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Context Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable. Objective To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases. Methods Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison. Results We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The “nascent” phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key “transitional” phase, use of specialists depended on development of “comfort and trust”, which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the “mature” phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team. Conclusion This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.

Family members of critically ill patients with COVID-19 have described increased symptoms of Post-Traumatic Stress Disorder (PTSD). Little is known about how these symptoms may change over time.We studied changes in PTSD symptoms in family members of critically ill patients with COVID-19 over 12-months.This prospective, multi-site observational cohort study recruited participants at 12 hospitals in 5 states. Calls were made to participants at 3-4 months, 6-months, and 12-months post-patient admission to the ICU.There were 955 eligible family members, of whom 330 (53.3% of those reached) consented to participate. Complete longitudinal data was acquired for 115 individuals (34.8% of consented). PTSD symptoms were measured by the Impact of Events Scale-6 (IES-6), with a score of ≥10 identifying significant symptoms. At 3-months, the mean IES-6 score was 11.9±6.1 with 63.6% having significant symptoms, decreasing to 32.9% at one year (mean IES-6 score 7.6±5.0). Three clusters of symptom evolution emerged over time: persistent symptoms (34.8%, n=40), recovered symptoms (33.0%, n=38) and non-development of symptoms (32.2%, n=37). While participants identifying as Hispanic demonstrated initially higher adjusted IES-6 scores (2.57 points higher [95% CI: 1.1, 4.1, p =0.001]), they also demonstrated a more dramatic improvement in adjusted scores over time (4.7 greater decrease at 12 months [95% CI: 3.2-6.3, p.001]).One year later, some family members of patients with COVID-19 continue to experience significant symptoms of PTSD. Further studies are needed to better understand how various differences contribute to increased risk for these symptoms.

BackgroundAlthough use of mechanical circulatory support is increasing, it is unclear how providing such care affects clinicians’ moral distress.ObjectiveTo measure moral distress among intensive care unit clinicians who commonly care for patients receiving mechanical circulatory support.MethodsIn this prospective study, the Moral Distress Scale-Revised was administered to physicians, nurses, and advanced practice providers from 2 intensive care units in an academic medical center. Linear regression was used to assess whether moral distress was associated with clinician type, burnout, or desire to leave one’s job. Clinicians’ likelihood of reporting frequent moral distress when caring for patients receiving mechanical circulatory support vs other critically ill patients also was assessed.ResultsThe sample comprised 102 clinicians who had a mean (SD) score of 100.5 (51.6) on the Moral Distress Scale- Revised. After adjustment for clinician characteristics, moral distress was significantly higher in registered nurses than physicians/advanced practice providers (115.9 vs 71.0, P < .001), clinicians reporting burnout vs those who did not (114.7 vs 83.1, P = .003), and those considering leaving vs those who were not (121.1 vs 89.2, P = .001). Clinicians were more likely to report experiencing frequent moral distress when caring for patients receiving mechanical circulatory support (26.5%) than when caring for patients needing routine care (10.8%; P = .004), but less likely than when caring for patients with either chronic critical illness (57.8%) or multisystem organ failure (56.9%; both P < .001).ConclusionMoral distress was high among clinicians who commonly care for patients receiving mechanical circulatory support, suggesting that use of this therapy may affect well-being among intensive care unit clinicians.

