1
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. Crit Care Med 2024; 52:314-330. [PMID: 38240510 DOI: 10.1097/ccm.0000000000006072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, ON, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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2
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU. Crit Care Med 2024; 52:307-313. [PMID: 38240509 DOI: 10.1097/ccm.0000000000006071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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An Exploratory Investigation into the Roles of Critical Care Response Teams in End-of-Life Care. Crit Care Res Pract 2021; 2021:4937241. [PMID: 34336279 PMCID: PMC8324371 DOI: 10.1155/2021/4937241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 04/29/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Critical Care Response Teams (CCRTs) represent an important interface between end-of-life care (EOLC) and critical care medicine (CCM). The aim of this study was to explore the roles and interactions of CCRTs in the provision of EOLC from the perspective of CCRT members. Methods Twelve registered nurses (RNs) and four respiratory therapists (RTs) took part in focus groups, and one-on-one interviews were conducted with six critical care physicians. Thematic coding using a modified constructivist grounded theory approach was used to identify emerging themes through an iterative process involving a four-member coding team. Results Three main perspectives were identified that spoke to CCRT interactions and perceptions of EOLC encounters. CCRT members felt that they provide a unique skill set of multidisciplinary expertise in treating critically ill patients and evaluating the utility of intensive care treatments. However, despite feeling that they possessed the skills and resources to deliver quality EOLC, CCRT members were ambivalent with respect to whether EOLC was a part of their mandate. Challenges were also identified that impacted the ability of CCRTs to deliver quality EOLC. Conclusions This research aids in understanding for the first time CCRT roles in EOLC from the perspectives of individual CCRT members themselves. While CCRTs provide unique multidisciplinary expertise to evaluate the utility of intensive care treatments, opportunities exist to support CCRTs in EOLC, such as dedicated EOLC training, protocols for advance care planning, documentation, and transitions to palliative care.
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Yang E, Lee H, Lee SM, Kim S, Ryu HG, Lee HJ, Lee J, Oh SY. Effectiveness of a daytime rapid response system in hospitalized surgical ward patients. Acute Crit Care 2020; 35:77-86. [PMID: 32506872 PMCID: PMC7280793 DOI: 10.4266/acc.2019.00661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/15/2020] [Indexed: 11/30/2022] Open
Abstract
Background Clinical deteriorations during hospitalization are often preventable with a rapid response system (RRS). We aimed to investigate the effectiveness of a daytime RRS for surgical hospitalized patients. Methods A retrospective cohort study was conducted in 20 general surgical wards at a 1,779-bed University hospital from August 2013 to July 2017 (August 2013 to July 2015, pre-RRS-period; August 2015 to July 2017, post-RRS-period). The primary outcome was incidence of cardiopulmonary arrest (CPA) when the RRS was operating. The secondary outcomes were the incidence of total and preventable cardiopulmonary arrest, in-hospital mortality, the percentage of “do not resuscitate” orders, and the survival of discharged CPA patients. Results The relative risk (RR) of CPA per 1,000 admissions during RRS operational hours (weekdays from 7 AM to 7 PM) in the post-RRS-period compared to the pre-RRS-period was 0.53 (95% confidence interval [CI], 0.25 to 1.13; P=0.099) and the RR of total CPA regardless of RRS operating hours was 0.76 (95% CI, 0.46 to 1.28; P=0.301). The preventable CPA after RRS implementation was significantly lower than that before RRS implementation (RR, 0.31; 95% CI, 0.11 to 0.88; P=0.028). There were no statistical differences in in-hospital mortality and the survival rate of patients with in-hospital cardiac arrest. Do-not-resuscitate decisions significantly increased during after RRS implementation periods compared to pre-RRS periods (RR, 1.91; 95% CI, 1.40 to 2.59; P<0.001). Conclusions The day-time implementation of the RRS did not significantly reduce the rate of CPA whereas the system effectively reduced the rate of preventable CPA during periods when the system was operating.
