; our units serve a broader population, which could impact cost differences. Two of the studies were international, with different patterns of healthcare expenditures than those seen in the United States. Despite these limitations, these data are a good starting point for assessing the cost impact of such units on the healthcare system, and the remarkable degree of consistency in hospice to general ward cost ratios strengthens our faith in these figures. May 2014 • Volume 42 • Number 5
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These limitations notwithstanding, our data support a role for DHIPUs. While end-of-life care remains an integral part of ICU care, DHIPUs and palliative care units offer an alternative to variable quality care in the ICU for critically ill terminal patients. DHIPUs provide a more supportive and appropriate environment for patients and families at the end of life than the ICU, and hospice’s structured bereavement program (available in the DHIPU) is a distinct benefit that provides support and counseling to family members for 13 months after the death of their loved one. This benefit—unique to hospice—is not available from ICUs. Finally, DHIPUs may reduce costs by avoiding additional aggressive interventions and structuring a plan with family members to deescalate ICU-level care at the end of life.
CONCLUSIONS DHIPUs are a feasible way to provide end-of-life care for ICU patients. DHIPUs hold great promise for delivering highquality end-of-life care from specialized, experienced staff to patients and families, but further research—including prospective studies of patients dying in ICUs versus dedicated palliative care or hospice units—is needed to assess their potential benefits and barriers to their use.
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39. Bergman J, Saigal CS, Lorenz KA, et al; Urologic Diseases in America Project: Hospice use and high-intensity care in men dying of prostate cancer. Arch Intern Med 2011; 171:204–210 40. Brumley R, Enguidanos S, Jamison P, et al: Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007; 55:993–1000 41. Candy B, Holman A, Leurent B, et al: Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence. Int J Nurs Stud 2011; 48:121–133
May 2014 • Volume 42 • Number 5
Feasibility and Economic Impact of Dedicated Hospice Inpatient Units for Terminally Ill ICU Patients* Zachary O. Binney, MPH1; Tammie E. Quest, MD2; Paul L. Feingold, MD3; Timothy Buchman, MD, PhD3,4, Alyssa A. Majesko, MD, MS1,4
Objectives: End-of-life care is frequently provided in the ICU because patients receiving life-sustaining treatments are often unsuitable for transfer to home or community hospices. In-hospital dedicated hospice inpatient units are a novel option. This study was designed to 1) demonstrate the feasibility of ICU to dedicated hospice inpatient unit transfer in critically ill terminal patients; 2) describe the clinical characteristics of those transferred and compare them to similar patients who were not transferred; and 3) assess the operational and economic impact of dedicated hospice inpatient units. Design: Retrospective chart review. Setting: ICUs and dedicated hospice inpatient units at two southeast urban university hospitals. Interventions: Charts of ICU and dedicated hospice inpatient unit deaths over a 6-month period were reviewed. Patients: Dedicated hospice inpatient unit transfers were identified from hospice administrator records. Missed opportunities were patients admitted to the hospital for more than 48 hours who either adopted a comfort care course or had a planned termination of life-sustaining therapy. Patients were excluded if they were declared brain dead, were organ donors, required high-frequency ventilation, or if there was insufficient information in the medical record to make a determination. Measurements and Main Results: We identified 167 transfers and 99 missed opportunities; 37% of appropriate patients were not *See also p. 1288. 1 Emory Palliative Care Center, Emory University, Atlanta, GA. 2 U.S. Department of Veterans Affairs Medical Center and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA. 3 Department of Surgery, Emory University School of Medicine, Atlanta, GA. 4 Emory Center for Critical Care Medicine, Emory University, Atlanta, GA. This work was performed at Emory University Hospital, Atlanta, GA, and Emory University Hospital Midtown, Atlanta, GA. Dr. Quest is employed by Gentiva Hospice. Dr. Buchman’s institution received grant support from the James S. McDonnell Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000120
