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OBJECTIVE. To describe a physician (MD) and registered nurse (RN) led palliative care consultation team embedded in the medical intensive care unit (MICU). To compare patterns of palliative care consultation, and rates of goals of care documentation and in-ICU mortality before and after the implementation of the embedded team. CONTEXT. By embedding MD/RN palliative care team in the MICU, more critically ill patients with unmet palliative care needs could receive an earlier palliative care consultation. METHODS. In a retrospective cohort study of patients admitted to the MICU who received a palliative care consultation, we compared sociodemographic and clinical characteristics of patients who received a referral-based consultation (01/01/2019–06/30/2019) and those who received an embedded MD/RN consult (09/01/2019–02/28/2020). Using the electronic health record data, we compared palliative care consultation characteristics, rates of documentation of medical decision-maker and goals of care, and percentage of in-ICU mortality between the referral group and the embedded group. RESULTS. In a six-month period, 169 MICU patients received an embedded consultation, as compared to 52 MICU patients who received a referral-based consultation. As compared to the referral-based period, those patients who received an embedded consult were seen significantly earlier in hospitalization (median number of days from hospital admission to consult: 10 days [pre] vs. 3 days [embedded], P

Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1–June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities.

Background: Palliative care seeks to support the physical, psycho-social and spiritual needs of patients and families who are facing life threatening diseases. Advantages of establishing a palliative care unit, or alternatively co-locating patients, include promoting optimal physical and psychological symptom management; increased family satisfaction; and facilitating resource allocation. Objective: To design a stand-alone hospital unit to provide end of life care during a pandemic. Setting: Mount Sinai Hospital (MSH), a 1,144 bed tertiary- and quaternary-care teaching facility and Brookdale Department of Geriatrics and Palliative Medicine of the Icahn School of Medicine at Mt Sinai. Method: Tracking key indicators signaling the need for conversion to a COVID-19 unit, and identifying factors to facilitate a successful conversion. Result/Implementation: Using previously identified key focused action categories as framework, we describe our successful palliative care unit (PCU) conversion into a COVID-19 care unit. Conclusion: We believe that these operational insights gained from transforming our unit during COVID-19 will be helpful to other programs and institutions during a pandemic, or public health emergencies.

Background: Meeting the needs of seriously ill SARS-CoV-2 (COVID-19) patients requires novel models of deploying health social workers (SWs) to expand the palliative care workforce. To inform such expansion, understanding the current state of health SWs' core palliative care skills is necessary. Methods: Following minimal training, health SWs in one New York City hospital were surveyed about their frequency, competence, and confidence in using core palliative care skills. Results: Of the 170 health SWs surveyed, 46 (27%) responded, of whom 21 (46%) and 24 (52%) had palliative care training before and during the COVID-19 surge, respectively. Health SWs reported a "moderate improvement" in the use of three skills: "identify a medical decision maker," "assess prognostic understanding," and "coordinate care." There was "minimal decrease" to "no improvement" to "minimal improvement" in competence and confidence of skill use. Conclusion: Our findings suggest that educational initiatives can improve health SWs' use of core palliative care skills.

The sudden and unprecedented increase in seriously ill patients with COVID-19, coupled with both the lack of core palliative care training and expertise among frontline providers and the specialty-trained palliative care workforce shortage, produced immediate challenges to meet the needs of this novel seriously ill patient population. In this article, we describe the rapid expansion and creation of new specialty palliative care services across a health system to meet demands of the COVID-19 surge in New York City. During April 2020, 1019 patients received inpatient specialty palliative care consultations across the Mount Sinai Health System. This overview demonstrates how palliative care services can be titrated up rapidly to meet the acute increase in hospitalized persons with serious illness due to COVID-19, and how these services tailored to the changing needs across a health system.

Background: Workplace violence (WPV) in the health care sector remains a prominent, under-reported global occupational hazard and public health issue. Objective: To determine the types and prevalence of WPV among doctors. Methods: Primary papers on WPV in medicine were identified through a literature search in 4 health databases (Ovid Medline, EMBASE, PsychoINFO and CINAHL). The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the mapping and identification of records. To assess the studies included in our review, we used the Critical Appraisal Skills Programme cohort review checklist and the Risk of Bias Assessment. Results: 13 out of 2154 articles retrieved were reviewed. Factors outlining physician WPV included (1) working in remote health care areas, (2) understaffing, (3) mental/emotional stress of patients/visitors, (4) insufficient security, and (5) lacking preventative measures. The results of 6 studies were combined in a meta-analysis. The overall prevalence of WPV was 69% (95% CI 58% to 78%). Conclusion: The impact of WPV on health care institutions is profound and far-reaching; it is quite common among physicians. Therefore, steps must be taken to promote an organizational culture where there are measures to protect and promote the well-being of doctors.

