Faculty Bibliography

BACKGROUND:Preadmission functional status has important predictive values for outcomes among hospitalized patients, and may facilitate healthcare resource allocation including early palliative care referral. OBJECTIVES/OBJECTIVE:To compare acute healthcare and palliative care utilization among hospitalized patients with different levels of baseline functional impairment. METHODS:We conducted a retrospective cohort study of adult patients ≥ 18 years discharged from a quaternary academic hospital between July 1, 2022, and December 31, 2024, with baseline functional status assessed on admission via Karnofsky Performance Status (KPS) scale. Using electronic health records and billing data, we collected patients' socio-demographic information, clinical characteristics, and utilization of acute healthcare and palliative care. RESULTS:Among 18,049 patients, baseline functional impairment was classified as mild (KPS 70%-100%): 13,411 (74.3%), moderate (KPS 50%-60%): 2953 (16.4%), severe (KPS30%-40%): 974 (5.4%) and very severe (KPS 10%-20%): 711 (3.9%). Overall, 2089 (11.6%) patients had a intensive care unit (ICU) admission, 1574 (8.7%) received palliative care consultation, and 1021 (5.6%) died in the hospital. In generalized linear models stratified by functional status category, increasing severity of functional impairment was significantly associated with increasing ICU admission, ICU and hospital length of stay, in-hospital mortality, and receipt of palliative care intervention. Mean number of days between admission and palliative care consultation was significantly decreased among patients with very severe impairment when compared with those with mild impairment (5.3 vs. 6.7 days, p < .001). CONCLUSIONS:Baseline functional status assessment may offer an easy-to-measure guide for timely inpatient palliative care intervention among patients at elevated risk for in-hospital morbidity and mortality.

IntroductionCommunication regarding serious illness is an integral part of Pulmonary and Critical Care Medicine (PCCM) fellows' day-to-day practice, however routine communication skills training is not consistently built in PCCM fellowship curricula nationwide. Geritalk, a previously validated interactive curriculum, can be adapted to address unique communication challenges in critical illness.MethodsIn 2024, after performing a needs assessment among PCCM fellows at Mount Sinai Hospital, a two-part curriculum was adapted from Geritalk through collaborations between PCCM and palliative care specialists. The curriculum consisted of a one-hour didactic followed by a one-hour small group workshop with case discussion and role-play. Pre- and post-curricular surveys were conducted among the fellows to assess changes in self-reported comfort levels in different components of communication during a family meeting.ResultsAmong 17 eligible PCCM fellows, a total of 14 (82.4%) fellows completed the pre-curricular survey, and 8 fellows (47.1%) completed the curriculum and post-curricular survey. Prior to the curriculum, fellows reported lower comfort levels in communicating prognosis (mean[SD] 3.8[1.0] on a 5-point Likert scale), responding to emotions (mean[SD] 4.0[0.8]), eliciting values (mean[SD] 3.8[0.8]), and describing comfort care (mean[SD] 3.9[1.0]). After the training, fellows reported moderate to significant increase in comfort levels, especially in responding to emotions (mean[SD] 4.3[0.7]) and eliciting values (mean[SD] 4.4[0.5]).ConclusionA two-part, critical care-focused curriculum adapted from Geritalk showed feasibility in communication training among PCCM fellows with improved self-assessed comfort levels in leading a family meeting. Future studies should incorporate objective assessment of competency and evaluate generalizability to other training programs.

CONTEXT:Hospitalized patients with functional impairment have higher symptom burden and mortality. Little is known about how increased patient volume and acuity during the coronavirus disease 2019 (COVID-19) pandemic affected access to palliative care among patients with functional impairment. OBJECTIVES:To examine changes in functional status and hospital outcomes among patients receiving inpatient palliative care consultation before, during and after the COVID-19 pandemic. METHODS:We conducted a retrospective, multisite cohort study of all adult patients (≥ 18 years) admitted to four hospitals in New York City, USA, who received inpatient palliative care consultation between March 1, 2019 and February 28, 2022 with documented functional status at the time of consultation measured by Karnofsky Performance Status scale. RESULTS:Among 13,180 eligible patients identified, patients' functional status at the time of consultation decreased as palliative care consult volume increased with the onset of the pandemic. Compared to pre-pandemic, there was a statistically significant trend of lower functional status (P < 0.001) and higher in-hospital mortality (P < 0.001) among patients with noncancer and non-COVID-19 diagnoses two years after the pandemic. In contrast, patients with cancer had a statistically significant trend of higher functional status (P < 0.001) and no significant changes in in-hospital mortality over time. CONCLUSION:As the healthcare system was stressed with high demand and limited resources, palliative care consultation prioritized highest acuity patients by shifting towards those with lower functional status and higher in-hospital mortality. This shift disproportionately affected noncancer patients. Innovative approaches to ensure upstream palliative care consultation during increased resource constraints are needed.