Abstract

Background

Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU). The impact and timing of goals of care discussions on HCRU are not well described.

Methods

221 patients enrolled in a prospective cohort study of patients admitted with AKI and cirrhosis were reviewed. Documentation and timing of a goals of care discussions were analyzed as predictors of HCRU, defined as a composite outcome of intubation, initiation of renal replacement therapy, and/or admission to the intensive care unit.

Results

Median MELD score was 26 [IQR 19, 33]. 29% patients were listed for liver transplant. 90-day mortality was 61%. 51% patients had at least one HCRU episode. Code status changed from admission to discharge from 91%/7%/0% to 68%/14%18% (full code/do not resuscitate/comfort measures, p < 0.001). 28% patients underwent goals of care discussions, with change in code status at a median of 16 [9, 22] days into admission. Only 18% of discussions were within 7 days of admission and all were after an HCRU event. Being listed for liver transplant was not associated with whether goals of care discussions occurred (23% listed vs. 31% non-listed, p = 0.24) but was associated with higher HCRU (69% vs. 43%; p < 0.001).

Conclusion

Goals of care discussions occurred late into the hospital course, after episodes of HCRU. Efforts should be made to engage in these discussions earlier in the hospital stay, which may decrease HCRU rates in this critically ill population and align with patients’ goals of care.

中文翻译：

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肝硬化和急性肾损伤患者的医疗资源利用和护理讨论目标

摘要

背景

肝硬化和急性肾损伤（AKI）患者病情危重，医疗资源利用率（HCRU）较高。HCRU 护理讨论目标的影响和时间安排尚未得到很好的描述。

方法

对参加一项前瞻性队列研究的 221 名患者进行了审查，研究对象是因 AKI 和肝硬化入院的患者。护理讨论目标的记录和时间安排被分析为 HCRU 的预测因素，HCRU 被定义为插管、开始肾脏替代治疗和/或入住重症监护病房的综合结果。

结果

MELD 评分中位数为 26 [IQR 19, 33]。29% 的患者被列入肝移植名单。90 天死亡率为 61%。51% 的患者至少有过一次 HCRU 发作。代码状态从入院到出院从 91%/7%/0% 变为 68%/14%18%（完整代码/不复苏/舒适措施，p  < 0.001）。28% 的患者接受了护理目标讨论，代码状态在入院后平均 16 [9, 22] 天发生变化。只有 18% 的讨论是在入院后 7 天内进行的，而且全部都是在 HCRU 活动之后进行。被列入肝移植名单与护理讨论目标是否发生无关（列出的 23% vs. 未列出的 31%，p  = 0.24），但与较高的 HCRU 相关（69% vs. 43%；p  < 0.001）。

结论

护理目标讨论发生在医院病程后期、HCRU 发作后。应努力在住院期间尽早参与这些讨论，这可能会降低危重患者的 HCRU 率并与患者的护理目标保持一致。