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Borges GBFL, Dias CB. Evaluating the Utility of the Surprise Question Among General Physicians for Appropriate Palliative Care Indication in Brazil. Palliat Med Rep 2024; 5:261-268. [PMID: 39044763 PMCID: PMC11262583 DOI: 10.1089/pmr.2024.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 07/25/2024] Open
Abstract
Objectives This study aimed to assess the agreement between established tools, such as the Palliative Performance Scale (PPS) and Brazilian version of the Supportive and Palliative Care Indicators Tool (SPICT-BR), and the subjective assessment of palliative care (PC) need using the Surprise Question (SQ) administered by resident physicians. This assessment was conducted among hospitalized patients, with and without cancer, to determine the efficacy of these tools in indicating the need for PC. Methods A six-month cross-sectional study in 2019 of medical records of patients hospitalized in a single center in IAMSPE-Brazil. The SPICT-BR and PPS were applied to the medical record data, and the SQ was posed to each resident physician. Comparisons for categorical data were made using the chi-square test, with p < 0.05 considered statistically significant. Results Of 203 patients evaluated, 57.6% were male and 81.2% were older adults (≥60 years). The mean age was 67.40 ± 9.72 years. Chronic disease was nonneoplastic in 78.32% of patients, and 56.65% had not been hospitalized in the preceding year. The PPS score was <70% in 69.4% of patients, and 51.2% met at least one SPICT-BR criterion. Among patients with cancer, 40.9% had over two positive SPICT-BR criteria; 97.5% of these patients received NO responses to SQ by residents (p < 0.0001). Similarly, 90.6% of patients with one SPICT-BR criterion received NO responses to SQ, with no significant difference between groups. Conclusion The SQ proved to be a valuable tool for PC indication, particularly when administered by untrained professionals. Consistent with SPICT-BR findings, our study highlights the SQ's role in facilitating early identification of patients in need of PC.
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Chauhan HA, Adat R, Garofide H, Bhandari M, Viramuthu S. Quality improvement: treatment escalation plans in oncology. BMJ Open Qual 2024; 13:e002625. [PMID: 38637021 PMCID: PMC11029376 DOI: 10.1136/bmjoq-2023-002625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/09/2024] [Indexed: 04/20/2024] Open
Abstract
Treatment escalation plans (TEPs) are increasingly appreciated tools in modern hospital medicine. It records and advises on the appropriate escalation of care for our patients, often when those of us who know them best are not available. It is of value in all specialties, though notably in oncology where an oncologist would be best placed at advising on the care of their patients.A baseline study in September 2021 found only 22% of patients admitted under oncology at Northampton General Hospital had TEP forms completed within 72 hours of admission. This quality improvement project aimed to significantly and sustainably improve this. Education and increasing the understanding of the medical and nursing teams about the importance of timely TEP form completion was essential. We also made TEPs a part of every multidisciplinary team discussion regarding a patient. Though, most significantly was the recognition that one of the responsibilities of the admitting registrar was to fill out a TEP form once the decision to admit had been made. Our ensuing study found an increase in our completion rate to 83% in February 2022.A fall in performance after introduction of new medical staff was swiftly remedied by re-education and encouragement to join daily board rounds. We sustained and improved the team's rate of TEP completion, within 72 hours of admission, to 80% in February 2023 and 91% in May 2023.
