Advance Care Planning Among Patients With Advanced Illness Presenting to the Emergency Department

BACKGROUND

Advance care planning (ACP) benefits emergency department (ED) patients with advanced illness. Although Medicare implemented physician reimbursement for ACP discussions in 2016, early studies found limited uptake.

OBJECTIVE

We conducted a pilot study to assess ACP documentation and billing to inform the development of ED-based interventions to increase ACP.

METHODS

We conducted a retrospective chart review to quantify the proportion of ED patients with advanced illness with Physician Orders for Life-Sustaining Treatment (POLST) or coding of ACP discussion in the medical record. We surveyed a subset of patients via phone to evaluate ACP participation.

RESULTS

Of 186 patients included in the chart review, 68 (37%) had a POLST and none had ACP discussions billed. Of 50 patients surveyed, 18 (36%) recalled prior ACP discussions.

CONCLUSIONS

Given the low uptake of ACP discussions in ED patients with advanced illness, the ED may be an underused setting for interventions to increase ACP discussions and documentation.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

IMPORTANCE

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

OBJECTIVE

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

EVIDENCE REVIEW

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

FINDINGS

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

CONCLUSIONS AND RELEVANCE

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Association of Residential Racial and Ethnic Segregation With Legal Intervention Injuries in California

IMPORTANCE

The continued harm of Black individuals in the US by law enforcement officers calls for reform of both law enforcement officers and structural racism embedded in communities.

OBJECTIVE

To examine the association between county characteristics and racial and ethnic disparities in legal intervention injuries.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional study was conducted among 27 671 patients presenting to California hospitals from January 1, 2016, to December 31, 2019, with legal intervention injuries (defined as any injury sustained as a result of an encounter with any law enforcement officer) as identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

MAIN OUTCOMES AND MEASURES

Legal intervention injuries were classified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision external cause of injury code Y35. Expected injury counts were calculated for each county by multiplying statewide median rates of injury per capita for each age-racial and ethnic group, and then observed to expected injury ratios were measured. The association between county injury ratio, percentage of Black individuals, and residential segregation (measured using an index of dissimilarity) was modeled, stratifying by race and ethnicity.

RESULTS

A total of 27 671 patients (24 159 male patients [87.3%]; 1734 Asian and Pacific Islander [6.3%], 5049 Black [18.2%], 11 250 Hispanic [40.7%], and 9638 White [34.8%]; mean [SD] age, 34.2 [12.5] years) presented with legal intervention injuries in California from 2016 to 2019. Observed to expected injury ratios ranged from 0 to 7 for Black residents and from 0 to 5 for White residents. High observed to expected injury ratios for Black residents (408 observed vs 60 expected; ratio = 7) were clustered around San Francisco Bay Area counties and corresponded with a higher proportion of Black residents. High observed to expected injury ratios for White residents (57 observed vs 11 expected; ratio = 5) clustered around rural northern California counties and corresponded with higher mean percentage of residents with income below the federal poverty level and fewer urban areas.

CONCLUSIONS AND RELEVANCE

This study suggests that residential segregation may be associated with increased legal intervention injury rates for Black residents of California counties with a large percentage of Black residents. Reform efforts to address racial and ethnic disparities in these injuries should carefully consider and address the legacy of discriminatory policies that has led to segregated communities in California and the United States.

Early head CT in post-cardiac arrest patients: A helpful tool or contributor to self-fulfilling prophecy?

OBJECTIVE

Neuroprognostication guidelines suggest that early head computed tomography (HCT) might be useful in the evaluation of cardiac arrest (CA) patients following return of spontaneous circulation. We aimed to determine the impact of early HCT, performed within the first 6 h following CA, on decision-making following resuscitation.

METHODS

We identified a cohort of initially unconscious post-CA patients at a tertiary care academic medical center from 2012 to 2017. Variables pertaining to demographics, CA details, post-CA care, including neuroimaging and neurophysiologic testing, were abstracted retrospectively from the electronic medical records. Changes in management resulting from HCT findings were recorded. Blinded board-certified neurointensivists adjudicated HCT findings related to hypoxic-ischemic brain injury (HIBI) burden. The gray-white matter ratio (GWR) was also calculated.

