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Proactive palliative care in the medical intensive care unit: Effects
on length of stay for selected high-risk patients
Sally A. Norton, PhD, RN; Laura A. Hogan, MS, RN, ACHPN; Robert G. Holloway, MD, MPH;
Helena Temkin-Greener, PhD, MPH; Marcia J. Buckley, MS, RN, BC-PCM; Timothy E. Quill, MD
Inpatient palliative care (PC) ser-
vices are growing rapidly across
academic healthcare centers in
the United States (1). This growth
has been triggered in part by an extensive
body of research that documents difficul-
ties in providing adequate pain and symp-
tom management as well as inconsistent
communication and decision making for
hospitalized persons with serious and/or
life-threatening illness (2–12).
Historically, PC was initially most
strongly associated with end-of-life care.
PC providers have tended to see patients
very late in their illness trajectories, often
only after all possible life-prolonging in-
terventions have been tried to no avail
and there is “nothing else left to do.”
However, there is a national movement
to consult on patients earlier, while they
continue to pursue life-prolonging inter-
ventions. The argument is that PC is po-
tentially relevant to all seriously ill pa-
tients who might be experiencing
symptoms that could be better treated,
who may have support needs, or who may
need assistance with goal clarification
and complex medical decision making.
The argument is especially compelling in
intensive care units (ICUs), where the
sickest patients are treated and where ap-
proximately 20% of U.S. deaths occur
each year (13). These deaths occur most
often after shifts in patients’ care goals
and decisions to withdraw life-sustaining
treatment (14). There is a growing body
of literature describing innovative ap-
proaches to and endorsements of the in-
tegration of palliative and intensive care
(15–21). However, PC providers have
been urged to identify measurable out-
comes of such changes in care delivery,
and more research is needed (22–26).
Although most PC research has focused
on improved symptom management and
more informed decision making, a few re-
searchers have examined the financial out-
comes, defined by such factors as length of
stay, of PC delivered within a hospital set-
ting (27–29). Examining a select group of
patients in an adult medical intensive care
unit (MICU), Campbell and Guzman (27)
found that PC nurse practitioner case-
finding and early PC intervention in pa-
tients with multiple-organ system failure
and global cerebral ischemia were associ-
ated with substantial institutional cost sav-
ings generated through decreased length of
stay in ICU and avoidance of often costly,
nonbeneficial treatments. In another study,
these same authors found that proactive PC
case-finding and early PC approach for
MICU patients with terminal dementia
were associated with shorter hospital and
ICU lengths of stay (29).
From the School of Nursing (SN), Center for Ethics,
Humanities, and Palliative Care (LH, RH, MB, TQ), and
the Departments of Community and Preventive Medi-
cine (RH, HTG) and Neurology (RH), University of Roch-
ester Medical Center, Rochester, NY.
Supported, in part, by the Fraser-Parker Founda-
tion, Atlanta, GA.
The authors have not disclosed any potential con-
flicts of interest.
For information regarding this article, E-mail:
Sally_Norton@urmc.rochester.edu
Copyright © 2007 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000266533.06543.0C
Objective: The purpose of this study was to examine the effect
of proactive palliative care consultation on length of stay for
high-risk patients in the medical intensive care unit (MICU).
Design: A prospective pre/post nonequivalent control group
design was used for this performance improvement study.
Setting: Seventeen-bed adult MICU.
Patients: Of admissions to the MICU, 191 patients were iden-
tified as having a serious illness and at high risk of dying: 65
patients in the usual care phase and 126 patients in the proactive
palliative care phase. To be included in the sample, a patient had
to meet one of the following criteria: a) intensive care admission
following a current hospital stay of >10 days; b) age >80 yrs in
the presence of two or more life-threatening comorbidities (e.g.,
end-stage renal disease, severe congestive heart failure); c) di-
agnosis of an active stage IV malignancy; d) status post cardiac
arrest; or e) diagnosis of an intracerebral hemorrhage requiring
mechanical ventilation.
Interventions: Palliative care consultations.
Measurements and Main Results: Primary measures were pa-
tient lengths of stay a) for the entire hospitalization; b) in the
MICU; and c) from MICU admission to hospital discharge. Sec-
ondary measures included mortality rates and discharge dispo-
sition. There were no significant differences between the usual
care and proactive palliative care intervention groups in respect
to age, gender, race, screening criteria, discharge disposition, or
mortality. Patients in the proactive palliative care group had
significantly shorter lengths of stay in the MICU (8.96 vs. 16.28
days, pⴝ.0001). There were no differences between the two
groups on total length of stay in the hospital or length of stay from
MICU admission to hospital discharge.