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transferred. Transfers were older (66.9 vs 60.4 yr; p < 0.05), less likely to use mechanical ventilation (71.9% vs 90.9%) and vasopressors (70.9% vs 95.0%; p < 0.05), and less likely to receive a palliative care consult (70.4% vs 43.4%; p < 0.05) than missed opportunities. Transfers saved 585 ICU bed days. Conclusions: Dedicated hospice inpatient units are a feasible way to provide care for terminal ICU patients, but barriers including lack of knowledge of the units and provider or family comfort with leaving the ICU remain. Dedicated hospice inpatient units are potentially significant sources of bed days and cost savings for hospitals and the healthcare system overall. (Crit Care Med 2014; 42:1074–1080) Key Words: critical care; healthcare costs; hospice care; palliative care; terminal care
O
f Medicare beneficiaries with a severe chronic illness who died in 2007, nearly one fifth (17.6%) did so in the ICU (1). This figure varies geographically, with the proportion approaching one third in some areas (31.1% in Brunswick, NJ) (1). Nationally, 10–20% of patients admitted to the ICU will die in the ICU (1–4). Providing quality end-of-life care with spiritual, psychosocial support and bereavement care is challenging in the critical care setting (5–8). Several studies have documented the negative psychologic impacts including depression and posttraumatic stress disorder on family members who have experienced the death of a loved one in the ICU (6–8). Communication interventions to mitigate these have had modest success (9, 10). In 2008, the American College of Critical Care Medicine issued a consensus statement outlining the importance of palliative and end-of-life care—ranging from symptom management to caregiver support and bereavement follow-up—in the ICU (5). Although end-of-life care is an integral part of ICU care, several studies over time have demonstrated considerable shortfalls and variability in the quality of end-of-life care in the ICU (11, 12). One recent analysis found that 10–40% of patients did not have a pain assessment in the last 24 hours of May 2014 • Volume 42 • Number 5
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life; 20–40% did not have a family meeting within 72 hours of admission; and 50–80% did not have a prognostic discussion within 72 hours of admission (12). As ICUs strive to continue improving patient-centered care (13), the use of hospital-based palliative care units or hospice partnerships is rising: in 2001, 19% of 100 teaching hospitals surveyed had an inpatient palliative care unit and 22% reported a hospice affiliation (14), and recent growth in the prevalence of palliative care teams suggests that these figures are higher today (15). Furthermore, these palliative teams have demonstrated their ability to improve care quality when integrated into the ICU (16, 17). Our study seeks to describe an alternative to variable end-of-life care in an ICU. In the outpatient setting, when a patient has a prognosis of 6 months or less and the patient/surrogate elects a comfort care course, hospice is appropriate. However, critically ill patients, especially those on mechanical ventilation and infusions, have not traditionally been suitable for hospice. Some hospice models for critically ill patients with invasive support exist, such as a “swing bed” model where critical care staff provides end-of-life care in the critical care unit under the direction of hospice (18). Such models may deliver fractured, nonspecialized and nonstandardized care, however (19). Some hospitals use a dedicated palliative care unit with critical care capabilities (20), but these units have variable bereavement support. A more comprehensive approach is a dedicated hospice unit within the hospital. These units have expertise in end-of-life care and the flexibility to accept critical care patients on invasive support. These units help shift the focus to comfort care and provide access to a multidisciplinary hospice team that works with families as they plan for discontinuation of life-sustaining therapies. This same team provides a number of ancillary benefits such as spiritual and caregiver support and continues providing bereavement support months after the patient’s death. The three objectives of this study were 1) to demonstrate the feasibility of ICU to dedicated hospice inpatient unit (DHIPU) transfer in the university hospital setting; 2) to describe the clinical characteristics of those transferred and compare them with critically ill terminal patients who were not transferred (“missed opportunities”); and 3) to assess the operational and economic impact of DHIPUs.
