Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit.

BACKGROUND: Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU). METHODS: We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization. RESULTS: A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05). CONCLUSION: Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.

Relationship Between Changes in Prehospital Blood Pressure and Early Neurological Deterioration in Spontaneous Intracerebral Hemorrhage.

The aim of this study was to explore the relationship between changes in prehospital blood pressure (BP) and the incidence of early neurological deterioration (END) after spontaneous intracerebral hemorrhage (SICH) in patients who arrive at the emergency department (ED) with a normal Glasgow Coma Scale (GCS) score. Records of consecutive adults with SICH transported by ambulance and treated in our ED from January 2015 to December 2017 were retrospectively reviewed. The study cohort included all patients with SICH occurring within the previous 6 hr who had a normal GCS score on ED arrival. Detailed information was retrieved from our hospital's intracerebral hemorrhage databank and then cross-checked in the medical and nursing charts to confirm completeness and accuracy. Early neurological deterioration was defined as a decrease of 2 or more points in the GCS score within 6 hr after ED arrival. The change in prehospital BP was defined as the BP on ED arrival minus the initial on-scene BP. An association between a change in prehospital BP and the occurrence of END was assessed by univariate and multivariate analyses (multiple logistic regression analysis). Of the 168 patients evaluated, 36 (21.4%) developed END. Factors associated with END on univariate analysis were regular antiplatelet agent use, shorter elapsed time, on-scene systolic blood pressure (SBP), prehospital SBP increase of 15 mmHg or more, intraventricular extension of the hematoma, and the presence of 3 or more noncontrast computed tomographic signs of hematoma expansion. After adjusting for other covariates, an increase in prehospital SBP of 15 mmHg or more was significantly associated with a higher risk of END. In patients with SICH who arrive at the ED with a normal GCS score, an increase in the prehospital SBP of more than 15 mmHg is associated with a higher incidence of END.