Conclusions: Proactive palliative care consultation was associ-
ated with a significantly shorter MICU length of stay in this high-risk
group without any significant differences in mortality rates or dis-
charge disposition. (Crit Care Med 2007; 35:1530–1535)
KEY WORDS: palliative care; critical care; intensive care unit;
length of stay; terminal care; patient care
1530 Crit Care Med 2007 Vol. 35, No. 6
Proactive ethics consultations and
family meetings also have been studied in
the ICU (30, 31). Schneiderman and col-
leagues (31) conducted a proactive ethics
consultation intervention for patients
when there were imminent or manifest
value-laden treatment conflicts and re-
ported an almost 3-day reduction in hos-
pital and a 1.5-day reduction in ICU
length of stay in the proactive ethics con-
sultation group. Lilly and colleagues (30),
studying consecutive admissions to an
ICU, reported a 1-day reduction in the
median length of MICU stay in the pop-
ulation receiving the proactive family-
meeting intervention.
Ideally, PC consultations primarily
provide patient/family-centered care di-
rected at improving the patient’s quality
of life by providing excellent pain and
symptom management, goal clarification,
assistance with medical decision making,
and support (32). The majority of the
secondary cost savings associated with PC
consultations arise from two potential
sources: a) decreased length of stay in the
hospital or ICU, when the treatments
available in these settings do not align
with patients’ goals in light of a full un-
derstanding of their medical condition
and prognosis; and b) earlier cessation of
unwanted or ineffective medical therapies
(33). The associated cost savings when
informed patients and families choose to
forgo unwanted or ineffective therapies
are an unintended benefit, not a goal of
PC service. At the same time, in today’s
hospital milieu, services that result in
improved patient care and institutional
financial savings are especially attractive
to administrators and insurers.
One of the difficulties with demon-
strating the effect of PC interventions on
hospital length of stay is that PC consul-
tations are frequently requested relatively
late in a patient’s hospital stay. Before
this initiative in our own institution, for
example, PC consultations were rarely
initiated in the MICU and then only on
patients who were failing all aggressive
treatments after being in the ICU ⬎2 wks
on average. In 2004, in conjunction with
the Institute for Healthcare Improve-
ment, we undertook a performance im-
provement initiative designed to address
this potential gap in quality of care by
initiating a routine proactive PC consul-
tation for selected high-risk MICU pa-
tients very early in their ICU stay. In this
study, we evaluated the impact of this
intervention on these patients’ lengths of
stay and mortality in the ICU and in the
hospital.
METHODS
A prospective pre/post nonequivalent con-
trol group design was used for this perfor-
mance improvement study. This study re-
ceived an exemption from our Institutional
Review Board.
Setting. The study was conducted in a 17-
bed adult MICU located in a 750-bed academic
tertiary care hospital in upstate New York with
a multidisciplinary PC consultation service.
Patients admitted to this MICU typically have
diagnoses such as respiratory distress/failure,
sepsis, intracranial hemorrhage, cardiac ar-
rest, advanced neurologic disorders, multiple
organ system failure, and/or other life-
threatening illness. The MICU admits approx-
imately 1,100 patients per year and has an
average mortality rate of 17.8% and an average
length of stay of 6 –7 days. It is a primarily
closed unit with a critical care intensivist as
the attending physician on almost all patients.
An intensivist, a critical care fellow, and resi-
dents comprise the physician portion of the
MICU team. The nursing leadership includes a
nurse manager, nurse patient care coordina-
tor, and three nurse leaders. There is a charge
registered nurse on each shift and one or two
registered nurses per patient.
Patient Inclusion Criteria. All patients ad-
mitted to the MICU between March 26, 2004,
and March 3, 2005, were screened within 72
hrs of admission. To help identify patients who
might best benefit from a PC intervention, PC
and MICU nursing and physician leaders de-
veloped screening inclusion criteria using lit-
erature review, survey of MICU deaths in the
previous year, and ICU clinical expertise to
identify those with an adverse burden/benefit
ratio and a high risk of dying. A patient had to
trigger at least one of the following inclusion
criteria to be included in our sample: a) ICU
admission following a current hospital stay of
ⱖ10 days; b) age ⬎80 yrs in the presence of
two or more life-threatening comorbidities
(e.g.; end-stage renal disease, severe conges-
tive heart failure); c) diagnosis of an active
stage IV malignancy; d) status post cardiac
arrest (usually with other serious co-morbid
conditions); or e) diagnosis of an intracerebral
hemorrhage requiring mechanical ventilation.
