Outcomes of COVID-19 in Patients With a History of Cancer and Comorbid Cardiovascular Disease.

BACKGROUND: Cancer and cardiovascular disease (CVD) are independently associated with adverse outcomes in patients with COVID-19. However, outcomes in patients with COVID-19 with both cancer and comorbid CVD are unknown. METHODS: This retrospective study included 2,476 patients who tested positive for SARS-CoV-2 at 4 Massachusetts hospitals between March 11 and May 21, 2020. Patients were stratified by a history of either cancer (n=195) or CVD (n=414) and subsequently by the presence of both cancer and CVD (n=82). We compared outcomes between patients with and without cancer and patients with both cancer and CVD compared with patients with either condition alone. The primary endpoint was COVID-19-associated severe disease, defined as a composite of the need for mechanical ventilation, shock, or death. Secondary endpoints included death, shock, need for mechanical ventilation, need for supplemental oxygen, arrhythmia, venous thromboembolism, encephalopathy, abnormal troponin level, and length of stay. RESULTS: Multivariable analysis identified cancer as an independent predictor of COVID-19-associated severe disease among all infected patients. Patients with cancer were more likely to develop COVID-19-associated severe disease than were those without cancer (hazard ratio [HR], 2.02; 95% CI, 1.53-2.68; P<.001). Furthermore, patients with both cancer and CVD had a higher likelihood of COVID-19-associated severe disease compared with those with either cancer (HR, 1.86; 95% CI, 1.11-3.10; P=.02) or CVD (HR, 1.79; 95% CI, 1.21-2.66; P=.004) alone. Patients died more frequently if they had both cancer and CVD compared with either cancer (35% vs 17%; P=.004) or CVD (35% vs 21%; P=.009) alone. Arrhythmias and encephalopathy were also more frequent in patients with both cancer and CVD compared with those with cancer alone. CONCLUSIONS: Patients with a history of both cancer and CVD are at significantly higher risk of experiencing COVID-19-associated adverse outcomes. Aggressive public health measures are needed to mitigate the risks of COVID-19 infection in this vulnerable patient population.

Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care.

BACKGROUND: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects. MATERIALS AND METHODS: The National Inpatient Sample database (2009-2013) was queried for patients aged ≥55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness ≥24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy. RESULTS: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC. CONCLUSIONS: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.

The Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has a substantial mortality risk with increased rates in the elderly. We hypothesized that age is not sufficient, and that frailty measured by preadmission Palliative Performance Scale would be a predictor of outcomes. Improved ability to identify high-risk patients will improve clinicians' ability to provide appropriate palliative care, including engaging in shared decision-making about life-sustaining therapies. AIM: To evaluate whether preadmission Palliative Performance Scale predicts mortality in hospitalized patients with COVID-19. DESIGN: Retrospective observational cohort study of patients admitted with COVID-19. Palliative Performance Scale was calculated from the chart. Using logistic regression, Palliative Performance Scale was assessed as a predictor of mortality controlling for demographics, comorbidities, palliative care measures and socioeconomic status. SETTING/PARTICIPANTS: Patients older than 18 years of age admitted with COVID-19 to a single urban public hospital in New Jersey, USA. RESULTS: Of 443 admitted patients, we determined the Palliative Performance Scale score for 374. Overall mortality was 31% and 81% in intubated patients. In all, 36% (134) of patients had a low Palliative Performance Scale score. Compared with patients with a high score, patients with a low score were more likely to die, have do not intubate orders and be discharged to a facility. Palliative Performance Scale independently predicts mortality (odds ratio 2.89; 95% confidence interval 1.42-5.85). CONCLUSIONS: Preadmission Palliative Performance Scale independently predicts mortality in patients hospitalized with COVID-19. Improved predictors of mortality can help clinicians caring for patients with COVID-19 to discuss prognosis and provide appropriate palliative care including decisions about life-sustaining therapy.

Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum.

BACKGROUND: Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk. METHODS: Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression. RESULTS: Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes. CONCLUSIONS: Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.

Palliative Care in Surgery: Defining the Research Priorities.

OBJECTIVE: To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. BACKGROUND: Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. METHODS: The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps. RESULTS: To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients. CONCLUSIONS: Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.

Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions.

OBJECTIVE: To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies. SUMMARY BACKGROUND DATA: Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies. METHODS: An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created. RESULTS: Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patient's condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patient's goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family. CONCLUSIONS: Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.

Quantitative increase in frailty is associated with diminished survival after transcatheter aortic valve replacement.