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Affiliation(s)
- Hiten Arun Chauhan
- Oncology Department, Northampton General Hospital NHS Trust, Northampton, UK
| | - Rehaan Adat
- Oncology Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Harieta Garofide
- Oncology Department, Northampton General Hospital NHS Trust, Northampton, UK
| | - Monica Bhandari
- Oncology Department, Northampton General Hospital NHS Trust, Northampton, UK
| | - Sivalekha Viramuthu
- Oncology Department, Northampton General Hospital NHS Trust, Northampton, UK
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Paulik O, Whitaker R, Mesuria M, Wong D, Swanson K, Green H, Sikhosana N, Fernandez R. Implementation and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT™) in acute care. Australas J Ageing 2024. [PMID: 38558296 DOI: 10.1111/ajag.13308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/18/2024] [Accepted: 03/03/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The Supportive and Palliative Care Indicators Tool (SPICT™) has been used to identify patients at risk of deteriorating and dying within 1 year. Early identification and integration of advance care planning (ACP) provides the opportunity for a better quality of life for patients. The aims of this study were to identify the number of patients who were SPICT™ positive; their mortality rates at 6 and 12 months of the SPICT™ assessment; and level of adherence to ACP documentation. METHODS A retrospective audit of the Supportive and Palliative Care database was conducted at an acute aged care precinct in a major metropolitan tertiary referral hospital in New South Wales, Australia. Data comprising demographics, clinical conditions, SPICT™ positivity and compliance with ACP documentation were collected. SPICT™-positive patients and mortality were tracked at 6 and 12 months, respectively. RESULTS Data from 153 patients were collected. The mean age of the patients was 84.1 (±7.8) years, and the length of hospital stay was 10 (±24.7) (range 1-269) days. Approximately 37% were from residential care, and 80% had family deciding on their care. About 15% died during hospitalisation, and 48% were discharged to a care facility. The ACP documentation showed various levels of completion. Mortality rates at 6 and 12 months were 36% and 39%, respectively. Most patients (99%) were SPICT™-positive, with indicators correlating with higher mortality rates at both follow-ups. CONCLUSIONS The study emphasises the critical need for addressing ACP and palliative care among older patients with life-limiting conditions. It underscores the importance of timely discussions, documentation, and cessation of futile interventions.
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Affiliation(s)
- Olivia Paulik
- St George Hospital, Sydney, New South Wales, Australia
| | | | | | - Debbie Wong
- St George Hospital, Sydney, New South Wales, Australia
| | - Katie Swanson
- St George Hospital, Sydney, New South Wales, Australia
| | - Heidi Green
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Nqobile Sikhosana
- School of Nursing and Midwifery, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ritin Fernandez
- School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia
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Bouri M, Sakellari E, Krentiris D, Lagiou A. Palliative Care in the Community: The Greek Version of the Supportive and Palliative Care Indicators Tool (SPICT™). J Prim Care Community Health 2024; 15:21501319241245842. [PMID: 38605629 PMCID: PMC11010743 DOI: 10.1177/21501319241245842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION/OBJECTIVES Systematic identification of persons with palliative care needs constitutes a major challenge for promoting palliative care in all levels of the health system, including primary care. The aim of this study was to translate, cross-culturally adapt, and content validate Supportive and Palliative Care Indicators Tool (SPICT) for use in the Greek primary care context. Secondary objectives were to probe the use of SPICT-GR in exemplary case vignettes, to discuss the clarity and comprehensibility of its content as well as the appropriateness, acceptability, and feasibility of the tool within the Greek primary care. METHODS The Greek translation and cross-cultural adaptation of SPICT™ followed World Health Organization recommendations for translation and adaptation of instruments. For this purpose a working group was set up consisting of 2 senior researchers, a primary care professional with postgraduate training in Palliative Medicine and a general practitioner (GP) with special interest in primary palliative care. Three focus groups comprised of health professionals (n = 23) working in primary care settings participated in the pilot testing phase. Participants also completed a questionnaire including rating their perceptions on tool's utility and feasibility as well as on the clarity and relevance of its items. Thematic analysis was used for focus groups discussions on how the tool was perceived and interpreted by health professionals in a Greek healthcare context and descriptive statistics for the quantitative analysis of the questionnaire data. RESULTS The majority assessed the tool as useful (65%), considered its implementation in primary care as feasible (91%) and rated its items as "relevant" or "very relevant" and "clear" or "very clear." Three themes emerged from focus groups discussions: Guiding clinical practice and facilitating collaboration; promoting comprehensive care and awareness for palliative care; applicability in and suitability for primary care. CONCLUSIONS SPICT-GR™ was identified as a practical and applicable tool for primary care, a source of guidance for the comprehensive identification of patients' palliative care needs, promoting awareness on palliative care and facilitating a shared language among health care professionals.