Aim The purpose of this systematic review is to identify the antecedent factors in different types of workplace violence (WPV) against nurses and understand its impact in order to promote safe working conditions in health care. Background Currently, the evidence examining antecedent factors associated with workplace violence in nursing is restricted to cross-sectional studies and a somewhat heterogeneous subject matter, thus confining the inferences that are possible. In healthcare, workplace violence towards nurses is a growing and serious public health issue and occupational hazard. Methods Primary papers on workplace violence in nursing were identified through a literature search in four health databases (Ovid Medline, Embase, PsychoINFO and CINAHL), using a systematic review protocol tailored to each database. After the finalization of all search strategies, another health librarian searched on November 29th, 2016, as well as an updated search on August 29th, 2017.The Critical Appraisal Skills Programme (CASP), and the Cochrane Collaboration ‘Risk of bias’ assessment tools were used to assess study quality. Results The study identified a total of 3309 articles before the removal of duplicate records. The mean CASP score was 8.14(±1.29) out of a total score of 10. Antecedent factors of workplace were grouped into two categories of WPV: Type II (patient/client) and Type III (worker-on-worker).” Discussion The antecedent factors identified the studies need to be developed and implemented into intervention studies. Furthermore such studies need to be rigorously evaluated through a meta-analytic approach to develop robust solutions and offer recommendations to nurses and workplaces. Implications for nursing & health policy The identified antecedent factors build on the existing evidence related to workplace violence. This systematic review supports the need for intervention-based organizational and state level policies that are evidence-based to mitigate or prevent workplace violence among nurses.

Objective: To examine the relationship between admission Karnofsky Performance Status (KPS) and discharge disposition. Background: Little is known about the relationship between functional status before hospitalization and discharge disposition. Methods: In a retrospective cohort study of patients seen by Mount Sinai Hospital Medicine Primary Palliative Care Program (HPPC), we used demographic and clinical data to compare discharge disposition by patients' functional status before admission into the hospital. Results: Overall, 596 patients received HPPC consults (286 [48%] female, mean age 68.4 years, median admission KPS 40% [requires hospital level care]). Of the 33 patients with a KPS ≥60% (unable to work) 30 (91%) were discharged home, whereas those 262 patients with KPS ≤30% (severely disabled) 52 (20%) were discharged home, 40 (15%) enrolled in hospice, 130 (49.5%) discharged to a facility, and 32 (12%) died in hospital. Conclusions: Worse functional status was associated with a hospice or facility discharge and better functional status was associated with discharge home. Key Message: This retrospective cohort study examined the relationship between KPS before hospital admission and discharge disposition in hospitalized seriously ill patients admitted to the hospital medicine service who received a HPPC consultation. The results suggest that those with a higher admission KPS (more functional) are more likely to be discharged home, whereas those with a lower KPS (less functional) are more likely to be discharged to a facility or hospice. KPS before hospital admission could guide palliative care resource allocation and discharge needs.

Objective: To increase earlier access to palliative care, and in turn increase documented goals of care and appropriate hospice referrals for seriously ill patients admitted to hospital medicine. Background: Due to the growing number of patients with serious illness and the specialty palliative care workforce shortage, innovative primary palliative care models are essential to meet this population's needs. Methods: Patients with serious illness admitted to hospital medicine at a quaternary urban academic medical center in New York City and received an embedded palliative care social worker consultation in 2017. We used univariate analyses of sociodemographic, clinical, and utilization data to describe the sample. Results: Overall, 232 patients received a primary palliative care consultation (mean age of 69 years, 44.8% female, 34% white, median Karnofsky Performance Status of 40%), and 159 (69%) had capacity to participate in a goals-of -are conversation. Referrals were from palliative care solid tumor oncology trigger program (113 [49%]), specialty palliative care consultation team (42[18%]), and hospital medicine (34[14.6%]). Before the consultation, 10(4.3%) had documented goals of care and 207 (89%) did after the consultation. The percentage of those referred to hospice was 24.1%. Of those transferred to specialty palliative care consultation service, nearly half required symptom management. Discussion: Patients who received a primary palliative care consultation were seen earlier in their illness trajectory, based on their higher functional impairment, and the majority had capacity to participate in goals-of-care discussions, compared with those who were seen by specialty palliative care. The consultation increased goals-of-care documentation and the hospice referral rate was comparable with that of the specialty palliative consultation team.