BACKGROUND: The purpose of this study is to assess the impact of frailty index comprised of commonly used frailty metrics on outcomes following transcatheter aortic valve replacement (TAVR) outcomes, including mortality, length of stay, and discharge destination. METHODS AND RESULTS: Retrospective data collection was performed for 342 consecutive patients who underwent TAVR at a single center from May 15, 2012, to September 17, 2015. Frailty index score was calculated using 15-ft walk test, Katz activities of daily living, preoperative serum albumin, and dominant handgrip strength. Patients were given a frailty score from 0/4 to 4/4, with higher scores indicating greater levels of frailty. There were 27 patients (8%) in 0/4, 82 patients (24%) in 1/4, 129 patients (38%) in 2/4, 73 patients (21%) in 3/4, and 31 patients (9%) in 4/4 frailty group. Multivariate cox, logistic, and linear regression analyses showed that patients with frailty score of 3/4 or 4/4 had increased all-cause mortality (P = .015 and P < .001) and were more likely to be discharged to an acute care facility (P = .083 and P = .001). 4/4 frail patients had increased post-operative length of stay (P = .014) when compared to less frail patients. Individual components of the frailty score were also independent predictors of all-cause mortality. Median survival in 4/4 frail patients was 7 months. CONCLUSIONS: Frailty index comprised of commonly used frailty metrics and its components are independent predictors of poor post-TAVR outcomes. There is a stepwise increase in mortality and post-TAVR length of stay with increasing frailty with dismal prognosis in extremely frail patients.

Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care.

OBJECTIVES: To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. DATA SOURCES: A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury." DATA EXTRACTION AND SYNTHESIS: We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. CONCLUSIONS: Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults.

BACKGROUND: Hospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age>50 y) admitted to the SICU. METHODS: A prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1-10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis. RESULTS: Of 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12-6/12) and 66 postintervention (7/12-3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P=0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P=0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P=0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P=0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P=0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P=0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P=0.02), received less total opioids (pre 401 versus 260 mg, P=0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P=0.04). CONCLUSIONS: Although delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.

Integrating palliative care into the PICU: a report from the Improving Palliative Care in the ICU Advisory Board.

OBJECTIVE: This review highlights benefits that patients, families and clinicians can expect to realize when palliative care is intentionally incorporated into the PICU. DATA SOURCES: We searched the MEDLINE database from inception to January 2014 for English-language articles using the terms "palliative care" or "end of life care" or "supportive care" and "pediatric intensive care." We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. STUDY SELECTION: Two authors (physicians with experience in pediatric intensive care and palliative care) made final selections. DATA EXTRACTION: We critically reviewed the existing data and tools to identify strategies for incorporating palliative care into the PICU. DATA SYNTHESIS: The Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: pain and symptom management, enhancing quality of life, communication and decision-making, length of stay, sites of care, and grief and bereavement. CONCLUSIONS: Palliative care should begin at the time of a potentially life-limiting diagnosis and continue throughout the disease trajectory, regardless of the expected outcome. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically ill children with complex underlying conditions and others receiving intensive care for prolonged periods. Integrating palliative care delivery into the PICU is rapidly becoming the standard for high quality care of critically ill children. Interdisciplinary ICU staff can take advantage of the growing resources for continuing education in pediatric palliative care principles and interventions.

Nirmatrelvir-Ritonavir for Acute COVID-19 in Patients With Cardiovascular Disease and Postacute Sequelae of SARS-CoV-2 Infection.