OBJECTIVES To evaluate neurodevelopmental and mental disorders after PICU hospitalization in children requiring invasive mechanical ventilation for severe respiratory illness. DESIGN Retrospective longitudinal observational cohort. SETTING Texas Medicaid Analytic eXtract data from 1999 to 2012. PATIENTS Texas Medicaid-enrolled children greater than or equal to 28 days old to less than 18 years old hospitalized for a primary respiratory illness, without major chronic conditions predictive of abnormal neurodevelopment. INTERVENTIONS We examined rates of International Classification of Diseases, 9th revision-coded mental disorder diagnoses and psychotropic medication use following discharge among children requiring invasive mechanical ventilation for severe respiratory illness, compared with general hospital patients propensity score matched on sociodemographic and clinical characteristics prior to admission. Children admitted to the PICU for respiratory illness not necessitating invasive mechanical ventilation were also compared with matched general hospital patients as a negative control exposure. MEASUREMENTS AND MAIN RESULTS Of 115,335 eligible children, 1,351 required invasive mechanical ventilation and were matched to 6,755 general hospital patients. Compared with general hospital patients, children requiring invasive mechanical ventilation had increased mental disorder diagnoses (hazard ratio, 1.43 [95% CI, 1.26-1.64]; p < 0.0001) and psychotropic medication use (hazard ratio, 1.67 [1.34-2.08]; p < 0.0001) following discharge. Seven-thousand seven-hundred eighty children admitted to the PICU without invasive mechanical ventilation were matched to 38,900 general hospital patients and had increased mental disorder diagnoses (hazard ratio, 1.08 [1.02-1.15]; p = 0.01) and psychotropic medication use (hazard ratio, 1.11 [1.00-1.22]; p = 0.049). CONCLUSIONS Children without major comorbidity requiring invasive mechanical ventilation for severe respiratory illness had a 43% higher incidence of subsequent mental disorder diagnoses and a 67% higher incidence of psychotropic medication use. Both increases were substantially higher than in PICU patients with respiratory illness not necessitating invasive mechanical ventilation. Invasive mechanical ventilation is a life-saving therapy, and its application is interwoven with underlying health, illness severity, and PICU management decisions. Further research is required to determine which factors related to invasive mechanical ventilation and severe respiratory illness are associated with abnormal neurodevelopment. Given the increased risk in these children, identification of strategies for prevention, neurodevelopmental surveillance, and intervention after discharge may be warranted.

Recent Bayesian reanalyses of prominent trials in critical illness have generated controversy by contradicting the initial conclusions based on conventional frequentist analyses. Many clinicians might be sceptical that Bayesian analysis, a philosophical and statistical approach that combines prior beliefs with data to generate probabilities, provides more useful information about clinical trials than the frequentist approach. In this Personal View, we introduce clinicians to the rationale, process, and interpretation of Bayesian analysis through a systematic review and reanalysis of interventional trials in critical illness. In the majority of cases, Bayesian and frequentist analyses agreed. In the remainder, Bayesian analysis identified interventions where benefit was probable despite the absence of statistical significance, where interpretation depended substantially on choice of prior distribution, and where benefit was improbable despite statistical significance. Bayesian analysis in critical care medicine can help to distinguish harm from uncertainty and establish the probability of clinically important benefit for clinicians, policy makers, and patients.

BACKGROUND In patients with serious illness, use of specialist palliative care may result in improved quality of life, patient and caregiver satisfaction and advance care planning, as well as lower health care utilization. However, evidence of efficacy is limited for patients with dementia, particularly in the setting of an acute hospitalization. OBJECTIVE To determine whether implementation of hospital-based specialist palliative care was associated with differences in treatment intensity outcomes for hospitalized patients with dementia. DESIGN Retrospective cohort study. SETTING Fifty-one hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. PARTICIPANTS Hospitalized patients with dementia. MEASUREMENTS The primary outcome of this study was discharge to hospice from an acute hospitalization. Secondary outcomes included hospital length of stay, use of mechanical ventilation and dialysis, and days in intensive care. Difference-in-difference analyses were performed using multilevel regression to assess the association between implementing a palliative care program and outcomes, while adjusting for patient and hospital characteristics and time trends. RESULTS During the study period, 82,118 patients with dementia (mean (SD) age, 83.04 (10.04), 51,170 (62.21%) female) underwent an acute hospitalization, of which 41,227 (50.27%) received care in hospitals that implemented a palliative care program. In comparison to patients who received care in hospitals without palliative care, patients with dementia who received care in hospitals after the implementation of palliative care were more 35% likely to be discharged to hospice (adjusted odds ratio (aOR) = 1.35 (1.19-1.51), P

