B. T. Young1,2, J. K. Bhangu1,2, S. J. Zolin1,2, S. E. Posillico1,2, H. A. Ladhani1,2, C. W. Towe2,3, J. A. Claridge1,2, V. P. Ho1,2 1MetroHealth Medical Center,Division Of Trauma, Critical Care, Burns And Emergency General Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA 3University Hospitals Cleveland Medical Center,Thoracic & Esophageal Surgery,Cleveland, OH, USA
Introduction:
Traumatic injury affects patients of varying age groups and comorbidity profiles and carries a significant risk of in-hospital mortality of 10-20%. The American College of Surgeons palliative care guidelines recommend a formal goals-of-care-conversation (GOCC) within 72 hours of admission for trauma patients with a prognosis of death, permanent disability, or uncertainty of either. At our institution, no such protocol exists, and the timing of GOCC is therefore provider dependent. We hypothesize that occurrence of GOCCs within 3 hospital days (early GOCC) in moribund patients would be associated with earlier transition to comfort care status, fewer deaths during code, and shorter duration of intensive care treatment.
Methods:
We performed a retrospective analysis of all adult primary patients of the trauma surgery service at an academic Level 1 trauma center from 12/2014 to 12/2017 who died during their index admission. Patients who died within 24 hours of admission or were transferred to another service prior to death were excluded. A GOCC was defined as any documented discussion between a physician and the patient and/or surrogate regarding prognosis or goals of care. Demographics, injury characteristics including arrival Glasgow coma scale (GCS), injury severity score (ISS), and abbreviated injury scale Head (AIS-Head) score, ventilator days, comfort care status, length of stay (LOS) and intensive care length of stay (ICU LOS) were collected. Bivariate analysis was performed to compare patients with early GOCC to those with later or no conversations.
Results:
177 patients met inclusion criteria. Patients were 68% male; 63% were over age 65. 90% were injured in a fall or other accident while 10% were injured by gunshot wound or assault. Median ISS was 26 (IQR 18-32). Median LOS was 6 days (IQR 4-12) and median time to first GOCC was 2 days (IQR 1-5). 43% of patients had an early GOCC. Compared to patients with later or no GOCC, patients who received an early GOCC had lower median GCS on arrival (6 vs 13 p = 0.004), but they did not differ in age, gender, ISS, or AIS-Head. Early GOCC was associated with reduced hospital LOS (5 vs 11 days, p < 0.001), ICU LOS (5 vs 11 days, p <0.001), ventilator days (4 vs 8.5 days, p<0.001), and deaths during a code (1.2% vs 13.2%, p = 0.001). Amongst patients who transitioned to comfort care status (n =130, 73.4%), these transitions took place sooner for patients with early GOCC (5 vs 13 days p<0.001).
Conclusion:
In patients who died after trauma, early GOCC was associated with reduced length of stay, ventilator days, death during a code, and time to comfort care transition. Based on this data, we recommend early GOCC to be routine in the trauma ICU setting. We plan to prospectively study a new palliative care protocol mandating early GOCC for critically injured patients at our trauma center.