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Affiliation(s)
| | | | - Dimitrios Krentiris
- Health Center of Salamina, 2nd Regional Health Authority of Piraeus and the Aegean, Greece
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Piasecki RJ, Himmelfarb CRD, Gleason KT, Justice RM, Hunt EA. The associations between rapid response systems and their components with patient outcomes: A scoping review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2023; 5:100134. [PMID: 38125770 PMCID: PMC10732356 DOI: 10.1016/j.ijnsa.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background While rapid response systems have been widely implemented, their impact on patient outcomes remains unclear. Further understanding of their components-including medical emergency team triggers, medical emergency team member composition, additional roles in patient care beyond responding to medical emergency team events, and their involvement in "Do-Not-Resuscitate" order placement-may elucidate the relationship between rapid response systems and outcomes. Objective To explore how recent studies have examined rapid response system components in the context of relevant adverse patient outcomes, such as in-hospital cardiac arrests and hospital mortality. Design Scoping review. Methods PubMed, CINAHL, and Embase were searched for articles published between November 2014 and June 2022. Studies mainly focused on rapid response systems and associations with in-hospital cardiac arrests were considered. The following were extracted for analysis: study design, location, sample size, participant characteristics, system characteristics (including medical emergency team member composition, additional system roles outside of medical emergency team events), medical emergency team triggers, in-hospital cardiac arrests, and hospital mortality. Results Thirty-four studies met inclusion criteria. While most studies described triggers used, few analyzed medical emergency team trigger associations with outcomes. Of those, medical emergency team triggers relating to respiratory abnormalities and use of multiple triggers to activate the medical emergency team were associated with adverse patient outcomes. Many studies described medical emergency team member composition, but the way composition was reported varied across studies. Of the seven studies with dedicated medical emergency team members, six found their systems were associated with decreased incidence of in-hospital cardiac arrests. Six of seven studies that described additional medical emergency team roles in educating staff in rapid response system use found their systems were associated with significant decreases in adverse patient outcomes. Four of five studies that described proactive rounding responsibilities reported found their systems were associated with significant decreases in adverse patient outcomes. Reporting of rapid response system involvement in "Do-Not-Resuscitate" order placement was variable across studies. Conclusions Inconsistencies in describing rapid response system components and related data and outcomes highlights how these systems are complex to a degree not fully captured in existing literature. Further large-scale examination of these components across institutions is warranted. Development and use of robust and standardized metrics to track data related to rapid response system components and related outcomes are needed to optimize these systems and improve patient outcomes.
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Affiliation(s)
- Rebecca J. Piasecki
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Kelly T. Gleason
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Elizabeth A. Hunt
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
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Brean SJ, Recoche K, William L, Lakhani A, Zhong Y, Shimoinaba K. Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis. BMJ Support Palliat Care 2023:spcare-2023-004162. [PMID: 37380215 DOI: 10.1136/spcare-2023-004162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/08/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Evidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines or frameworks that have been used to support ACP interventions with vulnerable and disadvantaged adult populations as well as their experiences and outcomes with them. The findings will inform practice in ACP programmes. METHODS A systematic search of six databases from 1 January 2010 to 30 March 2022 was conducted to identify original peer-reviewed research that used ACP interventions via tools, guidelines or frameworks with vulnerable and disadvantaged adult populations and reported qualitative findings. A narrative synthesis was conducted. RESULTS Eighteen studies met the inclusion criteria. Relatives, caregivers or substitute decision-makers were included in eight studies. SETTINGS hospital outpatient clinics (N=7), community settings (N=7), nursing homes (N=2), prison (N=1) and hospital (N=1). A variety of ACP tools, guidelines or frameworks were identified; however, the facilitator's skills and approach in delivering the intervention appeared to be as important as the intervention itself. Participants indicated mixed experiences, some positive, some negative and four themes emerged: uncertainty, trust, culture and decision-making behaviour. The most common descriptors relating to these themes were prognosis uncertainty, poor end-of-life communication and the importance of building trust. CONCLUSION The findings indicate that ACP communication could be improved. ACP conversations should incorporate a holistic and personalised approach to optimise efficacy. Facilitators should be equipped with the necessary skills, tools and information needed to assist ACP decision-making.