IMPORTANCE: The psychological symptoms associated with having a family member admitted to the intensive care unit (ICU) during the COVID-19 pandemic are not well defined. OBJECTIVE: To examine the prevalence of symptoms of stress-related disorders, primarily posttraumatic stress disorder (PTSD), in family members of patients admitted to the ICU with COVID-19 approximately 90 days after admission. DESIGN, SETTING, AND PARTICIPANTS: This prospective, multisite, mixed-methods observational cohort study assessed 330 family members of patients admitted to the ICU (except in New York City, which had a random sample of 25% of all admitted patients per month) between February 1 and July 31, 2020, at 8 academic-affiliated and 4 community-based hospitals in 5 US states. EXPOSURE: Having a family member in the ICU with COVID-19. MAIN OUTCOMES AND MEASURES: Symptoms of PTSD at 3 months, as defined by a score of 10 or higher on the Impact of Events Scale 6 (IES-6). RESULTS: A total of 330 participants (mean [SD] age, 51.2 [15.1] years; 228 [69.1%] women; 150 [52.8%] White; 92 [29.8%] Hispanic) were surveyed at the 3-month time point. Most individuals were the patients’ child (129 [40.6%]) or spouse or partner (81 [25.5%]). The mean (SD) IES-6 score at 3 months was 11.9 (6.1), with 201 of 316 respondents (63.6%) having scores of 10 or higher, indicating significant symptoms of PTSD. Female participants had an adjusted mean IES-6 score of 2.6 points higher (95% CI, 1.4-3.8; P

The identification of delirium in electronic health records (EHRs) remains difficult due to inadequate assessment or under-documentation. The purpose of this research is to present a classification model that identifies delirium using retrospective EHR data. Delirium was confirmed with the Confusion Assessment Method for the Intensive Care Unit. Age, sex, Elixhauser comorbidity index, drug exposures, and diagnoses were used as features. The model was developed based on the Columbia University Irving Medical Center EHR data and further validated with the Medical Information Mart for Intensive Care III dataset. Seventy-six patients from Surgical/Cardiothoracic ICU were included in the model. The logistic regression model achieved the best performance in identifying delirium; mean AUC of 0.874 ± 0.033. The mean positive predictive value of the logistic regression model was 0.80. The model promises to identify delirium cases with EHR data, thereby enable a sustainable infrastructure to build a retrospective cohort of delirium.

BackgroundExtracorporeal membrane oxygenation (ECMO) use in the United States occurs often in cardiothoracic ICUs (CTICU). It is unknown how it varies across ICU types.MethodsWe identified 10 893 ECMO runs from the Extracorporeal Life Support Organization (ELSO) Registry across 2018 and 2019. Primary outcome was ECMO case volume by ICU type (CTICU vs. non-CTICU). Adjusting for pre-ECMO characteristics and case mix, secondary outcomes were on-ECMO physiologic variables by ICU location stratified by support type.ResultsCTICU ECMO occurred in 65.1% and 55.1% (2018 and 2019) of total runs. A minority of total runs related to cardiac surgery procedures (CTICU: 21.7% [2018], 18% [2019]; non-CTICU: 11.2% [2018], 13% [2019]). After multivariate adjustment, non-CTICU ECMO for cardiac support associated with lower 4- and 24-h circuit flow (3.9 liters per minute [LPM] vs. 4.1 LPM, p&nbsp

BACKGROUND: Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures. METHODS: In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and peri-operative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012–2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve. RESULTS: In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85–0.87) for the derivation cohort and 0.83 (95% CI, 82–0.85) for the validation cohort. CONCLUSIONS: About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes. (Anesth Analg XXX;XXX:00–00)

BackgroundDespite the well-known impact of delirium on long-term clinical outcomes, identification of delirium in electronic health records (EHR) remains difficult due to inadequate assessment or documentation of delirium. The purpose of this research is to present a classification model that identifies delirium using retrospective EHR data. The classification model would support the additional identification of delirium cases otherwise undocumented during routine practice.MethodsDelirium was confirmed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Age, sex, Elixhauser comorbidity index, drug exposures, and diagnoses were used as features to train the logistic regression and multi-layer perceptron models. The clinical notes from the EHR were parsed to supplement the features that were not recorded in the structured data. The model performance was evaluated with a 5-fold cross-validation area under the receiver operating characteristic curve (AUC).ResultsSeventy-six patients (17 cases and 59 controls) with at least one CAM-ICU evaluation result during ICU stay from January 30, 2018 to February 20, 2018 were included in the model. The multi-layer perceptron model achieved the best performance in identifying delirium; mean AUC of 0.967 ± 0.019. The mean positive predictive value (PPV), mean negative predicted value (NPV), mean sensitivity, and mean specificity of the MLP model were 0.9, 0.88, 0.56, and 0.95, respectively.ConclusionA simple classification model showed a mean AUC over 0.95. This model promises to identify delirium cases with EHR data, thereby enable a sustainable infrastructure to build a retrospective cohort of delirium in the ICU. The cohort would be useful for the evaluation of long-term sequelae of delirium in ICU.

