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Int J Nurs Stud. 2017 Oct;75:147-153. doi: 10.1016/j.ijnurstu.2017.07.017. Epub 2017 Aug 8.

Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital.

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School of Nursing, Lansing Community College & Sparrow Hospital , Lansing, USA. Electronic address:
The Simpson Centre for Health Services Research and Ingham Institute for Applied Medical Research, The University of New South Wales, Sydney, Australia.
Sparrow Hospital, Lansing, USA.
School of Nursing, Duquesne University, Pittsburgh, USA.



Research indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients' CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective.


A retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison.


A sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S.


Ninety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR=1.43, 95%CI 1.08-1.89, p=0.012), being a male (OR=3.14; 95%CI 1.40-7.05, p=0.006), and the presence of two or more comorbidities (OR=3.71, 95%CI 1.67-8.24, p=0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation.


A positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.


End-of-life care; Inpatients; Palliative care; Rapid response team; Referral and consultation; Risk assessment

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