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Affiliation(s)
- Samantha Jane Brean
- Advance Care Planning, Eastern Health, Wantirna, Victoria, Australia
- Monash University, School of Nursing and Midwifery Peninsula Campus, Frankston, Victoria, Australia
| | - Katrina Recoche
- Monash University, School of Nursing and Midwifery Peninsula Campus, Frankston, Victoria, Australia
| | - Leeroy William
- Supportive and Palliative Care Service, Eastern Health, Wantirna, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Ali Lakhani
- La Trobe University, School of Psychology and Public Health, Melbourne, Victoria, Australia
| | - Yaping Zhong
- Monash University, School of Nursing and Midwifery Peninsula Campus, Frankston, Victoria, Australia
| | - Kaori Shimoinaba
- Monash University, School of Nursing and Midwifery Peninsula Campus, Frankston, Victoria, Australia
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van Baal K, Wiese B, Müller-Mundt G, Stiel S, Schneider N, Afshar K. Quality of end-of-life care in general practice - a pre-post comparison of a two-tiered intervention. BMC PRIMARY CARE 2022; 23:90. [PMID: 35443614 PMCID: PMC9022313 DOI: 10.1186/s12875-022-01689-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/04/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND General practitioners (GPs) play a crucial role in the provision of end-of-life care (EoLC). The present study aimed at comparing the quality of GPs' EoLC before and after an intervention involving a clinical decision aid and a public campaign. METHODS The study was part of the larger interventional study 'Optimal care at the end of life' (OPAL) (Innovation Fund, Grant No. 01VSF17028). The intervention lasted 12 months and comprised two components: (1) implementation of the Supportive and Palliative Care Indicators Tool (SPICT-DE™) in general practice and (2) a public campaign in two German counties to inform and connect regional health care providers and stakeholders in EoLC. Participating GPs completed the General Practice End of Life Care Index (GP-EoLC-I) pre- (t0) and post- (t1) intervention. The GP-EoLC-I (25 items, score range: 14-40) is a self-assessment questionnaire that measures the quality of GPs' EoLC. It includes two subscales: practice organisation and clinical practice. Data were analysed descriptively, and a paired t-test was applied for the pre-post comparison. RESULTS Forty-five GPs (female: 29%, median age: 57 years) from 33 general practices participated in the intervention and took part in the survey at both times of measurement (t0 and t1). The mean GP-EoLC-I score (t0 = 27.9; t1 = 29.8) increased significantly by 1.9 points between t0 and t1 (t(44) = - 3.0; p = 0.005). Scores on the practice organisation subscale (t0 = 6.9; t1 = 7.6) remained almost similar (t(44) = -2.0; p = 0.057), whereas those of the clinical practice subscale (t0 = 21.0; t1 = 22.2) changed significantly between t0 and t1 (t(44) = -2.6; p = 0.011). In particular, items regarding the record of care plans, patients' preferred place of care at the end of life and patients' preferred place of death, as well as the routine documentation of impending death, changed positively. CONCLUSIONS GPs' self-assessed quality of EoLC seemed to improve after a regional intervention that involved both the implementation of the SPICT-DE™ in daily practice and a public campaign. In particular, improvement related to the domains of care planning and documentation. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register ( DRKS00015108 ; 22/01/2019).