Background: There is limited evidence of association of nirmatrelvir-ritonavir (NMV-r) and incidence of postacute sequelae of SARS-CoV-2 infection (PASC) in patients with pre-existing cardiovascular disease (CVD). Objectives: The objective of this study was to assess the association of NMV-r in nonhospitalized, vaccinated patients with pre-existing CVD and occurrence of PASC. Methods: We conducted a retrospective cohort study utilizing the TriNetX research network, including vaccinated patients with pre-existing CVD who developed COVID-19 between December 2021 and December 2022. Two cohorts were created based on NMV-r administration within 5 days of diagnosis: NMV-r and non-NMV-r cohort. The main outcome was presence of PASC, assessed between 30 to 90 days and 90 to 180 days after index COVID-19 infection. After propensity score matching, both cohorts were compared using t-test and chi-square test for continuous and categorical variables, respectively. Results: A total of 26,953 patients remained in each cohort after propensity score matching. Broadly defined PASC occurred in 6,925 patients (26%) in the NMV-r cohort vs 8,150 patients (30.6%) in the non-NMV-r cohort (OR: 0.80; 95% CI: 0.76-0.82; P < 0.001) from 30 to 90 days and in 6,692 patients (25.1%) as compared to 8,910 patients (33.5%) (OR: 0.25, 95% CI: 0.23-0.29; P < 0.001) from 90 to 180 days. Similarly, narrowly defined PASC occurred in 5,335 patients (20%) in the NMV-r cohort vs 6,271 patients (23.6%) in the non-NMV-r cohort between 30 and 90 days (OR: 0.81, 95% CI: 0.78-0.84, P < 0.001) and in 5,121 patients (19.2%) as compared to 6,964 patients (26.1%) (OR: 0.67, 95% CI: 0.64-0.70, P < 0.001) between 90 and 180 days. Conclusions: NMV-r in nonhospitalized vaccinated patients with pre-existing CVD with COVID-19 was associated with a reduction in PASC and health care utilization.

Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board.

OBJECTIVE: To review the use of screening criteria (also known as "triggers") as a mechanism for engaging palliative care consultants to assist with care of critically ill patients and their families in the ICU. DATA SOURCES: We searched the MEDLINE database from inception to December 2012 for all English-language articles using the terms "trigger," "screen," "referral," "tool," "triage," "case-finding," "assessment," "checklist," "proactive," or "consultation," together with "intensive care" or "critical care" and "palliative care," "supportive care," "end-of-life care," or "ethics." We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. STUDY SELECTION: Two members (a physician and a nurse with expertise in clinical research, intensive care, and palliative care) of the interdisciplinary Improving Palliative Care in the ICU Project Advisory Board presented studies and tools to the full Board, which made final selections by consensus. DATA EXTRACTION: We critically reviewed the existing data and tools to identify screening criteria for palliative care consultation, to describe methods for selecting, implementing, and evaluating such criteria, and to consider alternative strategies for increasing access of ICU patients and families to high-quality palliative care. DATA SYNTHESIS: The Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: existing screening criteria; optimal methods for selection, implementation, and evaluation of such criteria; and appropriateness of the screening approach for a particular ICU. CONCLUSIONS: Use of specific criteria to prompt proactive referral for palliative care consultation seems to help reduce utilization of ICU resources without changing mortality, while increasing involvement of palliative care specialists for critically ill patients and families in need. Existing data and resources can be used in developing such criteria, which should be tailored for a specific ICU, implemented through an organized process involving key stakeholders, and evaluated by appropriate measures. In some settings, other strategies for increasing access to palliative care may be more appropriate.

The Geriatric Patient One Year After Trauma: Palliative Performance Scale Predicts Functional Outcomes.

INTRODUCTION: Frailty in trauma has been found to predict poor outcomes after injury including additional in-hospital complications, mortality, and discharge to dependent care. These gross outcome measures are insufficient when discussing long-term recovery as they do not address what is important to patients including functional status and quality of life. The purpose of this study is to determine if the Palliative Performance Scale (PPS) predicts mortality and functional status one year after trauma in geriatric patients. MATERIAL AND METHODS: Prospective observational study of trauma survivors, age ≥55 years. Patients were stratified by pre-injury PPS high (>70) or low (≤70). Outcomes were functional status at 1 year measured by Glasgow Outcome Scale Extended (GOSE), Euroqol-5D and SF-36. Adjusted relative risks (aRR) were obtained using modified Poisson regression. RESULTS: Follow-up was achieved on 215/301 patients. Mortality was 30% in low PPS group vs 8% in the high PPS group (P<0.001). A greater percentage of patients in the high group had a good functional outcome at one year compared to patients in the low group (78% vs 30% p<0.001). The high PPS patients were more likely to have improvement of GOSE at 1 year from discharge compared to low group (66% vs 27% P<0.001). Low PPS independently predicted poor functional outcome (aRR, 2.64; 95% confidence interval, 1.79-3.89) and death at 1 year (aRR, 3.64; 95% confidence interval 1.68-7.92). An increased percentage of low PPS patients reported difficulty with mobility (91% vs 46% p<0.0001) and usual activities (82% vs 56% p=0.002). Both groups reported pain (65%) and anxiety/depression (47%). CONCLUSION: Low pre-Injury PPS predicts mortality and poor functional outcomes one year after trauma. Low PPS patients were more likely to decline, rather than improve. Regardless of PPS, most patients have persistent pain, anxiety, and limitations in performing daily activities.