Usual Care Phase. During the 4-month
usual care phase, all patients who screened
positive received the usual care. As was the
standard, PC consultations occurred when a
MICU physician called in a patient referral
through the standard referral mechanisms
that existed before the study. Results of the
screening were not discussed with the MICU
staff, and no notes were placed in the medical
records of those patients who met the criteria.
However, when a patient screened positive,
the nursing care coordinator was sometimes
aware that a patient had met the criteria for
inclusion in the study. The 7.5-month proac-
tive PC intervention phase followed this
4-month “usual care” baseline period.
Proactive Palliative Care Phase. During
the 7.5-month proactive PC intervention
phase, all patients who met one of the inclu-
sion criteria received a basic or a complete PC
consultation.
A basic PC consultation intervention in-
cluded a) a thorough review of the chart, in-
cluding the patient’s medical history, course
of hospitalization, events leading up to the
ICU admission, presence or absence of health-
care proxy or other advance directive, family
involvement in decision making, the use of
time-limited trials, and documented treat-
ment limitation decisions; b) a brief history of
present illness and physical exam including an
assessment of common symptoms such as
pain, dyspnea, nausea, agitation, depression,
and anxiety, as well as the plan in place to
address symptoms as necessary and the effec-
tiveness of the plan; c) discussions with med-
ical, nursing, and social work MICU team
members regarding the status of symptom
management and the patient’s and team’s
goals of care, family members’ needs for sup-
port, and any difficulties related to treatment
decision making; d) discussion and review of
PC recommendations with PC attending phy-
sician; and e) consolidation of the aforemen-
tioned information with PC recommendations
on a two-page yellow PC assessment form that
was placed in the chart. (A sample is available
on request from the authors.) When PC needs
were being addressed or when MICU attending
physicians felt that the addition of another
provider involved with the family would not
contribute to patient care, the PC interven-
tions remained at this basic level and the pal-
liative care nurse practitioner continued to
follow the patient without direct involvement
with the family during the patient’s MICU
stay. However, if the patient’s clinical situa-
tion changed such that unaddressed PC needs
were subsequently identified, then with the
MICU attending physician’s consent a com-
plete PC consultation was initiated.
A complete PC consultation intervention
included all of the components of a basic in-
tervention plus a) full involvement of a PC
attending physician including assessment and
recommendations; b) direct regular involve-
ment by the PC team (usually the nurse prac-
titioner and doctor) with the patient’s family
members, including involvement in family
meetings to facilitate decision making on
goals of care and potential treatment limita-
tions; c) direct regular involvement of mem-
bers of the PC team and other consultants and
medical providers involved in the patient’s
treatment in determining efficacy of treat-
ment and goals of care; and d) review by and
availability of the entire multidisciplinary PC
team for additional support for the patient and
family as needed (e.g., chaplain, music and
massage practitioners, psychologist). Patients
receiving a complete PC consultation inter-
1531Crit Care Med 2007 Vol. 35, No. 6
vention were followed in the MICU and
throughout their subsequent hospital stay by
PC team members.
Analytical Sample. The study was con-
ducted between March 26, 2004, and March 3,
2005. During this time, there were 743 admis-
sions to the MICU. Of these, 192 admissions
(26%) resulted in a positive PC screen. One
admission from the usual care phase was de-
leted because of missing data. The final ana-
lytical sample included 191 MICU admissions
that screened positive. Of these admissions, 65
were identified during the usual care phase as
potential PC candidates; this was conducted
between March 26 and July 23, 2004, with an
average of 3.82 patients screening positive per
week. During this 4-month baseline period,
only five patients were referred for PC consul-
tation following the usual care phase process.
They are included in the sample. On average,
these patients received a PC consultation re-
ferral on day 14 of their MICU stay, which was
typical of the usual MICU referral pattern be-
fore the beginning of the study. There were no
differences between the consultation rate dur-
ing the usual phase and the time before the
commencement of the study. Another 126 ad-
missions were identified during the proactive
PC phase—July 26, 2004, through March 3,
2005—with an average of 3.94 patients
screening positive per week.