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Affiliation(s)
- Katharina van Baal
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Gabriele Müller-Mundt
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Nils Schneider
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Kambiz Afshar
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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Won YH, Kang J. Development of a comprehensive model for the role of the rapid response team nurse. Intensive Crit Care Nurs 2021; 68:103136. [PMID: 34736834 DOI: 10.1016/j.iccn.2021.103136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/28/2021] [Accepted: 08/17/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To develop a comprehensive model of the role of the rapid response team nurse. DESIGN Using an experience-based co-design approach, qualitative data concerning the categories and components of the role of the rapid response team nurse were generated via workshops and one-on-one interviews with service users and providers. The appropriateness of the comprehensive model was evaluated through an online survey. SETTING Forty-six tertiary hospitals across South Korea. A total of 114 rapid response team service providers and users were recruited using convenience sampling. FINDINGS The comprehensive model included the requirements, facilitating factors, barriers, and outcomes as well as the roles and tasks of rapid response team nurses. The key roles in the final model were found to be: 1) Screening of patients with acute exacerbation, 2) Professional support for emergencies, 3) Education for service users, 4) Consultation for high-risk patient care, 5) Support for patient and family decision-making, 6) Coordination between departments, and 7) Management of the rapid response team. These roles contain 57 specific tasks. Rapid response team professionals finalised the model by evaluating the appropriateness of its components. CONCLUSION An experience-based co-design approach was used to develop a comprehensive model that reflects the insights and needs of rapid response team service users and providers. We recommend that the model be validated and supplemented by data from different institutions and countries.
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Affiliation(s)
- Youn-Hui Won
- Rapid Response Team, Dong-A University Medical Center, Busan, South Korea
| | - Jiyeon Kang
- College of Nursing, Dong-A University, Busan, South Korea.
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Batterbury A, Douglas C, Coyer F. The illness severity of patients reviewed by the medical emergency team: A scoping review. Aust Crit Care 2021; 34:496-509. [PMID: 33509705 DOI: 10.1016/j.aucc.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Medical emergency teams (METs) are internationally used to manage hospitalised deteriorating patients. Although triggers for MET review and hospital outcomes have previously been widely reported, the illness severity at the point of MET review has not been reported. As such, levels of clinical acuity and patient dependency representing the risk of exposure to short-term adverse clinical outcomes remain largely unknown. OBJECTIVE This scoping review sought to understand the illness severity of MET review recipients in terms of acuity and dependency. METHODS This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The published and grey literature since 2009 was searched to identify relevant articles reporting illness severity scores associated with hospitalised adult inpatients reviewed by a MET. After applying the inclusion and exclusion criteria, 17 articles (16 quantitative studies, one mixed-methods study) were reviewed, summarised, collated, and reported. RESULTS A total of 17 studies reported clinical acuity metrics for patients reviewed by a MET. No studies described an integrated risk score encompassing acuity, patient dependency, or wider parameters that might be associated with increased patient risk or the need for intervention. Multi-MET review, the use of specialist interventions, and delayed/transfer to the intensive care unit were associated with a greater risk of clinical deterioration, higher clinical acuity score, and predicted mortality risk. A single dependency metric was not reported although organisational levels of care, the duration of MET review, MET interventions, chronic illness, and frailty were inferred proxy measures. CONCLUSION Of the 17 studies reviewed, no single study provided an integrated assessment of illness severity from which to stratify risk or support patient management processes. Patients reviewed by a MET have variable and rapidly changing health needs that make them particularly vulnerable. The lack of high-quality data reporting acuity and dependency limits our understanding of true clinical risk and subsequent opportunities for pathway development.
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Affiliation(s)
- Anthony Batterbury
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia; School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
| | - Clint Douglas
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia; Metro North Hospital and Health Service, Herston, QLD, 4029, Australia.
| | - Fiona Coyer
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia; School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
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Hogan H, Hutchings A, Wulff J, Carver C, Holdsworth E, Nolan J, Welch J, Harrison D, Black N. Type of Track and Trigger system and incidence of in-hospital cardiac arrest: an observational registry-based study. BMC Health Serv Res 2020; 20:885. [PMID: 32948171 PMCID: PMC7501601 DOI: 10.1186/s12913-020-05721-5] [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: 03/27/2020] [Accepted: 09/08/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team. METHODS TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates. RESULTS The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival. CONCLUSIONS The introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system.
