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Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review.

ABSTRACT: Background:Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed. Methods:Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients. Results:Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary. Conclusion:Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

SUBMITTER: Sood R

PROVIDER: S-EPMC6940657 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review.

Sood R R Mancinetti M M Betticher D D Cantin B B Ebneter A A

Annals of medicine and surgery (2012) 20191218

<h4>Background</h4>Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situat ...[more]

PMID: 31908774

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Project description:Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre-post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre-post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre-post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.

Project description:BackgroundThe capacity of general internal medicine (GIM) clinical teaching units has been strained by decreasing resident supply and increasing patient demand. The objective of our study was to compare the number of residents (supply) with the volume and duration of patient care activities (demand) to identify inefficiency.MethodsUsing the most recently available data from an academic teaching hospital in Toronto, Ontario, we identified each occurrence of a set of patient care activities that took place on the clinical teaching unit from 2015 to 2019. We completed a descriptive analysis of the frequencies of these activities and how the frequencies varied by hour, day, week, month and year. Patient care activities included admissions, rounds, responding to pages, meeting with patients and their families, patient transfers, discharges and responding to cardiac arrests. The estimated time to complete each task was based on the available data in our electronic medical record system and interviews with GIM physicians and trainees. To calculate resident utilization, the person-hours of patient care tasks was divided by the person-hours of resident supply. Resident utilization was computed for 3 scenarios corresponding to varying levels of resident absenteeism.ResultsDuring the study period, there were 14 581 consultations to GIM from the emergency department. Patient volumes tended to be highest during January and lowest during May and June, and highest on Monday morning and lowest on Friday night. Daily admissions to hospital from the emergency department were higher on weekdays than on weekends, and hourly admissions peaked at 8 am and between 3 pm and 1 am. Weekday resident utilization was generally highest between 8 am and 2 pm, and lowest between 1 am and 8 am. In a scenario in which all residents were present apart from those who were post-call, resident utilization generally never exceeded 100%; in scenarios in which at least 1 resident was absent owing to illness or vacation, it was common for resident utilization to approach or exceed 100%, particularly during daytime working hours.InterpretationAnalyzing supply and demand on a GIM ward has allowed us to identify periods when supply and demand are not aligned and to demonstrate empirically the vulnerability of current staffing models. These data have the potential to inform and optimize scheduling on an internal medicine ward.

Project description:BACKGROUND: The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care. OBJECTIVE: To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus. DESIGN: Retrospective cohort study SUBJECTS: Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice. MEASUREMENTS: Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care. MAIN RESULTS: Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7-5.7), urine microalbumin (OR 3.3, 95% CI 2.1-5.5), blood pressure (OR 1.8, 95% CI 1.1-2.8), retinal examination (OR 1.9, 95% CI 1.3-2.7), foot monofilament examination (OR 4.2, 95% CI 3.0-6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0-9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02-3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1-4.5) compared to controls. CONCLUSIONS: A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.

Project description:We provide a systematic review and meta-analysis on the efficacy, tolerability, and safety of cannabinoids in palliative medicine. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, Scopus, and http://clinicaltrials.gov, and a selection of cancer journals were searched up until 15th of March 2017. Of the 108 screened studies, nine studies with a total of 1561 participants were included. Overall, the nine studies were at moderate risk of bias. The quality of evidence comparing cannabinoids with placebo was rated according to Grading of Recommendations Assessment, Development, and Evaluation as low or very low because of indirectness, imprecision, and potential reporting bias. In cancer patients, there were no significant differences between cannabinoids and placebo for improving caloric intake (standardized mean differences [SMD]: 0.2 95% confidence interval [CI]: [-0.66, 1.06] P = 0.65), appetite (SMD: 0.81 95% CI: [-1.14, 2.75]; P = 0.42), nausea/vomiting (SMD: 0.21 [-0.10, 0.52] P = 0.19), >30% decrease in pain (risk differences [RD]: 0.07 95% CI: [-0.01, 0.16]; P = 0.07), or sleep problems (SMD: -0.09 95% CI: [-0.62, 0.43] P = 0.72). In human immunodeficiency virus (HIV) patients, cannabinoids were superior to placebo for weight gain (SMD: 0.57 [0.22; 0.92]; P = 0.001) and appetite (SMD: 0.57 [0.11; 1.03]; P = 0.02) but not for nausea/vomiting (SMD: 0.20 [-0.15, 0.54]; P = 0.26). Regarding side effects in cancer patients, there were no differences between cannabinoids and placebo in symptoms of dizziness (RD: 0.03 [-0.02; 0.08]; P = 0.23) or poor mental health (RD: -0.01 [-0.04; 0.03]; P = 0.69), whereas in HIV patients, there was a significant increase in mental health symptoms (RD: 0.05 [0.00; 0.11]; P = 0.05). Tolerability (measured by the number of withdrawals because of adverse events) did not differ significantly in cancer (RD: 1.15 [0.80; 1.66]; P = 0.46) and HIV patients (RD: 1.87 [0.60; 5.84]; P = 0.28). Safety did not differ in cancer (RD: 1.12 [0.86; 1.46]; P = 0.39) or HIV patients (4.51 [0.54; 37.45]; P = 0.32) although there was large uncertainty about the latter reflected in the width of the CI. In one moderate quality study of 469 cancer patients with cancer-associated anorexia, megestrol was superior to cannabinoids in improving appetite, producing >10% weight gain and tolerability. In another study comparing megestrol to dronabinol in HIV patients, megestrol treatment led to higher weight gain without any differences in tolerability and safety. We found no convincing, unbiased, high quality evidence suggesting that cannabinoids are of value for anorexia or cachexia in cancer or HIV patients.

