S. J. Zolin1,2, J. Bhangu1,2, B. T. Young1,2, S. Posillico1,2, H. Ladhani1,2, J. Claridge1,2, V. P. Ho1,2 1Case Western Reserve University School Of Medicine,Cleveland, OH, USA 2MetroHealth Medical Center,Division Of Trauma, Critical Care, Burns, And Emergency General Surgery,Cleveland, OH, USA
Introduction:
Practitioners in the intensive care unit (ICU) provide not only physiologic support to severely injured patients, but also spend time to counsel families and provide primary palliative care services, including goals of care conversations and symptom palliation. It is unclear whether ICU physicians account for these services consistently in their critical care billing and documentation (CCBD). We analyzed CCBD practices for moribund trauma patients cared for in the ICU of an academic level 1 trauma center, hypothesizing that CCBD would be inconsistent despite the critically ill status of these patients near the end of life.
Methods:
An analysis of all adult admitted trauma patients who died between 12/2014 and 12/2017 was performed to evaluate the presence of CCBD on the day prior to death and on day of death. CCBD was defined as the critical care time documented in daily ICU progress notes. Age, injury severity score (ISS), race, code status at time of death, and family meetings discussing prognosis and/or goals of care held within one day of death were recorded. Patients already designated as comfort care prior to the day of analysis were not considered eligible for CCBD and patients who died within 24 hours of arrival were excluded. Multivariate logistic regression was used to determine patient factors associated with CCBD.
Results:
A total of 134 patients met study criteria. 71.6% were male and 87.3% were white. The median age was 69 (IQR 58-82). Median ISS was 26 (IQR 20-33). 82.1% had a family meeting within 1 day of death. 76.5% were made comfort care prior to death. Of patients eligible for CCBD, 42.5% had no CCBD on the day prior to death and 59.3% had no CCBD for day of death, corresponding to lost potential hospital compensation in excess of $30,000. For the day prior to death, a family meeting within 1 day of death was associated with increased likelihood of CCBD (p = 0.011), while increasing age was associated with decreased likelihood of CCBD (p = 0.008).
Conclusion:
In critically ill trauma patients near death, CCBD was inconsistent, representing an opportunity for improvement. Family meetings within 1 day of death were frequent and were associated with CCBD, suggesting that additional time spent with patients and families in end of life conversations may lead to more consistent CCBD. Given the downstream impacts of CCBD on health systems, further investigation into the mechanisms and generalizability of these findings is needed.