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Affiliation(s)
- Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Jerome Wulff
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Catherine Carver
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Elizabeth Holdsworth
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Jerry Nolan
- Royal United Hospital Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK
| | - John Welch
- Critical Care Outreach, University College London Hospitals NHS Foundation Trust, 235 Euston Rd, Fitzrovia, London, NW1 2BU, UK
| | - David Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Jennerich AL, Hobler MR, Sharma RK, Engelberg RA, Curtis JR. Unplanned Admission to the ICU: A Qualitative Study Examining Family Member Experiences. Chest 2020; 158:1482-1489. [PMID: 32502593 DOI: 10.1016/j.chest.2020.05.554] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/30/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Transfers to the ICU from acute care are common, and it is essential to understand how family members of critically ill patients experience these transitions of care. RESEARCH QUESTION Can we enhance our understanding of family members' experiences during hospital stays complicated by a patient's unplanned admission to the ICU? STUDY DESIGN AND METHODS Qualitative interviews were conducted with family members of patients were transferred from acute care to the ICU at a level I trauma center in Seattle, WA (n = 17). To organize data, we used thematic analysis, coupled with a validated conceptual model of clinician-surrogate communication. RESULTS Drawing from a validated conceptual model, we used two domains to frame our coding: "information processing" and "relationship building." Within information processing, we coded information disclosure, sensemaking, and expectations; within relationship building, we coded emotional support, trust, and consensus and conflict. Family members wanted timely, accurate information about the patient's condition both during and after transfer. An unplanned ICU admission was a stressful event for family members, who looked to clinicians for emotional support. Developing trust was challenging, because family members struggled to feel like integrated members of the medical team when patients transitioned from one setting to another. INTERPRETATION Family of patients who experience an unplanned ICU admission want high-quality communication both during and after a patient's transfer to the ICU. This communication should help family members make sense of the situation, address unmet expectations, and provide emotional support. In addition, interventions that foster family-clinician trust can help family members feel like integrated members of the care team as they face the challenge of navigating multiple different environments within the hospital.
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Affiliation(s)
- Ann L Jennerich
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
| | - Mara R Hobler
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Ruth A Engelberg
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - J Randall Curtis
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
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12
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Kim JS, Lee MJ, Park MH, Park JY, Kim AJ. Role of the Rapid Response System in End-of-Life Care Decisions. Am J Hosp Palliat Care 2020; 37:943-949. [PMID: 32452209 DOI: 10.1177/1049909120927372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE An important role of the rapid response system (RRS) is to provide opportunities for end-of-life care (EOLC) decisions to be appropriately operationalized. We investigated whether EOLC decisions were made after the RRS-recommended EOLC decision to the primary physician. MATERIALS AND METHODS We studied whether patients made EOLC decisions consistent with the rapid response team's (RRT) recommendations, between January 1, 2017, and February 28, 2019. The primary outcome was the EOLC decision after the RRT's recommendation to the primary physician. The secondary outcome was the mechanism of EOLC decision-making: through institutional do-not-resuscitate forms or the Korean legal forms of Life-Sustaining Treatment Plan (LSTP). RESULTS Korean LSTPs were used in 26 of the 58 patients who selected EOLC, from among the 75 patients for whom the RRS made an EOLC recommendation. Approximately 7.2% of EOLC decisions for inpatients were related to the RRT's interventions in EOLC decisions. Patients who made EOLC decisions did not receive cardiopulmonary resuscitation, mechanical ventilation, or dialysis. CONCLUSION The timely intervention of the RRS in EOLC facilitates an objective assessment of the patient's medical conditions, the limitation of treatments that may be minimally beneficial to the patient, and the choice of a higher quality of care. The EOLC decision using the legal process defined in the relevant Korean Act has advantages, wherein patients can clarify their preference, the family can prioritize the patient's preference for EOLC decisions, and physicians can make transparent EOLC decisions based on medical evidence and informed patient consent.