MATERIALS AND METHODS Setting The study included patients dying in the ICUs or DHIPUs of two academic medical centers (AMCs) in the same healthcare system in the southeast. AMC-1 is strictly an academic faculty practice hospital. AMC-2 is a blended university/community practice hospital. The units are a partnership between the academic health system and a third-party hospice provider with independent medical staff that administers both units. Each inpatient hospice unit, eight beds at AMC-1 and six beds at AMC-2, is staffed by two registered nurses and one nursing aide for each 12-hour period; a palliative care physician is on call as the hospice attending 24 hours a day. All DHIPU physicians are board-certified in Hospice and Palliative Medicine and supervise nurses in comfort care management of patients Critical Care Medicine
on mechanical ventilation. The Emory University Institutional Review Board approved this study. Sample We analyzed ICU and DHIPU records of patients 18 years old and older with an ICU admission who died in the hospital or DHIPU from January to June 2011. To identify DHIPU patients, a list of 358 DHIPU patient admissions during this period was obtained from the hospice administrator’s inpatient census. These were matched in the hospitals’ decision support system (DSS) on full name, Social Security number, and DHIPU admission date (± 1 d) to hospital encounter numbers immediately prior to the DHIPU admission. Of these 358 patients, 31 (8.7%) transferred from the emergency department and 117 (32.7%) from floor units were excluded; 208 (58.1%) transferred from an ICU were considered for further analysis. Of these 208, we further excluded 34 patients (16.3%) who were discharged alive from the DHIPU because these would be less comparable to ICU deaths. Finally, we also excluded seven patients (3.4%) with an ICU length of stay (LOS) of less than 24 hours because transferring ICU patients to a DHIPU that quickly may be infeasible. Deaths were confirmed in hospice and hospital records. We identified 167 eligible inpatient unit transfers. To identify missed opportunities for transfer from the ICU to the DHIPUs, we undertook a retrospective chart review on 395 deaths at the two AMCs between January 1, 2011, and June 30, 2011. We excluded 102 patients (25.8%) who died outside an ICU, were brain dead, organ donors, on high-frequency ventilation, or in the hospital for less than 48 hours prior to death. Any of these criteria would have made patients ineligible for DHIPU transfer from the ICU. Of these 293, we identified 99 missed opportunities (33.8%) for DHIPU transfer who were admitted to the hospital for at least 48 hours and who either: 1) adopted a comfort care course or 2) had a planned termination of life-sustaining therapy (Fig. 1). We excluded cases where there was insufficient information in the medical record to make a determination. Variable Definitions Hospital LOS is discharge day minus admit day. ICU LOS is the total ICU days from the hospitals’ DSS. DHIPU LOS is billable DHIPU days. DHIPU LOS was assumed to equal the number of ICU days avoided for transferred patients. We used primary and secondary International Classification of Diseases, 9th Edition, diagnosis codes grouped into ICUrelevant categories. For patients with multiple comorbidities, we developed a hierarchy to assign them a single category. Cancer was at the top of the hierarchy; if a patient had a diagnosis code for cancer their diagnosis was cancer despite any other codes. The hierarchy proceeded with heart failure, chronic obstructive pulmonary disease, sepsis, aortic aneurysm, endocarditis, acute respiratory infection (including influenza and pneumonia), gastrointestinal bleed, ischemic heart disease, acute kidney failure, and acute respiratory failure. Patients without codes in any of these categories were given a diagnosis of “other.” www.ccmjournal.org
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age of 66.6 years (sd, 13.7) and were predominantly white (54.7%). Approximately two thirds of these patients had either heart failure (32.1%) or cancer (33.0%). Most patients were on a ventilator and at least one vasopressor. Almost two thirds received a consult from the hospital’s inpatient palliative care service (Table 1). Also in Table 1, missed opportunities were significantly younger (mean, 59.6 [sd, 15.4] vs 66.6 [sd, 13.7] yr; p < 0.05) and more likely to be on both a ventilator (88.4% vs 74.5%; p < 0.05) and vasopressor (94.2% vs 70.8%; p 0.05) (Table 1). Similar to AMC-1, they were more likely to require mechanical ventilation (96.7% Data Analysis vs 75.4%; p < 0.05) and at least one vasopressor (96.7% vs Descriptive statistics are reported for patients who die in the 73.8%; p 0.05). As at AMC-1, missed opportunities were less likely reported for categorical variables. To compare DHIPU transfers with missed opportunities, to get a palliative care consult (50.0% vs 80.3%; p < 0.05). we used Fisher exact test for categorical variables and twoEconomic Impact of DHIPU Transfers sample t tests for continuous variables. LOS was normalized The mean DHIPU LOS was 3.5 days (sd, 3.2), translating to 585 using log transformation. Statistical tests are two-sided, with a ICU days avoided at an average cost of $4,882 per day (Table 2). p value of less than 0.05 considered significant. The daily estimated cost of a DHIPU day was $2,118, translating to a cost savings of approximately $1,384,110 (Table 2).
