Achieving Goal-Concordant Care With Goals of Care Consultations in the Emergency Department

IntroductionTime constraints may be prohibitive to adequate goals of care (GOC) discussions and could delay critical decision making in urgent or emergent situations. Foregoing these discussions could misalign GOC with the medical care plan, including admission level of care, diagnostics or therapeutics. This team wanted to determine if there was improvement in length of stay, intensive care utilization (ICU), or cost in assuring the discussion upon admission.MethodsA retrospective record review was conducted for patients 65 and older at a single community hospital between January and December 2023. Included patients had at least one GOC documented discussion with a nursing team called Advanced Illness Management (AIM) and were admitted or placed in observation.Results3377 patients met the inclusion criteria. When AIM was initiated in ED (AIM ED), the median LOS was 3 days shorter as compared to those patients having AIM GOC consultation initiated past 24 hours (AIM IP) (AIM ED = 3 vs AIM IP = 6, <i>P</i> < 0.001). Of patients requiring intensive care, the median ICU hours were significantly less in the early AIM consult group (AIM ED = 18.5 vs AIM IP = 40, <i>P</i> < 0.001). The median direct cost of care was significantly less for the ED consult group (AIM ED $8470 vs AIM IP $15,406, <i>P</i> < 0.0001).ConclusionsThere were positive findings in LOS, ICU, and cost with AIM consultation within 24 hours of presenting to the ED, when compared to waiting for a later consultation, supporting consideration of forward-placement of GOC discussion.