Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital.

BACKGROUND/OBJECTIVES: Research indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients' CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective. DESIGN: A retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison. SETTING/PARTICIPANTS: A sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S. METHODS/RESULTS: Ninety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR=1.43, 95%CI 1.08-1.89, p=0.012), being a male (OR=3.14; 95%CI 1.40-7.05, p=0.006), and the presence of two or more comorbidities (OR=3.71, 95%CI 1.67-8.24, p=0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation. CONCLUSION: A positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.

[Delayed discharge of older patients from the Department of Geriatric Medicine of the Erasmus Medical Centre and factors affecting the length of stay; July 2001--June 2002]. / Wachtduur bij ontslag van de afdeling Geriatrie van het Erasmus Medisch Centrum, en beïnvloedende factoren; juli 2001--juni 2002.

OBJECTIVE: To determine how the discharge of older patients proceeds and what factors affect it. DESIGN: Descriptive. METHOD: Data were collected on the 123 patients admitted to the Department of Geriatric Medicine of the Erasmus Medical Centre in Rotterdam, the Netherlands: retrospectively, from the patient files, for the admissions in the period from 1 July 2001 to 31 March 2002, and prospectively for the admissions between 1 April and 30 June 2002. Key figures in the discharge process were also interviewed during the period from 1 September to 21 November 2002. RESULTS: The average age was 83.5 years (SD: 7); 34% were males. The average duration of treatment was 13 days while the average length of admission was 22 days. There was an average of 10 days between the request from the Geriatrics Department to discharge from the hospital, via a care office for an additional-care facility, an Aftercare Office and a Regional Indicating Office (RIO). Patient characteristics that were associated with a longer duration of admission and a longer discharge procedure were: discharge to a somatic nursing home, a diagnosis of 'delirium' or 'dementia', and living independently at home before admission. Patients who were known to the Geriatrics Department (either via the outpatient clinic or via a previous admission) had a shorter duration of admission. Of all the indication decisions of the RIO, only one deviated from the recommendation of the Geriatrics Department. CONCLUSION: The average duration of admission was 9 days longer than the average duration of treatment. The discharge procedure could be accelerated by simplifying the bureaucratic process surrounding indication and referral to an additional-care facility and by accepting the recommendations of the Geriatrics Department.

Designing an incentive based health promotion program.

1. A health incentive program can be an effective intervention for reducing employee population risk and altering health care utilization patterns. 2. An incentive based health promotion program rewards employees for performing a selected set of behaviors. 3. Collecting supporting data (benchmarking, needs assessment, organization data, published data) provides the foundation for the health incentive program design. 4. Choose an incentive appropriate to the employee population and worksite culture.

On-site occupational health nursing services: estimating the net savings: Part II.

1. A primary management use of this quantitative assessment model is to estimate the overall net cost savings from operating an entire on-site occupational health nursing program. 2. Another management use of this model is to estimate the net cost savings contributed by individual occupational health nursing services included in the on-site program. 3. The exclusive focus of the model on the net cost savings arising from the direct substitution of on-site for off-site occupational health nursing services can be extended with the application of a break even analysis. 4. A sensitivity analysis can be applied to factors of the model to help overcome the effects of substantial uncertainty concerning their estimates.

On-site occupational health nursing services: estimating the net savings: Part I.

1. The following question can be successfully answered with a well developed quantitative assessment model: Is more money likely to be saved from the services of an on-site occupational health nursing program than is expended in providing these services? 2. The focus of this evaluation should be restricted to the net cost savings from the direct substitution of on-site for off-site provision of occupational health nursing services by such programs. 3. The evaluation model requires estimates of five separate factors for each occupational health nursing service provided by such programs that directly substitute for its off-site provision.