Colorado Palliative Care and Hospice Crisis Standards: Moving Beyond Critical Care Planning

Palliative care (PC) and hospice services have experienced shortages before 2020, and during the initial phases of the current pandemic, more critical gaps are expected with future surges, much as scarcity in intensive care unit services may recur during the COVID-19 pandemic. Although ethical allocation of ventilators and intensive care unit care is the subject of important discussions during this pandemic, caring for those at the end of life and those not desiring or qualifying for critical interventions must not be neglected, as critical care and comfort-focused care are intertwined. We review state and regional gaps already recognized in planning for scarcity in PC and hospice services during this pandemic and describe the planning initiatives Colorado has developed to address potential scarcities for this vulnerable and diverse group of people. We hope to encourage other state and regional groups to anticipate needs in the coming surges of this pandemic or in public health crises to come. Such planning is key to avoid the degradation of care that may result if it is necessary to invoke crisis standards of care and ration these essential services to our communities.

Gender disparities in leadership and scholarly productivity of academic hospitalists

BACKGROUND

Gender disparities still exist for women in academic medicine but may be less evident in younger cohorts. Hospital medicine is a new field, and the majority of hospitalists are <41 years of age.

OBJECTIVE

To determine whether gender disparities exist in leadership and scholarly productivity for academic hospitalists and to compare the findings to academic general internists.

DESIGN

Prospective and retrospective observational study.

SETTING

University programs in the United States.

MEASUREMENTS

Gender distribution of (1) academic hospitalists and general internists, (2) division or section heads for both specialties, (3) speakers at the 2 major national meetings of the 2 specialties, and (4) first and last authors of articles from the specialties' 2 major journals

RESULTS

We found equal gender representation of hospitalists and general internists who worked in university hospitals. Divisions or sections of hospital medicine and general internal medicine were led by women at 11/69 (16%) and 28/80 (35%) of university hospitals, respectively (P = 0.008). Women hospitalists and general internists were listed as speakers on 146/557 (26%) and 291/580 (50%) of the presentations at national meetings, respectively (P < 0.0001), first authors on 153/464 (33%) and 423/895 (47%) publications, respectively (P < 0.0001), and senior authors on 63/305 (21%) and 265/769 (34%) articles, respectively (P < 0.0001).

CONCLUSIONS

Despite hospital medicine being a newer field, gender disparities exist in leadership and scholarly productivity.

Caring about prognosis: a validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year

BACKGROUND

Identifying patients, at the time of hospital admission, who are at high risk for 1-year mortality is an ideal opportunity to introduce palliative interventions into the hospital care plan. The CARING (C = primary diagnosis of cancer, A = ≥ 2 admissions to the hospital for a chronic illness within the last year; R = resident in a nursing home; I = intensive care unit admission with multiorgan failure, NG = noncancer hospice guidelines [meeting ≥ 2 of the National Hospice and Palliative Care Organization's guidelines] criteria is a practical prognostic index developed and validated in the Veteran's Administration hospital setting that identifies patients at high risk of death within 1 year, although its effectiveness in a broader patient population is unknown.

OBJECTIVE

To validate the CARING criteria in a university and safety-net hospital setting.

DESIGN

Retrospective observational cohort study.

SETTING

Inpatient.

PATIENTS

Adults admitted to medical and surgical inpatient services during the study period of July 2005 through August 2005.

MEASUREMENTS

Mortality at 1 year following the index hospitalization was the primary end point. The CARING criteria were abstracted from the chart using only medical data available at time of admission.

RESULTS

At total of 1064 patients were admitted during the study period. Primary diagnosis of cancer (odds ratio [OR) = 7.23 [4.45-11.75]), intensive care unit admission with multiple organ failure (OR = 6.97 [2.75-17.68]), >2 noncancer hospice guidelines (OR = 15.55 [7.28-33.23]), and age (OR = 1.60 [1.32-1.93]) were predictive of 1-year mortality (C statistic = 0.79). One-year survival was significantly lower for those who met ≥ 1 of the CARING criteria.

CONCLUSIONS

The CARING criteria are a practical prognostic tool validated in a broad inpatient population that can be utilized on hospital admission to estimate risk of death in 1 year, with the goal of identifying patients who may benefit most from incorporating palliative interventions into their hospital plan of care. Journal of Hospital Medicine 2013;8:696-701. © 2013 Society of Hospital Medicine.

Prospective comparison of curbside versus formal consultations

BACKGROUND

Curbside consultations are commonly requested during the care of hospitalized patients, but physicians perceive that the recommendations provided may be based on inaccurate or incomplete information.

OBJECTIVE

To compare the accuracy and completeness of the information received from providers requesting a curbside consultation of hospitalists with that obtained in a formal consultation on the same patients, and to examine whether the recommendations offered in the 2 consultations differed.

DESIGN

Prospective cohort.

SETTING

University-affiliated, urban safety net hospital.

MAIN OUTCOME MEASURES

Proportion of curbside consultations with inaccurate or incomplete information; frequency with which recommendations in the formal consultation differed from those in the curbside consultation.

RESULTS

Curbside consultations were requested for 50 patients, 47 of which were also evaluated in a formal consultation performed on the same day by a hospitalist other than the one performing the curbside consultation. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24/47 (51%) of the curbside consultations. Management advice after formal consultation differed from that given in the curbside consultation for 28/47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal versus the curbside consultation differed in 22/24 patients (92%, P < 0.0001).

CONCLUSIONS

Information presented during inpatient curbside consultations of hospitalists is often inaccurate or incomplete, and this often results in inaccurate management advice.

ACUTE center for eating disorders

BACKGROUND

While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.

METHODS

We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported.

RESULTS

From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero.

DISCUSSION

Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Effect of sample dilutions on arterial blood gas determinations

A study was undertaken to determine the blood gas effects of incompletely purging heparinized saline flush solution from an indwelling arterial catheter and pressure tubing. Hematocrit and blood gases were measured after withdrawing 0, 2, 4, 6, 8, and 10 ml of flush-blood solutions before sampling from a 20-ga radial artery catheter and 7-ft pressure tubing and stopcock. The pH and hematocrit were nearly unchanged between purging volumes of 8 and 10 ml. The PaO2 had a 2.4% error, while the PaCO2 had a 4.4% error. Because there is no standard arterial line setup, it is recommended that each ICU undertake a similar study to determine the optimal volume of aspirated flush-blood solution before blood gas sampling, in order to achieve accurate blood gas results and minimize blood waste.

CSF lactate in diseases of the CNS

The usefulness of the CSF lactate concentration in the diagnosis of bacterial meningitis was studied in 109 adults and children with a variety of infectious and neurologic diseases. A positive correlation was found between elevated lactate levels and the presence of leukocytes in the CSF. Elevations of the CSF lactate concentration with concomitantly negative Gram's stains and cultures were found in patients with infections at anatomic sites other than the CNS, accidental or neurosurgical head trauma, subarachnoid hemorrhage, and seizures due to alcoholism. When performed routinely on CSF, the positive predictive value was 31%, indicating that a diagnosis other than bacterial meningitis is more likely. We conclude that the CSF lactate concentration does not contribute to the diagnosis in children or adults with suspected meningitis.