RESULTS

Of 302 patients, 182 (60.2%) underwent HCT within six hours of CA (early HCT group). Approximately 1 in 4 early HCTs were abnormal (most commonly HIBI changes; 78.7%, n = 37), which resulted in a change in management in nearly half of cases (46.8%, n = 22). The most common changes in management were de-escalation in care [including transition to do not resuscitate status), withholding targeted temperature management, and withdrawal of life sustaining therapy (WLST)]. In cases with radiographic HIBI, mean [standard deviation] GWR was lower (1.20 [0.10] vs 1.30 [0.09], P < 0.001) and progression to brain death was higher (44.4% vs 2.9%; P < 0.001). The inter-rater reliability (IRR) of early HCT to determine presence of HIBI between radiology and three neurointensivists had a wide range (κ 0.13-0.66).

CONCLUSION

Early HCT identified abnormalities in 25% of cases and frequently influenced therapeutic decisions. Neuroimaging interpretation discrepancies between radiology and neurointensivists are common and agreement on severity of HIBI on early HCT is poor (k 0.11).

Implementation of Federal Dependent Care Policies for Physician-Scientists at Leading US Medical Schools

This survey study explores whether leading US medical schools have policies about dependent care travel costs.

Abstract TP304: Stroke-Specific Quality of Life as an Independent Outcome in Intracerebral Hemorrhage

Introduction: Quality of life (QoL) is important to patients and decision makers. However, little is known about QoL in intracerebral hemorrhage (ICH) survivors. The purpose of this study is to investigate the relationship between clinical characteristics, measures of disability, and the stroke-specific quality of life (SS-QoL) among ICH survivors.

Methods: Sixty-eight ICH subjects were prospectively enrolled at Yale-New Haven Hospital from July 2015 to February 2017. The SS-QoL, modified Rankin Scale (mRS), and Barthel Index (BI) were obtained by phone interview at 3 (n=15), 6 (n=43), and 12 (n=10) months post ICH. The SS-QoL is a self-reported, 12-domain assessment utilizing 5-point Likert scales. SS-QoL domain scores are the mean of individual scores in each domain. A summary score was calculated as the mean of all 12 domain scores with a range of 1-5. Higher scores indicate better QoL. SS-QoL scores ≥4, BI scores ≥ 90, and mRS ≤ 2 were considered good. Logistic regression was used to investigate associations between covariates and QoL.

Results: The mean SS-QoL summary score was 3.8 (SD 0.80) at a mean follow up time of 6 months. Fifty-three percent of subjects reported a good QoL, compared to 66% and 78% of subjects with a good outcome on the mRS and BI, respectively. Subjects scored highest in the self-care (mean score 4.2) and vision (4.3) domains of the SS-QoL and lowest in the energy (3.2), social (3.3), and thinking (3.4) domains. Known predictors of outcome after ICH including age, sex, race/ethnicity, admission GCS, ICH location, ICH volume, and IVH extension were not associated with SS-QoL scores.

Conclusion: The SS-QoL provides information on domains that are not captured by the mRS and the BI and is not associated with traditional predictors of outcome after ICH. These data support further studies on the use of QoL as an outcome independent of disability measures.

Abstract WMP96: Racial Variation in Comfort Measures Only Status in Patients With Intracerebral Hemorrhage

Introduction: Prior studies of critically ill patients found that non-whites are less likely to pursue comfort measures only status (CMOs). We sought to identify determinants of CMOs in a large multi-ethnic cohort study of intracerebral hemorrhage (ICH).

Methods: We analyzed cases enrolled from 2010 to 2015 in the Ethnic/Racial Variations of ICH (ERICH) study, a multi-center study in the USA. Clinical, demographic and radiologic data on non-traumatic ICH patients were prospectively collected. Univariate and multivariate logistic regression was used to evaluate the association between ethnicity/race and CMOs after adjustment for potential confounders.

Results: 2705 ICH cases were included in this study (mean age 62 (14), female sex 1119 [41%]). Of these, 912 were black (34%), 893 Hispanic (33%) and 900 white (33%). CMOs patients comprised 276 (10%), 64 (7%), 79 (9%) and 133 (15%) of the entire cohort and the black, Hispanic and white cohorts, respectively (p<0.001) (Table 1). In multivariate analysis, black patients were half as likely as white patients to be made CMO (OR 0.50, 95% CI 0.34-0.75; p=0.001) and there was a trend for Hispanic patients to have CMOs less often than white patients (OR 0.72, 95% CI 0.49-1.06, p=0.093) (Table 2). Other factors associated with CMOs included age, premorbid modified Rankin Scale, dementia, admission Glasgow Coma Scale, ICH volume, intraventricular hematoma volume, lobar and brainstem bleeds and intubation.

Conclusion: Black patients were less likely than white patients to be made CMO after controlling for potential confounders. Further investigation is warranted to understand the causes and implications of racial disparities in CMO decisions.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.