PURPOSE: To understand clinicians’ views regarding use of clinical criteria, or triggers, for specialist palliative care consultation in the ICU. MATERIALS AND METHODS: Secondary analysis of a qualitative study that explored factors associated with adoption of specialist palliative care in the ICU. Semi-structured interviews with 36 ICU and palliative care clinicians included questions related to triggers for specialist palliative care. We performed a thematic analysis to identify participants’ views on use of triggers, including appropriateness of cases for specialists and issues surrounding trigger implementation. RESULTS: We identified five major themes: 1) Appropriate triggers for specialist palliative care, 2) Issues leading to clinician ambivalence for triggers, 3) Prospective buy-in of stakeholders, 4) Workflow considerations in deploying a trigger system, and 5) Role of ICU clinicians in approving specialist palliative care consults. Appropriate triggers included end-of-life care, chronic critical illness, frequent ICU admissions, and patient/family support. Most clinicians had concerns about “trigger overload” and ICU clinicians wanted to be broadly involved in implementation efforts. CONCLUSIONS: ICU and palliative care clinicians identified important issues to consider when implementing triggers for specialist palliative care consultation. Future research is needed to longitudinally examine the most appropriate triggers and best practices for trigger implementation.

Unplanned rehospitalization at a hospital other than the initial hospital may contribute to poor outcomes. We examined the location of rehospitalizations and assessed outcomes following critical illness in a single-payer healthcare system.Population-based retrospective cohort study using linked datasets (2012-2017) from Ontario, Canada including adults (≥18 years) with an unplanned rehospitalization within 30-days after an index hospitalization that included an ICU stay with mechanical ventilation. Outcomes were the percentage of 30-day rehospitalizations at non-index hospitals, mortality and costs. We employed logistic regression and generalized linear models to assess associations.There were 14,997 (16.4%) 30-day rehospitalizations. Of these 2765 (18.4%) occurred in a non-index hospital. Distance of home residence from the index hospital was the strongest predictor of a non-index rehospitalization (adjusted odds ratio (aOR) 8.40, 95%CI 7.05-10.01, highest vs. lowest distance quintile). Within 30-days of rehospitalization, deaths (aOR 0.91, 95%CI (0.80-1.04)) and total healthcare costs (adjusted relative risk 1.03 (1.00-1.06)), were similar for patients readmitted to the index or a non-index hospital.Non-index rehospitalization within 30-days of initial discharge is common following critical illness. These rehospitalizations were not significantly associated with an increased risk of harm or higher costs in a single-payer healthcare system.

Geriatric admissions to the intensive care unit (ICU) are common and require unique considerations for ICU clinicians. Admission to the ICU should be considered on an individual-patient basis. It is reasonable to consider a "trial of critical care" for many patients, even those who have uncertain chances of meaningful recovery. Quality of life and functional independence are especially important to older adults, and these outcomes should be considered when weighing the risks and benefits of admission or continuing ICU care.

Background: Chaplain-led communication-board-guided spiritual care may reduce anxiety and stress during an intensive care unit (ICU) admission for nonvocal mechanically ventilated patients, but clinical pastoral education does not teach the assistive communication skills needed to provide communication-board-guided spiritual care. Objective: To evaluate a four-hour chaplain-led seminar to educate chaplains about ICU patients' psychoemotional distress, and train them in assistive communication skills for providing chaplain-led communication-board-guided spiritual care. Design: A survey immediately before and after the seminar, and one-year follow-up about use of communication-board-guided spiritual care. Subjects/Setting: Sixty-two chaplains from four U.S. medical centers. Measurements: Multiple-choice and 10-point integer scale questions about ICU patients' mental health and communication-board-guided spiritual care best practices. Results: Chaplain awareness of ICU sedation practices, signs of delirium, and depression, anxiety, and post-traumatic stress disorder in ICU survivors increased significantly (all p