RESULTS
AMC-1 We identified 106 DHIPU transfers and 69 missed opportunities. As outlined in Table 1, DHIPU transfers had a mean 1076
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DISCUSSION DHIPU transfer is feasible for critically ill patients and families seeking to transition from life-sustaining treatments to May 2014 • Volume 42 • Number 5
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Table 1. Characteristics of ICU Patients Successfully Transferred to Dedicated Hospice Inpatient Unit (n = 167) and Missed Opportunities for Transfer (n = 99), January–June 2011 Combined Hospitals
Characteristic
DHIPU Deaths—ICU Transfers (n = 167)
ICU Deaths— Missed Opportunities (n = 99)
AMC-1 DHIPU Deaths—ICU Transfers (n = 106)
AMC-2
ICU Deaths—Missed Opportunities (n = 69)
DHIPU Deaths—ICU Transfers (n = 61)
ICU Deaths— Missed Opportunities (n = 30)
Patient demographics Age, yr; mean (sd)
66.9 (13.8)
60.4 (16.7)a
66.6 (13.7)
59.6 (15.4)a
67.3 (14.0)
62.2 (19.6)
Gender Female, %
55.1
46.5
52.8
45.0
59.0
50.0
White, %
41.5
49.4
54.7
53.3
23.0
41.4
Black, %
51.0
49.4
38.4
45.0
68.9
58.6
Other, %
7.5
1.1
7.0
1.7
8.2
0.0
Heart failure
34.7
28.3
32.1
23.2a
39.3
40.0
Cancer
27.5
29.3
33.0
33.3
18.0
20.0
Acute respiratory failure or infection
13.2
10.1
16.0
8.7
8.2
13.3
Sepsis
10.2
12.1
7.6
15.9
14.8
3.3
Chronic obstructive pulmonary disease
9.6
5.1
8.5
2.9
11.5
10.0
Ischemic heart disease
1.2
5.1
0.0
4.4
3.3
6.7
Other
3.6
10.1
2.8
11.6
4.9
6.7
Ventilator, %
74.9
90.9a
74.5
88.4a
75.4
96.7a
Vasopressor, %
71.9
95.0a
70.8
94.2a
73.8
96.7a
Palliative care consult, % Yes
70.7
43.4a
65.1
40.6a
80.3
50.0a
10.3 (2.0, 51.0)
13.6 (3.0, 6.0)a
9.8 (2.0, 40.0)
14.7 (3.0, 6.0)a
Race
b
Health information Diagnosis
c
Critical care interventions
Admission data LOS Hospital, d; mean (range) ICU, d; mean (range)
9.8 (1.0, 58.0)
Inpatient unit, d; mean (range)
3.5 (1.0, 18.0)
7.2 (1.0, 45.0)a 6.8 (1.0, 39.0) —
3.0 (1.0, 16.0)
11.1 (2.0, 51.0) 11.0 (3.0, 29.0)
10.7 (1.0, 58.0)a
7.8 (1.0, 48.0)
7.8 (1.0, 25.0)
—
4.5 (1.0, 18.0)
—
Total LOSd, d; mean (range) 12.8 (2.0, 54.0) 13.6 (3.0, 6.0) 11.8 (2.0, 41.0) 14.7 (3.0, 67.0)
14.6 (2.0, 54.0) 11.0 (3.0, 29.0)
AMC = academic medical center, DHIPU = dedicated hospice inpatient unit, LOS = length of stay. a p < 0.05. b Race missing for n = 30 subjects. c Includes acute kidney failure, aortic aneurysm, gastrointestinal bleed, endocarditis, and other. d Total LOS = hospital LOS for missed opportunities or hospital LOS + DHIPU LOS for successful DHIPU transfers.
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Table 2. Cost Impact of ICU Patients Successfully Transferred to Dedicated Hospice Inpatient Unit, January–June 2011 Patients
167
ICU Days Avoided Per Patient
Total ICU Days Avoided
Costs Per ICU Day
Cost Per Dedicated Hospice Inpatient Unit Daya
Cost Savings
3.5
585
$4,484
$2,118
$1,384,110
Estimated as 73% of the average daily hospital cost for patients during the study time frame with a “Hospice–Medical Facility” discharge disposition.