Finding New Meaning in the Practice of Medicine: A Quality Improvement Project Evaluating the Remote Communication Liaison Program During the Initial COVID Pandemic Surge.

Background: In spring 2020, the COVID-19 pandemic overwhelmed intensive care teams with severely ill patients. Even at the end of life, families were barred from hospitals, relying solely on remote communication. A Remote Communication Liaison Program (RCLP) was established to ensure daily communication for families, while supporting overstretched intensivists. Objectives: To evaluate the effectiveness and impact of the RCLP on participating liaisons and intensivists. Design: Two quality improvement surveys were developed and administered electronically. Setting/Subjects: Based in the United States, all liaisons and intensivists who participated in this program were invited to take the surveys. Measurements: Descriptive statistics were used to analyze the quantitative Likert-scale data, and qualitative analysis was used to assess themes. Results: Among respondents, all (100%) liaisons and more than 90% of intensivists agreed or strongly agreed that the RCLP provided a valuable service to families. More than 70% of intensivists agreed or strongly agreed that the program lessened their workload. More than 90% of liaisons agreed or strongly agreed that participation in the program improved their confidence and skills in end-of-life decision making, difficult conversations, and comprehension of critical care charts. Themes elicited from the liaisons revealed that participation fostered a renewed sense of purpose as physicians, meaningful connection, and opportunities for growth. Conclusions: RCLP successfully trained and deployed liaisons to rapidly develop skills in communication with beleaguered families during COVID-19 surge. Participation in the program had a profound effect on liaisons, who experienced a renewed sense of meaning and connection to the practice of medicine.

Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care.

OBJECTIVE: Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit. DATA SOURCES: We searched the MEDLINE database from inception to May 2011 for all English language articles using the term "surgical palliative care" or the terms "surgical critical care," "surgical ICU," "surgeon," "trauma" or "transplant," and "palliative care" or "end-of- life care" and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report. DATA EXTRACTION AND SYNTHESIS: We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families. CONCLUSIONS: Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. "Consultative," "integrative," and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and "culture" in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit.

Hospice and palliative medicine: a novel subspecialty of emergency medicine.

BACKGROUND: Emergency Medicine (EM) is a resuscitative discipline where the major focus in teaching and practice is to rapidly diagnose, stabilize, and initiate curative therapy. Thus, it may seem counterintuitive to have Hospice and Palliative Medicine (HPM), a specialty often perceived as a last resort measure "when no more can be done" for the patient, included as the latest subspecialty of EM. OBJECTIVE: We discuss the scope of practice and the role of HPM in the emergency department (ED) to clarify some commonly held misconceptions. DISCUSSION: HPM principles are frequently applied in ED patient care. EM clinicians routinely rely on many of the same skills that are refined and advanced by HPM when treating symptoms, facilitating goals of care discussions, communicating bad news, and integrating the treatment of the physical, psychological, and social suffering in patient care. The HPM approach to care is patient-centered as opposed to disease-centered, with a focus on the relief of distressing symptoms to improve the quality of life. This parallels ED care, where priority is given to alleviate distressing symptoms such as acute pain or vomiting, regardless of the underlying disease process. In fact, EM is one specialty in which we may submit a bill purely based on an International Classification of Diseases-9(th) Revision symptom code. CONCLUSION: In this article we explore the background of HPM; outline the principles and core skills of HPM that are applicable to the daily practice of EM; and explore the pathway, now available, towards a subspecialty certification.

Is There a Role for Rib Plating in Thoracic Trauma?

Rib fractures are a morbid consequence of blunt trauma and are associated with a highly variable clinical presentation ranging from nondisplaced rib fractures causing limited, manageable pain to severely displaced rib fractures with concomitant thoracic injuries leading to respiratory failure. Due to an evolution of techniques, hardware technology, and general acceptance, rib plating has increased substantially at trauma centers all throughout the United States over the past decade. This article aims to review the most recent and current reports for rib plating with respect to indications, preoperative evaluation and imaging, approaches, timing for intervention, outcomes in patients with flail chest and nonflail injuries, and the management of complications. From these data, it becomes clear that the surgical stabilization of rib fractures (SSRF) has a firm place in the management of thoracic trauma.

Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19.

Importance: Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. Objective: To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. Design, Setting, and Participants: This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Exposures: Race, ethnicity, Social Vulnerability Index. Main Outcomes and Measures: The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Results: Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. Conclusions and Relevance: In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.