Key Points Question Is implementation of palliative care services associated with a decrease in the use of intensive care at the end of life for hospitalized patients? Findings In this cohort study, implementation of palliative care at a hospital was associated with a 10% reduction in intensive care unit use for 73 370 patients who died during their hospitalization. Meaning Implementation of hospital-based palliative care services may be associated with decreased treatment intensity at the end of life for hospitalized patients., This cohort study examines whether implementation of hospital-based palliative care services is associated with decreased intensive care unit use during terminal hospitalizations., Importance The use of intensive care at the end of life continues to be common. Although the provision of palliative care has been advocated as a way to mitigate the use of high-intensity care, it is unknown whether implementation of hospital-based palliative care services is associated with reduced use of intensive care at the end of life. Objective To determine whether implementation of hospital-based palliative care services is associated with decreased intensive care unit (ICU) use during terminal hospitalizations. Design, Setting, and Participants This cohort study included 51 hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. Participants were adult patients who died during hospitalization. Data analysis was performed between January 2018 and July 2019. Exposure Implementation of a palliative care program. Main Outcomes and Measures The primary outcome was ICU use. A difference-in-differences analysis was performed using multilevel regression to assess the association between implementing a palliative care program and ICU use during terminal hospitalizations while adjusting for patient and hospital characteristics and time trends. Results During the study period, 73 370 patients (mean [SD] age, 76.5 [14.1] years; 38 467 [52.4%] women) died during hospitalization, of whom 37 628 (51.3%) received care in hospitals that implemented palliative care services and 35 742 (48.7%) received care in a hospital without palliative care implementation. Patients who received care in hospitals after implementation of palliative care services were less likely to receive intensive care than patients admitted to the same hospitals before implementation (49.3% vs 52.8%; difference 3.5%; 95% CI, 2.5%-4.5%; P

This study aimed to validate the ICD-9 code, V49.86 for Do-Not-Resuscitate Status in a cohort of hospitalized patients.

Rationale: In the intensive care unit (ICU), studies involving specialized palliative care services have shown decreases in the use of non-beneficial life-sustaining therapies and ICU length of stay for patients. However, whether widespread availability of hospital-based palliative care is associated with less frequent use of high intensity care is unknown. Objective: To determine whether availability of hospital-based palliative care is associated with decreased markers of treatment intensity for ICU patients. Methods: Retrospective cohort study of adult ICU patients in New York State hospitals, 2008-2014. Multilevel regression was used to assess the relationship between availability of hospital-based palliative care during the year of admission and hospital length of stay, use of mechanical ventilation, dialysis and artificial nutrition, placement of a tracheostomy or gastrostomy tube, days in ICU and discharge to hospice. Results: Of 1,025,503 ICU patients in 151 hospitals, 814,794 (79.5%) received care in a hospital with a palliative care program. Hospital length of stay was similar for patients in hospitals with and without palliative care programs (6 days, interquartile range (IQR) 3-12 vs. 6 days, IQR 3-11, adjusted rate ratio 1.04 [1.03 to 1.05], p < 0.001), as were other healthcare utilization outcomes. However, patients in hospitals with palliative care programs were 46% more likely to be discharged to hospice than those in hospitals without palliative care programs (1.7% vs. 1.4%, adjusted odds ratio 1.46 [1.30 to 1.64], p

Objectives Publicly reported postoperative 30-day mortality rates are commonly used to compare hospital quality after coronary artery bypass grafting. We sought to determine whether 90-day mortality rates, which are not publicly reported but better capture postdischarge mortality, are a better determinant of hospital performance. Methods We performed a retrospective cohort analysis of 30- versus 90-day risk-standardized mortality rates at adult cardiac surgical centers in New York State from 2008 to 2014. Hospitals were classified as good or poor performing outliers at each time point based on the bounds of the 95% confidence interval around each hospital's predicted risk-standardized mortality rates determined via hierarchical models. The primary outcome was change in institutional performance via outlier classification from 30 to 90 days. Results During the study period, 72,398 adults underwent a coronary artery bypass grafting procedure at 1 of 42 institutions. The risk-standardized mortality rates increased from 30 to 90 days at all institutions, with a median 30-day risk-standardized mortality rate of 2.16% (interquartile range, 0.69%) and median 90-day risk-standardized mortality rate of 3.69% (interquartile range, 1.00%). In using a 90-day instead of a 30-day metric, 3 hospitals changed outlier status. One hospital improved to a good from as expected performer, and 2 worsened to as expected from good performers. Conclusions In a cohort of patients who underwent coronary artery bypass grafting surgery from 2008 to 2014 in New York State, use of a 90-day mortality metric resulted in a change in hospital quality assessment for a minority of hospitals. The use of 90-day mortality may not provide additional value when evaluating institutional performance for this population.

