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Jt Comm J Qual Patient Saf. 2018 Sep;44(9):505-513. doi: 10.1016/j.jcjq.2018.04.001. Epub 2018 Jun 27.

Who Benefits from Aggressive Rapid Response System Treatments Near the End of Life? A Retrospective Cohort Study.

Author information

1
The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Sydney. Electronic address: magnolia.cardona@unsw.edu.au.
2
Biostatistics, Dean's Office Dunedin School of Medicine, University of Otago, Dunedin, New Zealand and formerly Senior Lecturer, Epidemiology, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia; Liverpool Hospital, Liverpool, Australia.
3
Liverpool Hospital, Liverpool, Australia.
4
Emergency Care Institute, Agency for Clinical Innovation, Chatswood, Australia.
5
The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Sydney.
6
The George Institute for Global Health, The University of New South Wales, Newtown, Australia.
7
ICU, Liverpool Hospital, Liverpool, Australia.
8
ICU, Liverpool Hospital, Liverpool, Australia; Associate Professor, Intensive Care, The University of Western Sydney, Australia.
9
The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia; ICU, Liverpool Hospital, South Western Sydney, and Foundation Director, The Simpson Centre for Health Services Research University of New South Wales, Liverpool, Australia.

Abstract

BACKGROUND:

Many patients near the end of life are subject to rapid response system (RRS) calls. A study was conducted in a large Sydney teaching hospital to identify a cutoff point that defines nonbeneficial treatment for older hospital patients receiving an RRS call, describe interventions administered, and measure the cost of hospitalization.

METHODS:

This was a retrospective cohort of 733 adult inpatients with data for the period three months before and after their last placed RRS call. Subgroup analysis of patients aged ≥ 80 years was conducted. Log-rank, chi-square, and t-tests were used to compare survival, and logistic regression was used to examine predictors of death.

RESULTS:

Overall, 65 (8.9%) patients had a preexisting not-for-resuscitation (NFR) or not-for-RRS order; none of those patients survived to three months. By contrast, patients without an NFR or not-for-RRS order had three-month survival probability of 71% (log-rank χ2 145.63; p < 0.001). Compared with survivors, RRS recipients who died were more likely to be older, to be admitted to a medical ward, and to have a larger mean number of admissions before the RRS. The average cost of hospitalization for the very old transferred to the ICU was higher than for those not requiring treatment in the ICU (US$33,990 vs. US$14,774; p = 0.045).

CONCLUSION:

Identifiable risk factors clearly associated with poor clinical outcomes and death can be used as a guide to administer less aggressive treatments, including reconsideration of ICU transfers, adherence to NFR orders, and transition to end-of-life management instead of calls to the RRS team.

PMID:
30166034
DOI:
10.1016/j.jcjq.2018.04.001

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