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Affiliation(s)
- Eunjin Yang
- College of Nursing, Seoul National University, Seoul, Korea
| | - Hannah Lee
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sulhee Kim
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea
| | - Ho Geol Ryu
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun Joo Lee
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea.,Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jinwoo Lee
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung-Young Oh
- Rapid Response Team, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University Hospital, Seoul, Korea
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5
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Gunasekaran B, Scott C, Ducharlet K, Marco D, Mitchell I, Weil J. Recognising and managing dying patients in the acute hospital setting: can we do better? Intern Med J 2019; 49:119-122. [DOI: 10.1111/imj.14177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/03/2018] [Accepted: 06/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Kathryn Ducharlet
- Department of Nephrology; St Vincent’s Hospital; Victoria Australia
- Department of Medicine; St Vincent’s Hospital; Victoria Australia
| | - David Marco
- Centre for Palliative Care; Victoria Australia
- Melbourne School of Psychological Sciences; The University of Melbourne; Melbourne Victoria Australia
| | - Imogen Mitchell
- Intensive Care Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
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6
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Pearse W, Oprescu F, Endacott J, Goodman S, Hyde M, O'Neill M. Advance care planning in the context of clinical deterioration: a systematic review of the literature. Palliat Care 2019; 12:1178224218823509. [PMID: 30718959 PMCID: PMC6348551 DOI: 10.1177/1178224218823509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 11/16/2022] Open
Abstract
Background: A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of reviews involve a patient approaching the end-of-life. It is not well understood whether patients have pre-existing advance care plans at the time of significant clinical deterioration requiring Rapid Response Team review. Nor is it understood whether such critical events prompt patients, their families and treating teams to discuss advance care planning and consider referral to specialist palliative care services. Aim and design: This systematic review examined advance care planning with patients who experience significant clinical deterioration in hospital and require Rapid Response Team review. The prevalence of pre-existing advance directives, whether this event prompts end-of-life discussions, the provision of broader advance care planning and referral to specialist palliative care services was examined. Data sources: Three electronic databases up to August 2017 were searched, and a manual review of article reference lists conducted. Quality of studies was appraised by the first and fourth authors. Results: Of the 324 articles identified through database searching, 31 met the inclusion criteria, generating data from 47,850 patients. There was a low prevalence of resuscitation orders and formal advance directives prior to Rapid Response Team review, with subsequent increases in resuscitation and limitations of medical treatment orders, but not advance directives. There was high short- and long-term mortality following review, and low rates of palliative care referral. Conclusions: The failure of patients, their families and medical teams to engage in advance care planning may result in inappropriate Rapid Response Team review that is not in line with patient and family priorities and preferences. Earlier engagement in advance care planning may result in improved person-centred care and referral to specialist palliative care services for ongoing management.
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Affiliation(s)
- Wendy Pearse
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia School of Health and Sports Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Florin Oprescu
- School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - John Endacott
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Sarah Goodman
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Mervyn Hyde
- School of Education, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Maureen O'Neill
- School of Law, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
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7
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Carvalho GD, Costa FP, Peruchi JAM, Mazzutti G, Benedetto IG, John JF, Zorzi LA, Prestes MC, Viana MV, Santos MC, Schwarz P, Berto PP, Buttelli TCD, Nedel W, Azeredo-da-Silva ALF, Boniatti MM. The Quality of End-of-Life Care after Limitations of Medical Treatment as Defined by a Rapid Response Team: A Retrospective Cohort Study. J Palliat Med 2018; 22:71-74. [PMID: 30251909 DOI: 10.1089/jpm.2018.0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite the increase in the identification of patients at the end of life after the introduction of rapid response team (RRT), there is doubt as to whether there has been an improvement in the quality of care offered to these patients. Proper end-of-life care is the next expected step after identifying patients who are dying. OBJECTIVE To evaluate the end-of-life care after limitations of medical treatment (LOMTs) as defined by an RRT. DESIGN This is a single-center retrospective cohort study at a tertiary teaching hospital in Porto Alegre, Brazil, from July 2014 to July 2016. SETTING/SUBJECTS We included 242 patients with an LOMT as defined by the RRT. MEASUREMENTS Outcomes of interest included symptoms and palliative measures after RRT review. RESULTS During the study period, there were 5396 calls to 2937 patients, representing 126 calls per 1000 hospital discharges. Of these calls, 4.9% (n = 242) resulted in an LOMT. The primary care team agreed with the LOMT decision proposed by the RRT in 91.7% of cases. Regarding end-of-life symptoms, 7.4% and 5.8% of patients presented with intense or moderate pain, respectively, and 62.4% of patients presented dyspnea in the last 48 hours of hospitalization. Less than 15% of patients received attention for their spiritual needs and/or received psychological support. CONCLUSIONS Our data reinforce the important role of RRTs in the identification of end-of-life patients with clinical deterioration. Despite the increase in the identification of these patients, the quality of end-of-life care needs to be improved.
