Influencia del Plan Integral de Cuidados Paliativos de la Comunidad de Madrid en la actividad de una unidad de cuidados paliativos hospitalaria

Aims: to investigate the possible changes occurring in the medical activity of a Palliative Care Unit (PCU) after the establismente of the Integrated Plan of Palliative Care of the Autonomous Community of Madrid (IPPC). Method: ambispective study of a cohort of palliative patients admitted to a PCU from 02/01/2002 to 11/30/2009 before (preESAD) and after (postESAD) the establishment of the IPPC. Two mutually exclusive groups of patients were made taking as a cutting point the admission date of 02/05/2007, when the team of palliative care home support ― ESAD, the firs initiative of the IPPC, begun working in our area. Our hospital is a second level centre, caring for 200.000 people. All patients meeting palliative criteria who had been evaluated by the PCU were include in the study. Results: A total of 1,562 patients were included with 3,409 admittances (either in the PCU or in other medical and surgical departments): 1,652 (48,4%) in the postESAD period (they had less emergencies admittances [p 0.108]). Re-admittances reach 27.3% in both periods; in the postESAD period re-admittances to the UCP and medical units were higher and decreased in the surgical units and in Internal Medicine beds (p 0.001). The UCP received 2.193 (96.6%) admittances and 77 (3,4%) as consultant for other units. The motives for this later task were: care organization 37 (48.1%) and symptom control 33 (42.9%); 49.4% of these patients were derived to the ESAD and 10.4% to intermediate stay centres. Of the admittances to the PCU 1,133 (51.7%) were in the preESAD period and 1,060 (48.3%) postESAD. Male sex was predominant in both periods (65.4% pre and 60.3% post; p 0.178 adjusted for the main disease); mean age was 68,7 (DE 13,6) preESAD vs. 69,39 (DE 12,01) postESAD (p 0,458). The main disease was oncological: 754 (92,3%) preESAD vs. 634 (93,4%) postESAD (p 0,420). In the postESAD period, 236 patients (34,7%) were derived to ESAD ― only 4 of them were being actively followed. No differences were found between periods concerning the type of admittance (p 0,752). The number of re-admittances was 696 (32%), 316 (27%) preESAD vs. 380 (35,8%) postESAD (p 0,922 adjusted by ESAD, main pathology and type of admittance). The risk of re-admittance if the patient had been derived to ESAD, even if he was not on active follow up, was 2,3 times higher (IC 95% 1,9-2,9). Median stay was 7 days (p25-75: 4-11) preESAD vs. 6 (p25-75: 3-10), (p 0,155) postESAD. Home discharge did not increase in the postESAD period (p 0,838) although discharges were made to intermediate stay centres (0,000). The number of deaths were 1.433 (91,7%): 763 (53,2%) preESAD vs. 670 (46,7%) postESAD (0,000) with an increase in the number of at home deaths (p 0,000) and at intermediate stay cen- tres (0,001) and a decrease in the number of deaths at the PCU. Conclusions: the establishment of ESAD improves continuity in the care of patients meeting terminal disease criteria as well as coordination between different levels of healthcare. Transfers to intermediate stay care centers increased as well as deaths at home. Median stay at the PCU decreased with the new workforce and the establishment of the ESH (Hospital Support Team) by the PICPCM.