Rationale: Intensive care unit (ICU) patients who receive mechanical ventilation are at high risk for early rehospitalization. Given their medical complexity, a lack of continuity of care may adversely affect outcomes during rehospitalization. Objective: To determine whether outcomes differ for patients who are rehospitalized at a different hospital versus the hospital of the index ICU stay. Methods: Retrospective cohort study of mechanically ventilated ICU patients rehospitalized within 30 days in New York State hospitals from 2008-2013. Measurements: Frequency of rehospitalization at a different hospital; mortality, length of stay and costs during rehospitalization. Main Results: Of 26,947 mechanically ventilated ICU patients rehospitalized within 30 days of discharge, 8,443 (31.3%) were rehospitalized at a different hospital than that of the index ICU stay. For patients at a different hospital, 13.7% died during rehospitalization versus 11.1% at the index hospital (adjusted rate ratio (aRR) 1.11 [1.03 -1.20], p=0.009). Patients who died at a different hospital had shorter length of stay (aRR 0.80 [0.70-0.92], p=0.001) and decreased costs (adjusted mean difference (aMD) -$9,632.73 [-$16,387.60 to -$-2,877.88], p=0.005), while survivors of rehospitalization at a different hospital had a modest increase in length of stay (aRR 1.06 [1.01-1.11], p=0.009) and increased costs of care (aMD $1,665.34 [$602.12 to $2,728.56], p=0.002). Conclusions: Almost one-third of mechanically ventilated critically ill patients were rehospitalized at a different hospital than that of the index ICU stay. This care discontinuity was associated with increased mortality. Further investigation should aim to elucidate reasons for differing patterns of care on rehospitalization and strengthen the causal relationship between care discontinuity and subsequent harm.

OBJECTIVE Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment. DESIGN Mixed-methods study. SETTING Medical and surgical ICUs at three large academic hospitals. PARTICIPANTS Three hundred three nurses, intensivists, and advanced practice providers. MEASUREMENTS AND MAIN RESULTS Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships. CONCLUSIONS Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

Although advance care planning is known to increase patient and caregiver satisfaction, its association with health care utilization is not well understood.To examine the association between billed advance care planning encounters and subsequent health care utilization among seriously ill patients.This retrospective cohort study conducted from October 1, 2015, to May 31, 2018, used a national commercial insurance claims database to retrieve data from 18 484 Medicare Advantage members 65 years or older who had a claim that contained a serious illness diagnosis.A claim that contained an advance care planning billing code between October 1, 2016, and November 30, 2017.Receipt of intensive therapies, hospitalization, emergency department use, hospice use, costs, and death during the 6-month follow-up period.The final study sample included 18 484 seriously ill patients (mean [SD] age, 79.7 [7.9] years; 10 033 [54.3%] female), 864 (4.7%) of whom had a billed advanced care planning encounter between October 1, 2016, and November 30, 2017. In analyses adjusted for patient characteristics and a propensity score for advance care planning, the presence of a billed advance care planning encounter was associated with a higher likelihood of hospice enrollment (incidence rate ratio [IRR], 2.52; 95% CI, 2.22-2.86) and mortality (hazard ratio, 2.27; 95% CI, 1.79-2.88) compared with no billed advance care planning encounter. Although patients with billed advance care planning encounters were also more likely to be hospitalized (IRR, 1.37; 95% CI, 1.26-1.49), including in the intensive care unit (IRR, 1.25; 95% CI, 1.08-1.45), they were less likely to receive any intensive therapies (IRR, 0.85; 95% CI, 0.78-0.92), such as chemotherapy (IRR, 0.65; 95% CI, 0.55-0.78). Similar results were observed in a propensity score-matched analysis (99% matched) and in a decedent analysis of patients who died during the 6-month follow-up period.Patients with billed advance care planning encounters were more likely than those without these encounters to receive hospice services and less likely to receive any intensive therapies, such as chemotherapy. However, they were also hospitalized more frequently than patients without billed advance care planning encounters. Although these findings were robust to multiple analytic methods, the results may be attributable to residual confounding because of a higher unmeasured severity of illness in the advance care planning group. Additional evidence appears to be needed to understand the effect of advance care planning on these outcomes.