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Affiliation(s)
- Guilherme D Carvalho
- 1 Department of Internal Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Fernanda P Costa
- 1 Department of Internal Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - João Alberto M Peruchi
- 1 Department of Internal Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Geris Mazzutti
- 1 Department of Internal Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Igor G Benedetto
- 1 Department of Internal Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Josiane F John
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Lia A Zorzi
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Marcius C Prestes
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Marina V Viana
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Moreno C Santos
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Patrícia Schwarz
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Paula P Berto
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Thais C D Buttelli
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | - Wagner Nedel
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
| | | | - Márcio M Boniatti
- 2 Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre , Porto Alegre, Brazil
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8
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The Role of Rapid Response Teams in End-of-Life Care. Jt Comm J Qual Patient Saf 2018; 44:503-504. [DOI: 10.1016/j.jcjq.2018.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Who Benefits from Aggressive Rapid Response System Treatments Near the End of Life? A Retrospective Cohort Study. Jt Comm J Qual Patient Saf 2018; 44:505-513. [PMID: 30166034 DOI: 10.1016/j.jcjq.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/02/2018] [Indexed: 11/23/2022]
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.
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10
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Carmona-Bayonas A, Gordo F, Beato C, Castaño Pérez J, Jiménez-Fonseca P, Virizuela Echaburu J, Garnacho-Montero J. Intensive care in cancer patients in the age of immunotherapy and molecular therapies: Commitment of the SEOM-SEMICYUC. Med Intensiva 2018. [PMID: 29519710 DOI: 10.1016/j.medin.2018.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cancer patients are a vulnerable group exposed to numerous and serious risks beyond cancer itself. In recent years, the prognosis of these individuals has improved substantially thanks to several advances such as immunotherapy, targeted molecular therapies, surgical techniques, or developments in support treatment. This coincides with the prolonged survival of oncological patients admitted to the ICU due to critical complications, and under the supervision of intensivists. The time has therefore come to revisit the intensive care support of these patients, which poses new professional as well as organizational challenges. An agreement was signed in 2017 between the SEOM and SEMICYUC with the aim of improving the quality of care of cancer patients with critical complications. The initiative seeks to aid in decision-making, standardize criteria, decrease subjectivity, generate channels of communication, and delve deeper into the ethical and scientific aspects of these situations. This document sets forth the most important reasons that have led us to undertake this initiative.
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Affiliation(s)
- A Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), UMU, Murcia, Spain
| | - F Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares (Coslada-Madrid), Grupo de investigación en patología crítica, Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - C Beato
- Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - J Castaño Pérez
- Intensive Care Department, Virgen de las Nieves University Hospital, Granada, Spain
| | - P Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J Virizuela Echaburu
- Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - J Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain.
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11
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Williams M, Cardona-Morrell M, Stevens P, Bey J, Smith Glasgow M. Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital. Int J Nurs Stud 2017; 75:147-153. [DOI: 10.1016/j.ijnurstu.2017.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 01/13/2023]
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12
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Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study. Pediatr Crit Care Med 2017; 18:571-579. [PMID: 28445242 DOI: 10.1097/pcc.0000000000001164] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. DESIGN Retrospective cohort study. SETTING Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS Cohort of 42,308 pediatric admissions to the general inpatient ward. INTERVENTIONS Data over 7 years were obtained from a prospectively maintained rapid response systems database. MEASUREMENTS AND MAIN RESULTS From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. CONCLUSIONS Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.
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Shimabukuro-Vornhagen A, Böll B, Kochanek M, Azoulay É, von Bergwelt-Baildon MS. Critical care of patients with cancer. CA Cancer J Clin 2016; 66:496-517. [PMID: 27348695 DOI: 10.3322/caac.21351] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Consultant, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Head of Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Éli Azoulay
- Director, Medical Intensive Care Unit, St. Louis Hospital, Paris, France
- Professor of Medicine, Teaching and Research Unit, Department of Medicine, Paris Diderot University, Paris, France
- Chair, Study Group for Respiratory Intensive Care in Malignancies, St. Louis Hospital, Paris, France
| | - Michael S von Bergwelt-Baildon
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Professor, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
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White K, Scott IA, Vaux A, Sullivan CM. Rapid response teams in adult hospitals: time for another look? Intern Med J 2016; 45:1211-20. [PMID: 26122775 DOI: 10.1111/imj.12845] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 06/23/2015] [Indexed: 11/28/2022]
Abstract
Rapid response teams (RRT), alternatively termed medical emergency teams, have become part of the clinical landscape in the majority of adult hospitals throughout Australia and New Zealand. These teams aim to bring critical care expertise to the bedside of clinically deteriorating patients residing in general hospital wards with the aim of preventing adverse outcomes, in particular death or cardiorespiratory arrests. While the concept of RRT has considerable face validity, there is little high quality evidence of their effectiveness and much uncertainty as to the optimal methods for identifying patients in need of RRT and calling the RRT (afferent limb) and how, and with whom, the RRT should then respond (efferent limb). Adverse unintended consequences of RRT systems and the opportunity costs involved in maintaining such systems have not been subject to study, amid concerns RRT may be compensating for other potentially remediable system of care failures. This article presents an overview of the current state of play of RRT in hospital practice as they pertain to the care of adult patients and identifies several issues around their implementation and evaluation that should be subject to further research.