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Affiliation(s)
- Jung Soo Kim
- Inha University Hospital Rapid Response Team (INHART), Incheon, Republic of Korea.,Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Man Jong Lee
- Inha University Hospital Rapid Response Team (INHART), Incheon, Republic of Korea.,Department of Hospital Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Mi Hwa Park
- Inha University Hospital Rapid Response Team (INHART), Incheon, Republic of Korea.,Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jae Yoen Park
- Inha University Hospital Rapid Response Team (INHART), Incheon, Republic of Korea.,Department of Hospital Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Ah Jin Kim
- Inha University Hospital Rapid Response Team (INHART), Incheon, Republic of Korea.,Department of Hospital Medicine, Inha University School of Medicine, Incheon, Republic of Korea
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13
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Afshar K, Wiese B, Schneider N, Müller-Mundt G. Systematic identification of critically ill and dying patients in primary care using the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE). GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc02. [PMID: 32047417 PMCID: PMC6997946 DOI: 10.3205/000278] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/01/2019] [Indexed: 11/30/2022]
Abstract
Objective: The systematic identification of patients who are at risk of deteriorating and dying is the prerequisite for the provision of palliative care (PC). This study aimed to investigate the feasibility and practicability of the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for the systematic identification of these patients in general practice. Methods: In the beginning of 2017, twelve general practitioners (GPs; female n=6) were invited to take part in the study. GPs were asked to apply the SPICT-DE in everyday practice over a period of two months in patients with chronic progressive diseases. Six months after initial assessment, a follow-up survey revealed how the clinical situation of the initially identified patients had changed and which PC actions had been initiated by GPs. In addition, GPs gave feedback on the practicability of SPICT-DE in daily routine. Results: 10 of the 12 GPs (female n=5, median age 46 years, range 38–68) participated in both the two-month assessment period and the follow-up survey. A total of 79 patients (female n=40, median age 79 years, range 44–94) was assessed with the SPICT-DE. Main diagnoses were predominately of cardio-vascular (n=28) or oncological (n=26) origin. Follow-up after six months showed that 38 patients (48%) went through at least one crisis during the course of disease and almost one third (n=26) had died. The majority of GPs (n=7) considered the SPICT-DE to be practical in daily routine and helpful in identifying patients who might benefit from PC. Seven GPs indicated that they would use the SPICT-DE as part of everyday practice. Conclusions: The SPICT-DE seems to be a practical tool supporting the systematic identification of critically ill and dying patients in general practice.
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Affiliation(s)
- Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Hannover, Germany
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14
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Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems. Resuscitation 2019; 141:1-12. [DOI: 10.1016/j.resuscitation.2019.05.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/25/2019] [Accepted: 05/03/2019] [Indexed: 01/17/2023]
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15
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Khandelwal N, Long AC, Lee RY, McDermott CL, Engelberg RA, Curtis JR. Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals. THE LANCET RESPIRATORY MEDICINE 2019; 7:613-625. [PMID: 31122895 DOI: 10.1016/s2213-2600(19)30170-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA; Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA.
