Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center

Highlights

• Palliative care consultation rate for elderly patients with traumatic brain injury (TBI) is low.

• Baseline dementia and severe TBI are associated with palliative care consultation.

• Average palliative care consultation timing was at 8.6 days.

• Patients with palliative care had longer admissions, more days intubated, and higher costs.

• Patients with earlier-than-average palliative care had lower costs and shorter hospitalization.

Abstract

We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4 % out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR = 5.030, 95 % CI 1.096–23.082, p =.038) and pre-existing dementia (OR = 6.577, 95 % CI 1.726–25.073, p =.006). Average consultation timing was 8.6 (standard deviation ± 7.0) days. Patients with PC consults had longer overall (p =.0031) and intensive care unit (ICU) length of stays (LOS) (p <.0001), more days intubated (p <.0001) and higher costs (p =.0006), although those with earlier-than-average PC consultation had shorter overall (p =.0062) and ICU (p =.011) LOS as well as fewer ventilator days (p =.030) and lower costs (p =.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.

Introduction

Patients over age 65 with traumatic injuries are at high risk of morbidity and mortality [1], [2]. Traumatic brain injuries (TBI) are highly prevalent in the United States, accounting for 2.5 million emergency department visits, hospital admissions, and deaths in 2010 [3]. According to the Centers for Disease Control and Prevention, patients over age 75 comprised 32 % of TBI-related hospitalizations and 28 % of deaths related to TBI [4]. Furthermore, elderly patients who are admitted to the intensive care unit (ICU) have greater rates of in-hospital mortality or discharge to other acute care facilities [5].

Due to the inherent risks related to head trauma and critical illness for the elderly patient population, more attention to care planning and supportive needs are warranted. Approximately 25 % of older patients who require neurosurgery for traumatic brain injuries die in the hospital [6]. For those who survive, there is a 50 % mortality rate even within one year after initial injury [6]. The American College of Surgeon’s Trauma Quality Improvement Program also implemented Palliative Care Best Practices Guidelines in 2017, which recommend special attention to these patients’ needs as well as palliative care (PC) screening for moderate and severe TBI [6]. Furthermore, TBIs are critical events that are also associated not only with short-term adverse health effects but also with future development of depression or dementia [7], [8].

With this single-institution cross-sectional study, we aim to identify factors and outcomes associated with early and late inpatient PC consultation for patients over 65 with TBI. The goals of this study are to: 1) characterize the demographic information for older patients presenting with TBI and intracranial hemorrhage on initial imaging who have received PC consultation; 2) determine factors associated with PC consultation; and 3) compare outcomes in length of stay (LOS), dispositions, and costs depending on timing of PC consultation.