A Tunneled Catheter Placement Program for Community Hospices

CONTEXT

The symptoms associated with the excessive fluid accumulation of ascites or pleural effusions can be intractable to medical management and can have a significant negative impact on quality of life of hospice patients. Hospice of the Valley, a community-based, nonprofit hospice agency has historically referred patients to outpatient providers for paracentesis, thoracentesis, and placement of tunneled drainage catheters.

OBJECTIVES

To describe an in-house pilot program of tunneled catheter placement to provide immediate and longer-term symptom relief for selected hospice patients.

METHODS

The logistics and cost of the pilot program are described. Key data elements, including select demographics, patient eligibility screening, and incidence of procedure-related or late complications are reported.

RESULTS

A total of 135 drainage procedures completed on 127 unique hospice patients over 27 months (2020-2023) were reviewed. The rate of procedure-related complications (<4%) and late complications (<3%) are low. The average cost per procedure ($1030) compares favorably with outpatient providers' fees. The program was well-accepted by the interdisciplinary hospice team, patients, and families.

CONCLUSIONS

An in-house program of tunneled catheter placement is a feasible option for hospice providers with low-cost exposure and high potential for improved quality of life and symptom relief for selected patients.

Avoided Hospitalization Criteria: Validating the Impact of a Community-Based Palliative Care Program

Objective: This report describes the experiences of a community-based palliative care (CBPC) program's efforts to understand the patterns of hospital utilization, specifically utilization reduction experienced by admitted patients. Efforts to quantify and describe an avoided hospitalization and opportunities to use these data to strengthen partnerships with local insurance payers to assure sustainability of the CBPC will be discussed. Background: Patients with serious chronic illness experience emergency room care and hospitalizations with increasing frequency as their health deteriorates. CBPC programs are well positioned to decrease hospital utilization by early involvement and improved care management. Methods: Arizona Palliative Home Care (AZPHC) program is a free standing CBPC in Maricopa County, Arizona, serving 3300 patients annually. An interdisciplinary team was formed within the CBPC to facilitate the identification of avoided hospital events and communicate these data to community partners in an effective and consistent manner. The processes developed by this team are described. Results: AZPHC has enhanced its hospitalization avoidance strategies by communicating the rate of hospitalization avoidance events in a consistent and strategic manner. Providing instances of avoided hospitalizations with accompanying patient narratives to payers has enabled AZPHC to demonstrate the impact the CBPC has on improving quality of care and reducing overall costs. Discussion: CBPC programs require payment for sustainability; therefore, partnerships with local insurance payers are essential. Presenting data that validate the impact of a program from a clinical and financial perspective will advance the growth of payer-CBPC provider relationships and secure a future for funded CBPC programs.

Impact of a Hospital Community Based Palliative Care Partnership: Continuum from Hospital to Home

Objectives: To discuss the outcomes of a formalized care transition process for palliative care patients from the hospital to the community. Background: Patients who received inpatient palliative care services from the specialist palliative care team in the hospital or who were identified as needing community palliative care services have inadequate support on discharge. Methods: A retrospective review of the medical records of patients admitted to the community based palliative care (CBPC) program, Arizona Palliative Home Care (AZPHC) over a 12-month period (June 2018 to May 2019) was undertaken with a focus on the frequency and pattern of hospital events pre- and postadmission to the program. Patient/family satisfaction data obtained from telephone surveys were evaluated. The medical records from patients (n = 294) with advanced complex illnesses who were admitted to AZPHC from the five Honor Health Network hospitals were included in this study. Results: Of the 294 patients' records reviewed, 80% were in the 65 and older age group and had a mean length of stay on AZPHC of ∼40 days. Comparing acute care utilization pre and post AZPHC admission, there was a reduction of 68.95% at 60 days and 68.22% at 90 days. In addition, 128 avoided hospital events were recorded, and 86% of patients were very likely to recommend AZPHC to family or friends. Discussion: Collaboration between a hospital palliative care team and a CBPC program resulted in high quality transitions across care settings and reduction in acute care utilization.

Adverse effects in hospice patients with chronic kidney disease receiving hydromorphone

BACKGROUND

Pain is one the most common symptoms experienced by palliative care patients. The treatment of pain involves the use of strong opioids such as hydromorphone, morphine, methadone, fentanyl, oxycodone, oxymorphone, or levorphanol for moderate to severe pain. Hydromorphone is metabolized by the liver to hydromorphone-3-glucuronide (H3G), a compound that can potentially cause neuroexcitatory phenomena with accumulation. Pharmacokinetic studies have shown that H3G levels in patients with renal insufficiency are 4 times as high as those with normal renal function; however, reports have been conflicting as to whether or not it is safe to use hydromorphone in renal insufficiency.

METHODS

In this study we sought to determine the prevalence of neuroexcitation in patients with renal insufficiency who were given hydromorphone, as measured by the glomerular filtration rate (GFR), and to investigate factors associated with increased risk of neuroexcitation in this patient group. For the 12- month period from June 2007 through June 2008, charts of inpatient hospice patients that showed a glomerular filtration rate of <60 (mL/min/1.73 m(2)) and hydromorphone administration for pain control via continuous infusion were reviewed for the occurrence of neuroexcitatory effects, including tremor, myoclonus, agitation, cognitive dysfunction, and seizures.

RESULTS

Overall prevalence of neuroexcitatory effects were: tremor 11 (20%), myoclonus 11 (20%), agitation 26 (48%), and cognitive dysfunction 21 (39%). No seizures were observed. No neuroexcitatory effects were observed for the lowest quartile of dose or duration of hydromorphone. There was a strong and graded increase in neuroexcitatory effects with increasing quartile of dose or duration of hydromorphone for agitation (dose, p<0.0001; duration, p<0.0001) and cognitive dysfunction (dose, p<0.0002; duration, p<0.002). Consistent but weaker trends were observed for tremor and myoclonus.

CONCLUSION

Parenteral hydromorphone has few neuroexcitatory symptoms until H3G accumulates past a neurotoxic threshold, such as might occur with increasing dose or duration, which, when exceeded, causes neuroexcitatory symptoms to manifest.