a
comfort care at the end of life. In general, ICU staff supported the use of DHIPUs, with more than 60% of qualifying patients being transferred. Transfer patterns in the two hospitals were similar, as were the characteristics of the missed opportunities. Potential reasons for not using the DHIPU include critical care physician, nurse, or family reluctance to transfer care because of established relationships. Additionally, patient or family reluctance to pursue a palliative course of treatment would preclude DHIPU transfer; the unit’s goal is to provide care in line with the patient’s goals rather than to withdraw intensive life-sustaining interventions a priori. This same reticence may occur among critical care physicians even when families express a desire for palliation; alternatively, clinicians may perceive end-of-life care resources as equivalent in the ICU or DHIPU. Clinician reticence in end of life and treatment withdrawal discussions is a barrier to effective family decision making (24); this likely translates to lower DHIPU use. Finally, some therapies (such as jet or oscillation modes of ventilation) could not be accommodated in the DHIPU and required termination in the traditional ICU setting, but this was a small minority of ICU patients. All of the above are barriers to DHIPU utilization that must be addressed to have a successful unit. That said, we present our DHIPUs as an alternative to ICU-based end-of-life care in patients and families seeking a transition to comfort-focused care; we do not assert that these units are a one-size-fits-all solution appropriate for every ICU death. As Truog et al (5) point out, an ICU admission is a therapeutic trial; if the trial fails, families and medical professionals should consider the transition from restorative to palliative care, which can include DHIPUs. Hospital-based palliative care is on the rise (15) and has been shown to reduce costs and improve quality for a broad array of patients (25, 26), including those dying in the hospital (27, 28). For example, early palliative care consultation decreases the time to comfort-focused care in patients with multisystem organ failure (16). In the ICU, evidence suggests that palliative care improves patient and family understanding of diagnosis, prognosis, and goals of care and provides emotional and spiritual support (29–31). Furthermore, palliative care teams often assist with end-of-life planning and decision making in the ICU (17, 32–34), and palliative care’s involvement in a patient’s care is associated with greater utilization of hospice (35, 36). Hospice care, if available, also provides the patient and family with caregiver support and midterm bereavement support not typically available from ICUs. 1078
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Despite the common concern that hospice accelerates dying, DHIPU transfer, like palliative (36) and hospice (37) care generally, does not appear to shorten life. Although previous data for DHIPUs are limited, one study from Korea found no association with the use of a palliative care facility and survival in cancer patients (38). In our study, ICU plus DHIPU LOS for patients transferred to the DHIPU was no different from that of patients who died in the ICU. While this could be a result of baseline differences in the acuity of patients deemed suitable for transfer that resulted in longer survival, our data refute the oft-raised objection that transfer to DHIPU accelerates dying. There are several limitations to this study. It focuses on AMCs where all ICUs are managed by intensive care physicians with access to palliative care physicians and on-site DHIPUs, limiting its generalizability. The AMCs studied also have high severity of illness scores compared with other AMCs and community hospitals. That said, currently 88% of all hospitals with greater than 300 beds and 66% of those with more than 50 beds have a palliative care service (15). The presence of a palliative care service that can assist with the knowledge and skills is required to provide high quality hospice care, in partnership with hospital-based or community hospice agencies to create a DHIPU, holds great promise for the majority of academic as well as community hospitals. Such a model may be particularly feasible for larger hospitals, but it is capable of being deployed in either an academic or community environment with an existing palliative care infrastructure. Additionally, the study reports initial data beginning 2 months after unit opening; this may not reflect the units’ mature steady-state pattern. Finally, DHIPU costs were unavailable, and we relied on historical data to estimate the units’ economic impact. Several studies suggest that hospice (39–41) reduces costs at the end of life; in our analysis, we used data from three studies that quantified cost differences for inpatient palliative care and hospice units similar to DHIPUs (21–23). All three studies focused on terminal cancer patients; our units serve a broader population, which could impact cost differences. Two of the studies were international, with different patterns of healthcare expenditures than those seen in the United States. Despite these limitations, these data are a good starting point for assessing the cost impact of such units on the healthcare system, and the remarkable degree of consistency in hospice to general ward cost ratios strengthens our faith in these figures. May 2014 • Volume 42 • Number 5
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These limitations notwithstanding, our data support a role for DHIPUs. While end-of-life care remains an integral part of ICU care, DHIPUs and palliative care units offer an alternative to variable quality care in the ICU for critically ill terminal patients. DHIPUs provide a more supportive and appropriate environment for patients and families at the end of life than the ICU, and hospice’s structured bereavement program (available in the DHIPU) is a distinct benefit that provides support and counseling to family members for 13 months after the death of their loved one. This benefit—unique to hospice—is not available from ICUs. Finally, DHIPUs may reduce costs by avoiding additional aggressive interventions and structuring a plan with family members to deescalate ICU-level care at the end of life.
CONCLUSIONS DHIPUs are a feasible way to provide end-of-life care for ICU patients. DHIPUs hold great promise for delivering highquality end-of-life care from specialized, experienced staff to patients and families, but further research—including prospective studies of patients dying in ICUs versus dedicated palliative care or hospice units—is needed to assess their potential benefits and barriers to their use.
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39. Bergman J, Saigal CS, Lorenz KA, et al; Urologic Diseases in America Project: Hospice use and high-intensity care in men dying of prostate cancer. Arch Intern Med 2011; 171:204–210 40. Brumley R, Enguidanos S, Jamison P, et al: Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007; 55:993–1000 41. Candy B, Holman A, Leurent B, et al: Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence. Int J Nurs Stud 2011; 48:121–133
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