Nanotechnology science has been diverged its application in several fields with the advantages to operate with nanometric range of objects. Emerging field of nanotechnology has been also being approached and applied in medical biology for improved efficacy and safety. Increased success in therapeutic field has focused several approaches in the treatment of the common metabolic disorder, diabetes. The development of nanocarriers for improved delivery of different oral hypoglycemic agents compared to conventional therapies includes nanoparticles (NPs), liposomes, dendrimer, niosomes and micelles, which produces great control over the increased blood glucose level and thus becoming an eye catching and most promising technology now-a-days. Besides, embellishment of nanocarriers with several ligands makes it more targeted delivery with the protection of entrapped hypoglycaemic agents against degradation, thereby optimizing prolonged blood glucose lowering effect. Thus, nanocarriers of hypoglycemic agents provide the aim towards improved diabetes management with minimized risk of acute and chronic complications. In this review, we provide an overview on distinctive features of each nano-based drug delivery system for diabetic treatment and current NPs applications in diabetes management.

Information from clinicians about the expected course of the patient's illness is relevant and important for decision-making by surrogates for chronically critically ill patients on mechanical ventilation.To observe how surrogates of chronically critically ill patients respond to information about prognosis from palliative care clinicians.This was a qualitative analysis of a consecutive sample of audio-recorded meetings from a larger, multisite, randomized trial of structured informational and supportive meetings led by a palliative care physician and nurse practitioner for surrogates of patients in medical intensive care units with chronic critical illness (i.e., adults mechanically ventilated for ≥7 days and expected to remain ventilated and survive for ≥72 h).A total of 66 audio-recorded meetings involving 51 intervention group surrogates for 43 patients were analyzed using grounded theory. Six main categories of surrogate responses to prognostic information were identified: (1) receptivity, (2) deflection/rejection, (3) emotion, (4) characterization of patient, (5) consideration of surrogate role, and (6) mobilization of support. Surrogates responded in multiple and even antithetical ways, within and across meetings.Prognostic disclosure by skilled clinician communicators evokes a repertoire of responses from surrogates for the chronically critically ill. Recognition of these response patterns may help all clinicians better communicate their support to patients and families facing chronic critical illness and inform interventions to support surrogate decision-makers in intensive care units. Clinical trial registered with www.clinicaltrials.gov (NCT 01230099).

Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.

OBJECTIVES: Family members commonly make medical decision for patients with chronic critical illness. This study examines how family members approach this decision-making role in real time. DESIGN: Qualitative analysis of interviews with family members in the intervention arm of a randomized controlled communication trial. SETTING: Medical Intensive Care Units at four US hospitals. PARTICIPANTS: Family members of patients with chronic critical illness (adults mechanically ventilated for ≥ 7 days and expected to remain ventilated and survive for ≥ 72 hours) who participated in the active arm of a communication intervention study. INTERVENTIONS: Family members participated in at least two content-guided, informational and emotional support meetings led by a palliative care physician and nurse practitioner. MEASUREMENTS AND MAIN RESULTS: Grounded theory was used for qualitative analysis of 66 audio-recordings of meetings with 51 family members. Family members perceived their role in 4 main ways: voice of the patient, advocate for the patient, advocate for others, and advocate for oneself. Their decision making was characterized by: balancing goals, sharing their role, keeping perspective, remembering previous experiences, finding sources of strength, and coping with various burdens. CONCLUSIONS: Family members take a multifaceted approach as they participate in decision-making. Understanding how surrogates perceive and act in their roles may facilitate shared decision-making among clinicians and families during critical care.

Palliative care consultation services (PCCS) decrease costs for patients by matching treatments received to patients' and families' goals of care. However, few studies have examined the costs of a specialized palliative care unit (PCU).To quantitatively describe Mount Sinai Hospital's PCU's first two years of operation; to examine how patient-related costs changed in the days before and after transfer to PCU; and to compare cost savings of PCU to those of PCCS.Cost and administrative data from PCU patients from the first 24.5 months of our PCU's operation were analyzed. To compare costs between PCU and PCCS patients, we matched PCU patients to similar PCCS patients and used propensity scores to adjust for differences across groups.The PCU admitted 1107 patients in its first 24.5 months. Over this time frame, there was a statistically significant (P 0.001) decrease in average daily direct costs per patient. The mean of patients' average cost per day was $687 less while on the PCU than before transfer to PCU. Among patients who died in the hospital, average daily direct cost per patient in the days after transfer to PCU was $240 lower as compared with patients being followed by PCCS on the general hospital wards (SE = $45, P 0.001).Among patients who died in the hospital, transfer to a PCU is associated with significant cost savings as compared with patients on hospital wards who are seen by a PCCS.

