MICU Palliative Care Team Improves Quality of Care, Decreases Inpatient Mortality

Embedding a team consisting of a palliative care physician and registered nurse into a medical intensive care unit (MICU) resulted in earlier palliative care consultations, improved rates of end-of-life care planning, and decreased in-hospital mortality rates. These findings were published in the Journal of Pain and Symptom Management.

In the MICU at the Mount Sinai Hospital in New York City, unmet palliative care needs were evaluated between June and August 2019, and a care model was formulated based on these observations. Between September 2019 and February 2020, a pilot program was launched to establish roles for a full-time palliative care physician and nurse team. In this retrospective study, the use of palliative care was evaluated prior to (January-June 2019) and after (September 2019-February 2020) the launch of the embedded palliative care team model.

The workflow of the palliative care team consisted of daily interdisciplinary team rounds and chart review, bedside rounds with patients and healthcare proxies, and meetings with families. Every Monday, Wednesday, and Friday the team walked rounds with the director of the MICU and the MICU social worker, and every Tuesday and Thursday the team had an update and discharge planning meeting with the MICU director, case manager, and attending physician.

Prior to implementation of the palliative care program, a total of 52 patients received palliative care consultation compared with 169 patients after the team was embedded in the MICU.

Compared with prior to implementation of the embedded care model, patients who received palliative care consultation via the embedded care model had better functional status (median Karnofsky Performance Status scores, 18.2% vs 25.2%, respectively; P <.001) and were associated with lower scores on the Premier Mortality Index (median, 38.3% vs 26.1%; P =.01), an instrument that predicts the risk of dying while in hospital. After the launch of the palliative care program, patients also had fewer days from admission to the MICU to consultation (median, 7.6 vs 14.3 days; P =.005) and more days between consultation and discharge (median, 14.6 vs 6.4 days; P <.001).

Compared with the preteam period, the embedded team model was associated with significant increases in the proportion of patients for whom goals of care were documented (71% vs 37%; P <.05); for whom a decision-maker was documented (66% vs 40%; P <.05); who were discharged to home (22.5% vs 1.9%; P <.05); and who were discharged to a skilled nursing facility, a rehabilitation facility, or a long-term acute care facility (25.4% vs 5.8%; P <.05). The embedded team model was also associated with significant decreases in the proportion of patients who were discharged to home hospice care (7.1% vs 17.3%; P <.05), to the palliative care unit (19% vs 48%; P <.05), or to a facility-based hospice service (8% vs 22%; P <.05), as well as the proportion of patients who died while hospitalized (44% vs 75%; P <.05).

A major limitation of this study is the lack of inclusion of patients who did not receive palliative care consultation.

The authors of this study found that an embedded palliative care team in an MICU facilitated earlier palliative care consultation among more patients, which increased rates of completion of goals of care and decision-maker documentation and reduced inpatient mortality. The investigators conclude, “Our future direction includes expanding this embedded ICU model of delivery to other ICU settings … [which] will require tailoring of the model to accommodate the unique needs, cultures, workflows, and clinician roles of each ICU.”