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Affiliation(s)
- K White
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - I A Scott
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - A Vaux
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - C M Sullivan
- Division of Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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15
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Ramos JGR, Teles Correa MD, de Carvalho RT, Jones D, Forte DN. Clinical significance of palliative care assessment in patients referred for urgent intensive care unit admission: A cohort study. J Crit Care 2016; 37:24-29. [PMID: 27610588 DOI: 10.1016/j.jcrc.2016.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 08/05/2016] [Accepted: 08/15/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate clinical characteristics of patients with palliative care (PC) and urgent intensive care unit (ICU) referrals in the same hospital admission. METHODS All urgent ICU referrals at an academic, tertiary hospital, and the co-occurrence and timing of PC assessment were retrieved from a prospectively collected database. RESULTS From May 2014 to May 2015, 2476 patients were analyzed and 179 (7%) had co-occurrence of PC assessment and urgent ICU referral in the same hospital admission. Hospital mortality was higher (odds ratio, 8.3; 95% confidence interval, 5.4-12.7) and ICU admission was lower (odds ratio, 0.54; 95% confidence interval, 0.40-0.74) in patients with PC assessment, compared with patients without concurrent PC and ICU referrals. Variables associated with PC assessment were older age, diagnosis of cancer, depressed level of consciousness, nonsurgical admission, lower performance status, physician's subjective prognosis of poor outcome, and length of hospitalization before ICU referral. CONCLUSION In this cohort of patients with urgent ICU referral, clinical characteristics at the moment of ICU referral were associated with co-occurrence of PC assessment in the same hospital admission. These characteristics might guide the development of instruments to enhance early referral of high-risk patients to PC services.
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Affiliation(s)
- Joao Gabriel Rosa Ramos
- Medical Sciences PhD Program, University of Sao Paulo Medical School, Sao Paulo, Brazil; Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil; UNIME Medical School, Lauro de Freitas, Brazil.
| | - Mario Diego Teles Correa
- Medical Sciences PhD Program, University of Sao Paulo Medical School, Sao Paulo, Brazil; Intensive Care Unit, Hospital Sao Camilo, iMED group, Sao Paulo, Brazil.
| | | | - Daryl Jones
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Austin Health, Melbourne, Australia.
| | - Daniel Neves Forte
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil; Palliative Care Team, Hospital Sirio-Libanes, Sao Paulo, Brazil.
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"Must do CPR??": strategies to cope with the new College of Physicians and Surgeons of Ontario policy on end-of-life care. Can J Anaesth 2016; 63:973-80. [PMID: 27126679 DOI: 10.1007/s12630-016-0665-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/23/2016] [Accepted: 04/20/2016] [Indexed: 10/21/2022] Open
Abstract
The College of Physicians and Surgeons of Ontario recently released a new policy, Planning for and Providing Quality End-of-Life Care. The revised policy is more accurate in its consideration of the legal framework in which physicians practice and more reflective of ethical issues that arise in end-of-life (EOL) care. It also recognizes valid instances for not offering cardiopulmonary resuscitation (CPR). Nevertheless, the policy poses a significant ethical and legal dilemma-i.e., if disputes over EOL care arise, then physicians must provide CPR even when resuscitation would fall outside this medical standard of care. While the policy applies in Ontario, it is likely to influence other physician colleges across Canada as they review their standards of practice. This paper explores the rationale for the mandated CPR, clarifies the policy's impact on the medical standard of care, and discusses strategies to improve EOL care within the policy. These strategies include understanding the help-hurt line, changing the language used when discussing cardiac arrest, clarifying care plans during the perioperative period, engaging the intensive care unit team early in goals-of-care discussions, mentoring hospital staff to improve skills in goals-of-care discussions, avoiding use of the "slow code", and continuing to advocate for quality EOL care and a more responsive legal adjudication process.
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