Background: Previous studies suggest that various factors including the type of occupation, employment status, and level of education have significant associations with the rates of occupational injuries. The aim of this study was to assess the impact of demographics, such as age and gender, and various occupational factors on the rate of occupational injuries for a 14-year period from 2001 to 2014 and to study the differences in trends over time. Methods: The Canadian Community Health Survey data for 2001, 2003, 2005, 2007, and 2009–2014 was used to examine the impact of various occupational factors on workplace injuries in the Canadian population. Various inclusion criteria such as age, employment type, and status were applied to select the final sample. The logistic regression was performed using StataMP 11 to determine the association between the rate of occupational injuries and the factors being considered. Results: Rates of injuries occurring at the workplace are associated with various occupational health factors, including, the type of occupation, level of education, the number of injuries sustained, and the employment status. Conclusion: The findings may be used by researchers and practitioners to address the impact of occupational injuries in the workforce, and to identify and resolve the factors that result in a high rate of workplace injuries.

Opioids are the mainstay of pain control for patients with chronic pain. Often, opioids with reported active metabolites, such as morphine and hydromorphone, are thought to increase the risk of neurotoxicity in renal impairment.To identify and assess the quality of evidence for neurotoxic effects in patients with renal impairment receiving morphine or hydromorphone.Systematic searches were conducted of the following databases from inception to December 2015: MEDLINE, CINAHL, EMBASE, in addition to hand-searching relevant review articles' citations. Studies were included if they reported neurotoxic effects of either morphine or hydromorphone for chronic or malignant pain in patients with renal impairment. Review articles and case reports were excluded. Narrative review was undertaken. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess study quality.Six original articles, three prospective and three retrospective studies were identified and assessed. No relevant randomized clinical trials were identified.Although morphine and hydromorphone use may be associated with neurotoxic effects in patients with renal impairment, current evidence consists of very low-quality studies with conflicting findings. Clinicians may consider using either morphine or hydromorphone in mild-to-moderate renal impairment, while closely monitoring for neurotoxic effects, particularly when used in high doses and for extended duration.

Importance Family caregivers of patients with chronic critical illness experience significant psychological distress. Objective To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression. Design, Setting, and Participants A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes. Interventions At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group. Main Outcomes and Measures The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival. Results Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, −0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, −4 days [95% CI, −6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different. Conclusions and Relevance Among families of patients with chronic critical illness, the use of palliative care–led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care–led discussion of goals of care for all families of patients with chronic critical illness. Trial Registration clinicaltrials.gov Identifier:NCT01230099

Pain during hospitalization and dissatisfaction with pain management are common. This project consisted of 4 phases: identifying a pain numeric rating scale (NRS) metric associated with patient satisfaction, identifying independent predictors of maximum NRS, implementing interventions, and evaluating trends in NRS and satisfaction. Maximum NRS was inversely associated with favorable pain satisfaction for both efficacy (n = 4062, χ(2) = 66.2, P.001) and staff efforts (n = 4067, χ(2) = 30.3, P.001). Independent predictors of moderate-to-severe maximum NRS were younger age, female sex, longer hospital stay, admitting department, psychoactive medications, and 10 diagnostic codes. After interventions, moderate-to-severe maximum NRS declined by 3.6% per quarter in 2010 compared with 2009. Satisfaction data demonstrated improvements in nursing units meeting goals (5.3% per quarter, r (2) = 0.67) and favorable satisfaction answers (0.36% per quarter, r (2) = 0.31). Moderate-to-severe maximum NRS was an independent predictor of lower likelihood of hospital discharge (likelihood ratio = 0.62; 95% confidence interval = 0.61-0.64). Targeted interventions were associated with improved inpatient pain management.

Patients with serious illnesses are living longer and with greater disabilities. Palliative-care interventions have been shown to increase quality of life, lower costs, and improve survival. In order to meet the palliative-care needs of patients, it is crucial for primary-care clinicians to understand how they can provide primary palliative care and when they should refer to palliative-care specialists. By working together, many more patients and families will receive the comprehensive, individualized, coordinated care and support that both primary care and palliative care offers to patients. This article will review literature illustrating the benefits of palliative care; discuss why primary-care clinicians are ideally suited to incorporate palliative care into their practice; and provide guidance to primary-care clinicians regarding how and when to access palliative-care specialist services, how to gain more training in palliative care, and how to be reimbursed for palliative-care visits.

While pain is a common symptom among older adults, it often is underdiagnosed and undertreated. Aging-related physiological changes, misperceptions about the use of pain medications by both patients and providers, and the lack of evidence-based clinical research on pain management in older adults are some of the reasons why pain in older adults is mismanaged. Using extrapolated evidence from pain research in younger patients, consensus statements, and best practice guidelines, this article summarizes and highlights areas of geriatric pain assessment and management that need special consideration. Some highlighted areas include 1) pain assessment in cognitively impaired patients; 2) medication choice and initiation doses; 3) duration of adequate medication trials; and 4) common medication side effects and suggested management.