Project description:Available systematic reviews showed uncertainty on the effectiveness of using acupuncture and related therapies for palliative cancer care. The aim of this systematic review and meta-analysis was to summarize current best evidence on acupuncture and related therapies for palliative cancer care. Five international and 3 Chinese databases were searched. Randomized controlled trials (RCTs) comparing acupuncture and related therapies with conventional or sham treatments were considered. Primary outcomes included fatigue, paresthesia and dysesthesias, chronic pain, anorexia, insomnia, limb edema, constipation, and health-related quality of life, of which effective conventional interventions are limited. Thirteen RCTs were included. Compared with conventional interventions, meta-analysis demonstrated that acupuncture and related therapies significantly reduced pain (2 studies, n = 175, pooled weighted mean difference: -0.76, 95% confidence interval: -0.14 to -0.39) among patients with liver or gastric cancer. Combined use of acupuncture and related therapies and Chinese herbal medicine improved quality of life in patients with gastrointestinal cancer (2 studies, n = 111, pooled standard mean difference: 0.75, 95% confidence interval: 0.36-1.13). Acupressure showed significant efficacy in reducing fatigue in lung cancer patients when compared with sham acupressure. Adverse events for acupuncture and related therapies were infrequent and mild. Acupuncture and related therapies are effective in reducing pain, fatigue, and in improving quality of life when compared with conventional intervention alone among cancer patients. Limitations on current evidence body imply that they should be used as a complement, rather than an alternative, to conventional care. Effectiveness of acupuncture and related therapies for managing anorexia, reducing constipation, paresthesia and dysesthesia, insomnia, and limb edema in cancer patients is uncertain, warranting future RCTs in these areas.

Project description:BACKGROUND:The precise scope of hospital care delivered under general internal medicine services remains poorly quantified. The purpose of this study was to describe the demographic characteristics, medical conditions, health outcomes and resource use of patients admitted to general internal medicine at 7 hospital sites in the Greater Toronto Area. METHODS:This was a retrospective cohort study involving all patients who were admitted to or discharged from general internal medicine at the study sites between Apr. 1, 2010, and Mar. 31, 2015. Clinical data from hospital electronic information systems were linked to administrative data from each hospital. We examined trends in resource use and patient characteristics over the study period. RESULTS:There were 136?208 admissions to general internal medicine involving 88?121 unique patients over the study period. General internal medicine admissions accounted for 38.8% of all admissions from the emergency department and 23.7% of all hospital bed-days. Over the study period, the number of admissions to general internal medicine increased by 32.4%; there was no meaningful change in the median length of stay or cost per hospital stay. The median patient age was 73 (interquartile range [IQR] 57-84) years, and the median number of coexisting conditions was 6 (IQR 3-9). The median acute length of stay was 4.6 (IQR 2.5-8.6) days, and the median total cost per hospital stay was $5850 (IQR $3915-$10?061). Patients received at least 1 computed tomography scan in 52.2% of admissions. The most common primary discharge diagnoses were pneumonia (5.0% of admissions), heart failure (4.7%), chronic obstructive pulmonary disease (4.1%), urinary tract infection (4.0%) and stroke (3.6%). INTERPRETATION:Patients admitted to general internal medicine services represent a large, heterogeneous, resource-intensive and growing population. Understanding and improving general internal medicine care is essential to promote a high-quality, sustainable health care system.

Dataset Information

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review.

Publications

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review.

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