Statistical Analysis. This analysis focuses
mainly on two outcome measures: days in the
MICU and total days in the hospital. Chi-
square tests were used to compare the char-
acteristics of the two groups with regard to
their demographics, screening criteria, and
discharge disposition. We used t-test proce-
dures to compute sample means for the two
outcome measures (MICU and hospital
lengths of stay) in both the baseline and the
intervention groups and to test the hypothesis
that the population means are the same. To
summarize inference results, statistical signif-
icance was attributed to comparisons associ-
ated with two-tailed pⱕ.05.
RESULTS
There were no statistically significant
differences between the usual care and pro-
active PC phase groups in respect to age,
gender, race, screening criteria, or dis-
charge disposition (Table 1). The total hos-
pital death rate (died in the MICU or hos-
pital floors) of the entire sample (n ⫽191)
was 58%, 36 of 65 (55.4%) in the usual care
group and 75 of 126 (59.5%) in the proac-
tive PC group. The MICU death rate (died in
the MICU) was 25 of 65 (38.5%) in the
usual care group and 46 of 126 (36.5%) in
the proactive PC intervention group. There
was no difference in the rate of death in the
MICU between the two groups (p⫽.6128).
The vast majority of the patients
screened during the study (160 of 191, or
84%) met one screening criterion. How-
ever, 29 of 191 (15%) met two criteria,
and 2 of 191 (1%) met three screening
criteria. The hospital mortality rate by
screening criteria was 27 of 50 (54%) for
patients hospitalized ⬎10 days before
MICU admission: 27 of 49 (55%) for pa-
tients age ⱖ80 with two or more life-
threatening comorbidities, 21 of 33
(63%) for those patients with stage IV
malignancy, 29 of 38 (74%) for patients
post cardiac arrest, 19 of 35 (54%) for
patients with intracerebral hemorrhage
requiring mechanical ventilation, and 10
of 19 (53%) for patients meeting the
“other” category (Table 2).
During the usual care phase, the aver-
age number of days from MICU admission
to complete PC consultation was 14. Dur-
ing the usual care phase, five patients
(8%) received a complete PC consulta-
tion. There were no basic PC consulta-
tions during the usual care phase.
During the proactive PC intervention
phase, all 126 patients received a basic PC
consultation within an average of 1.73
days, and 31 (25%) went on to receive a
complete PC consultation within an av-
erage of 4.9 days from MICU admission.
The MICU length of stay of the MICU
decedents was 5.72 days in the intervention
group and 14.12 in the usual care group, a
statistically significant difference of 8.40
days (p⫽.004). The MICU length of stay of
the hospital decedents (excluding MICU de-
cedents) was 9.17 days in the intervention
group and 16.09 in the usual care group, a
decrease of 6.92 days (p⫽.0510) that did
not achieve statistical significance. For
those patients who died in the hospital but
not in the MICU, there was no difference in
their overall hospital lengths of stay.
Table 1. Demographic characteristics of total study sample
Demographics
Usual Care
(n ⫽65)
Proactive Palliative Care
Intervention
(n ⫽126)
Age, mean (SD) 68.75 (15.44) 66.31 (16.31)
Gender, n (%)
Female 32 (49) 69 (55)
Male 33 (51) 57 (45)
Race, n (%)
White 51 (78.5) 95 (75.4)
African American 10 (15.4) 27 (21.4)
Hispanic 3 (4.6) 3 (2.4)
Other/unknown 1 (1.5) 1 (0.8)
Screening criteria, n (%)
a
Hospital stay ⬎10 days 21 (32.3) 29 (23.0)
Age 80 plus two or more comorbidities 12 (18.5) 37 (29.4)
Stage IV malignancy 7 (10.8) 26 (20.6)
Status post cardiac arrest 22 (17.5) 16 (24.6)
Intracerebral hemorrhage with ventilation 11 (16.9) 24 (19.1)
Other 7 (10.8) 12 (9.5)
Discharge, n (%)
Death in hospital
b
36 (55.4) 75 (59.5)
Home 10 (15.4) 24 (19.1)
Skilled nursing facility 16 (24.6) 23 (18.3)
Rehabilitation/other hospital 1 (1.54) 2 (1.6)
Missing 2 (3.1) 2 (1.6)
a
Thirty-one patients met more than one screening criteria;
b
this category includes all of the
patients who died in the medical intensive care unit and in other areas of the hospital.