Objectives The 1.5 million Medicare beneficiaries who survive intensive care each year have a high post-hospitalization mortality rate. We aimed to determine whether mortality after critical illness is higher for Medicare beneficiaries with Medicaid compared with those with commercial insurance. Design A retrospective cohort study from 2010 through 2014 with 1 year of follow-up using the New York Statewide Planning and Research Cooperative System database. Setting A New York State population-based study of older (age ≥65 y) survivors of intensive care. Participants Adult Medicare beneficiaries age 65 years or older who were hospitalized with intensive care at a New York State hospital and survived to discharge. Intervention None. Measurement Mortality in the first year after hospital discharge. Results The study included 340 969 Medicare beneficiary survivors of intensive care with a mean (standard deviation) age of 77 (8) years; 20% died within 1 year. There were 152 869 (45%) with commercial insurance, 78 577 (23%) with Medicaid, and 109 523 (32%) with Medicare alone. Compared with those with commercial insurance, those with Medicare alone had a similar 1-year mortality rate (adjusted hazard ratio [aHR] = 1.01; 95% confidence interval [CI] = .99-1.04), and those with Medicaid had a 9% higher 1-year mortality rate (aHR = 1.09; 95% CI = 1.05-1.12). Among those discharged home, the 1-year mortality rate did not vary by insurance coverage, but among those discharged to skilled-care facilities (SCFs), the 1-year mortality rate was 16% higher for Medicaid recipients (aHR = 1.16; 95% CI = 1.12-1.21; P for interaction Conclusions Older adults with Medicaid insurance have a higher 1-year post-hospitalization mortality compared with those with commercial insurance, especially among those discharged to SCFs. Future studies should investigate care disparities at SCFs that may mediate these higher mortality rates. J Am Geriatr Soc 67:2497-2504, 2019.

Background The frequency and safety of overnight extubation (OE) after cardiac surgery across intensive care units (ICUs) is unknown. Methods We performed a retrospective study of adults (≥ 18 years) in US ICUs after coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both, using The Society of Thoracic Surgery Adult Cardiac Surgery Database (July 2014 to June 2017); our primary cohort was elective CABGs. We assessed OE (7:00 pm to 6:59 am ) frequency and used multilevel regression modelling to identify factors associated with OE. Within mechanical ventilation (MV) duration strata, we used propensity score matching to evaluate associations of OE with reintubations (primary outcome), mortality, and complications. Results Among 142,225 patients with elective CABG, 42.2% had OEs. MV duration, cardiopulmonary bypass time, distal anastomosis number, and hospital of admission (median odds ratio [OR] 1.82, 95% confidence interval [CI]: 1.76 to 1.89) were independently associated with OE. After propensity matching, OE was associated with increased reintubation for patients with MV duration of 6 to 8 hours (2.2% vs 1.7%, OR 1.27, 95% CI: 1.04 to 1.56) and decreased reintubation for patients with MV duration of 15 to 17 hours (3.0% vs 4.2%, OR 0.70, 95% CI: 0.50 to 0.97) and 18 to 20 hours (2.3% vs 5.7%, OR 0.39, 95% CI: 0.21 to 0.72); OE was associated with increased ICU length of stay for patients with MV duration of 6 to 8 hours, but reduced length of stay for patients with MV duration of 9 to 20 hours. OE was not associated with increased mortality (hospital, 30-day). Other groups had similar OE rates (nonelective CABGs, 47.6%; elective AVR, 36.0%; elective CABG + AVRs, 51.0%) and outcomes. Conclusions OE is prevalent after cardiac surgery. OE is associated with little risk and reduces ICU length of stay for patients who require MV for more than 8 hours.