Evaluating the Care Pathway of Patients Diagnosed with Brain Metastases in the Emergency Department with Specific Focus on Early Palliative Care Involvement
Erin D'Agostino1, Sabrina Wirth1, Leland Nguyen1, Alissa Thomas1
1University of Vermont Medical Center
Objective:
To understand the care pathway for patients with brain metastases (Bmets) who present to the emergency department (ED) at initial diagnosis.
Background:
ED care and admission pathways are not standardized for patients with Bmets at our institution. The initial admission for a new Bmets diagnosis may be an opportunity to involve palliative care in symptom management and decision making.
Design/Methods:
Single institution retrospective quality review of patients who were diagnosed with Bmets at the time of an ED presentation between 2017 and 2019.
Results:
84 patients were included in the study, 40.5% (34 patients) of whom had a synchronous new diagnosis of cancer and Bmets. 97.6% of patients (n=82) were admitted (69.5% to medicine, 20.7% neurosurgery, 6.1% neurology, and 3.6% critical care). Average length of stay was 6.6 days (SD 4.9), with 11.92 hours (SD 6.85) in the ED. Overall survival after diagnosis averaged 448 days (SD 686). 19.2% died within 30 days, and 17.8% required unexpected readmission. Nearly half (48.8%) of patients saw palliative care during their initial admission. Patients who were seen by palliative care were more likely to have higher uRPA classifications (p=.02) and longer length of stay inpatient (p=.02). These patients were less likely to undergo any treatment (p=.00) and more likely to be discharged on hospice (p=.00). They were not more likely to have advanced directives documented (p=.33). They were not more likely to die (p=.32) or be readmitted (p=.08) within 30 days despite having a shorter overall survival (248 days versus 585 days (p=.02)).
Conclusions:
Our institution seems to involve palliative care early- during an initial admission- for patients with Bmets who are sicker (poorer performance status by uRPA, longer length of stay, shorter overall survival). We may consider whether other patients with Bmets may benefit from palliative care involvement at this earliest timepoint.
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