Table 2. Hospital mortality rate by screening criteria
Screening Criteria
No. of Patients
Meeting
Criterion
No. of Deaths
Associated With
Criterion
Mortality
Rate, %
Hospital stay ⬎10 days 50 27 54
Age 80⫹plus two or more comorbidities 49 27 55
Stage IV malignancy 33 21 63
Status post cardiac arrest 38 29 74
Intracerebral hemorrhage with ventilation 35 19 54
Other 19 10 53
1532 Crit Care Med 2007 Vol. 35, No. 6
The MICU length of stay of all patients
in the proactive PC intervention group was
8.96 days compared with 16.28 days for the
usual care group, a statistically significant
difference of 7.32 days (p⫽.0001) (Table
3). We observed no statistically significant
difference in the overall hospital length of
stay for the two groups. There was no dif-
ference in the hospital length of stay for the
usual care group: 41.40 days compared
with 35.8 days for the proactive PC inter-
vention group (p⫽.5011). There also was
no difference between the length of stay
from MICU admission to hospital dis-
charge. Because of the high degree of vari-
ability in the hospital length of stay group,
we conducted a log transformation of the
data, but the differences between the two
groups on hospital length of stay remained
statistically nonsignificant.
DISCUSSION
Although not its primary intention,
this proactive PC consultation process
was associated with a substantial reduc-
tion in the MICU length of stay for this
group of selected, high-risk patients. The
intervention was not associated with any
significant overall change in hospital
length of stay or the length of stay be-
tween MICU admission and hospital dis-
charge. The data for the total length of
stay in the hospital and length of stay
from MICU admission to hospital dis-
charge had high variability and were
skewed with a relatively small number of
long-stay outliers. Our rationale for in-
cluding all of the outliers was that they
were not unlike the patients routinely
seen by PC services. We only continued to
follow those MICU patients who had re-
ceived a complete PC consultation after
their transfer out of the MICU, potentially
diluting the impact of our intervention
and contributing to the lack of signifi-
cance between groups in the hospital por-
tion of the lengths of stay. However, these
results support a need to examine the
effect of identifying patients earlier in
their hospital stay and continuing full
follow-up until death or discharge for all
patients so identified.
Our proactive PC MICU screening tool
identified a group of patients admitted to
the MICU who were at high risk of dying
during their hospital stay. It was very
brief and simple to use. We sought such
criteria because we planned to continue
the performance improvement initiative
past the study phase, and our MICU does
not routinely collect acuity (e.g., Acute
Physiology and Chronic Health Evalua-
tion) data on all admissions. Our criteria
allowed us to very quickly identify pa-
tients who might benefit from early PC
consultation because of their high bur-
den of illness and relatively poor progno-
sis. The percentage of patients identified
as being at risk by the screening tool
remained relatively constant in the base-
line and intervention phases of the study.
Of the 65 patients who screened positive
during the usual care phase, only five
(8%) received complete PC consultation,
and those consultations occurred on av-
erage after 2 wks in the MICU. The num-
ber of basic and complete consultations
increased significantly in the interven-
tion phase, and the time from MICU ad-
mission to consultation was reduced sig-
nificantly.
We started our trial with the plan that
all patients who screened positive would
receive a complete PC consultation. How-
ever, much of the time, the patient’s PC
needs were being well addressed by MICU
staff. We developed our basic intervention
as a way to assess and monitor patients’
PC needs routinely and systematically
and then to track them in the medical
record. In the basic consultation model,
PC issues were made visibly present on a
yellow sheet in the medical record, but
the PC team did not add redundant per-
sonnel to the array of providers that pa-
tients’ families already encounter in the
ICU, unless a collaborative decision was
made to initiate a complete consultation.
Patients triggering the screen during
the intervention period who received the
PC intervention were no more likely to
die than those who triggered the screen
during the usual care phase who did not
receive the PC intervention. Both groups
had high MICU mortality rates (38.5%
and 36.5%, respectively). Although re-
ceiving PC consultation was associated
with much higher mortality than the typ-
ical MICU patient, having a baseline com-
parison group with similarly high mor-
tality rates supports a claim that it is not
PC consultation per se that increases
mortality. Instead, it is the population
seen by PC clinicians that is at much
higher risk for mortality. Although there
was not a significant difference between
mortality rates in the usual care and pro-
active PC groups, the decedents in the
proactive PC intervention group had sig-
nificantly shorter MICU lengths of stay.
Bringing PC issues to the fore earlier in a
seriously ill patient’s hospitalization may
facilitate and accelerate decision making.
Because many ICU deaths occur following
treatment withdrawal decisions, facilitating
an earlier discussion of the balance of bur-
dens and benefits, and of prognosis, may
lead to earlier withdrawal of treatment for
those patients for whom continued ad-
vanced life-support treatments are no
longer beneficial. In this sense, PC consul-
tation may shorten the time to death for
those who are inevitably dying. This would
be consistent with findings from other re-
search studies (27, 29 –31, 34).
The results of our study support the
growing body of literature that proactive
interventions focused on enhancing com-
munication regarding patients’ goals of
care and benefits vs. burdens of treatment
are associated with shortened lengths of
stay in the MICU. Investigators have used
differing mechanisms of proactive inter-
vention such as PC consultation, ethics
consultation, or communication-intensive
family meetings in different ICU popula-
tions but have consistently demonstrated
the association between such interventions
and shorter lengths of ICU stay, especially
among patients who do not survive their
ICU stay (27, 30, 31). If such consultations
can facilitate the cessation of futile and/or
unwanted treatment earlier, then they may
Table 3. Length of stay (in days)
Usual Care
(n ⫽65)
Proactive
Palliative Care
Intervention
(n ⫽126) Difference pValue
MICU 16.28 (16.54) [12] 8.96 (9.27) [5.5] ⫺7.32 [⫺6.5] .0001
a
MICU admission to
hospital discharge
33.87 (55.01) [18] 26.65 (43.95) [12] ⫺7.22 [⫺6] .3394
Hospital admission to
hospital discharge
41.40 (58.41) [24.5] 35.77 (50.19) [17] ⫺5.63 [⫺5.5] .5011
MICU, medical intensive care unit.
a
pⱕ.05. Values are mean (SD) [median].
1533Crit Care Med 2007 Vol. 35, No. 6
simultaneously contribute to improving
quality and saving money.
Although PC services may have limited
ability to generate revenue directly, reduc-
ing ICU lengths of stay has enormous fi-
nancial and patient-care implications for a
hospital. Extrapolating from our own find-
ings, our intervention potentially saves ap-
proximately 1,400 MICU bed-days per year
(estimating 17.5% of MICU admissions per
year or 191 of 1,100, multiplied by an av-
erage savings of 7.32 days per admission).
These bed-days would now be available for
other patients, making increased admis-
sions to the ICU possible, which in turn
would generate significant additional hos-
pital revenues in a hospital with high MICU
occupancy rates. This can be achieved with
an intervention designed to maximize the
patient’s quality of life and to support the
patient and family as they make informed
decisions about medical treatment. Recog-
nizing and demonstrating these indirect fi-
nancial effects are important steps if PC
consultation services are to continue ex-
panding in hospital settings.
The need for collaboration among the
PC and MICU teams cannot be overstated.
Members from both teams came to-
gether, collaborating at each phase of this
initiative. In our initiative, an experi-
enced PC nurse practitioner collaborated
with the MICU team to identify and place
in the foreground PC issues. When the
need for a complete consultation arose,
the PC nurse practitioner was also the
conduit to the PC physician and the rest
of the PC team.
A pre/post intervention design has
limitations. Although there were no con-
current MICU initiatives targeting our
sample, the changes in MICU length of
stay could have been related to other fac-
tors we did not consider. Our screening
criteria were not as precise or objective as
possible. This was an explicit trade-off to
facilitate the ongoing performance im-
provement initiative using the experience
of the MICU team and an easily imple-
mented screen, but it is nevertheless a
limitation of the study design.
We did not differentiate the baseline
usual care group by their level of PC needs.
This curtailed our ability to examine addi-
tional subgroup relationships between
complete and basic PC consultation re-
quirements and lengths of stay. Thus, it
was not possible to identify changes in
lengths of stay associated with the intensity
level of the intervention. Finally, the pa-
tients receiving only basic PC consultation
were not followed throughout their entire
hospitalization subsequent to their MICU
stay. This likely diluted any potential effect
of our intervention on length of stay for the
period between MICU admission and hos-
pital discharge.
Along with the increased number of
PC consultation services in the MICU, PC
and ICU clinicians are collaborating more
in this and other ICU settings. This and
other preliminary studies suggest the
need to examine the impact of this inte-
gration on quality indicators of patient
and family care, on length of stay, and on
medical decision making especially with
regard to potentially life-sustaining ther-
apies, as well as the impact on finances
using a much larger randomized clinical
trial.
ACKNOWLEDGMENTS
We thank the patients and families of
the PC and MICU teams, especially Dr.
Michael Apostolakos, Martha Neubert,
Lucy Nelson, Jill Szydlowski, and Mary
Wicks.
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