| | - Ann C Long
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, WA, USA; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
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16
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Hamano J, Oishi A, Kizawa Y. Prevalence and Characteristics of Patients Being at Risk of Deteriorating and Dying in Primary Care. J Pain Symptom Manage 2019; 57:266-272.e1. [PMID: 30447382 DOI: 10.1016/j.jpainsymman.2018.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
Abstract
CONTEXT Understanding the prevalence and characteristics of primary care outpatients being at risk of deteriorating and dying may allow general practitioners (GPs) to identify them and initiate end-of-life discussions. OBJECTIVES This study aimed to investigate the prevalence and characteristics of primary care outpatients being at risk of deteriorating and dying, as determined by the Supportive and Palliative Care Indicators Tool (SPICT™). METHODS A multicenter cross-sectional observational study was conducted at 17 clinics with 22 GPs. We enrolled all patients aged ≥65 years who visited the GPs in March 2017. We used the Japanese version of the SPICT to identify patients being at risk of deteriorating and dying. We assessed the demographic and clinical characteristics of enrolled patients. RESULTS In total, 382 patients with a mean age of 77.4 ± 7.9 years were investigated. Sixty-six patients (17.3%) had ≥2 positive general indicators or ≥1 positive disease-specific indicator in the SPICT-JP. Patients with dementia/frailty, neurological disease, cancer, and kidney disease showed a significantly elevated risk of deteriorating and dying, whereas patients with other specific disease did not. The patients at risk were significantly older and less likely to be living with family at home. They also had a higher Charlson Comorbidity Index score and a lower Palliative Performance Scale score. CONCLUSION Among primary care outpatients aged over 65 years, 17.3% were at risk of deteriorating and dying regardless of their estimated survival time, and many outpatients at risk were not receiving optimal multidisciplinary care.
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Affiliation(s)
- Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Ai Oishi
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School (Doorway 1), Edinburgh, UK
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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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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18
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Hogan H, Hutchings A, Wulff J, Carver C, Holdsworth E, Welch J, Harrison D, Black N. Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BackgroundUnchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time.ObjectiveTo determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes.DesignA mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals).SettingEnglish hospitals participating in the NCAA audit.ParticipantsNHS staff (approximately 300) and patients (13 million).InterventionsEducation, track-and-trigger systems (TTSs), standardised handover tools and outreach teams.Main outcome measuresIHCA rates, survival and hospital-wide mortality.Data sourcesNCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics.MethodsA literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15).ResultsAcross NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival.LimitationsThe organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall.ConclusionsStandardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival.Future workTo assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jerome Wulff
- Intensive Care National Audit & Research Centre, London, UK
| | - Catherine Carver
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Holdsworth
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - John Welch
- Critical Care Outreach, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, London, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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19
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Paterson TL, Greenaway MJ, Anstey MHR. Number of treating team reviews prior to rapid response team activation. Resuscitation 2018; 133:e5-e6. [PMID: 30291884 DOI: 10.1016/j.resuscitation.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Timothy L Paterson
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, 6009, Australia.
| | - Matthew J Greenaway
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, 6009, Australia
| | - Matthew H R Anstey
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, 6009, Australia; School of Public Health, Curtin University, Bentley, WA, 6102, Australia
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20
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Barrett J, Hawdon G, Wade J, Reeves J. Measuring the success of Medical Emergency Teams: potentially preventable deaths versus total cardiac arrest deaths. A single centre observational study. Intern Med J 2018; 48:264-269. [PMID: 29131479 DOI: 10.1111/imj.13676] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rapid response systems have been implemented with the aim of preventing patient deterioration, in-hospital cardiac arrests (IHCA) and related deaths. Not all 'unexpected deaths' are preventable, thus compromising the use of unexpected deaths as an outcome measure. AIMS To assess temporal trends in potentially preventable deaths as a subset of total unexpected death rates over a 4-year period. METHODS A single centre, cohort study of all unexpected deaths between 1 January 2010 and 31 December 2013. Unexpected deaths were identified from the rapid response systems database and patients' case histories were reviewed to reclassify the deaths into one of three categories: potentially preventable: if earlier MET activation may have prevented death; missed not for resuscitation opportunity; and not preventable. Total bed days were obtained from the hospital's patient administration system. RESULTS The rate of potentially preventable deaths decreased from 5.3 to 0.7 per 100 000 bed days (incident rate ratio (IRR) 0.53 (95% CI 0.31-0.90), P = 0.02). The rate of total unexpected deaths was unchanged (IRR 0.96 (0.80-1.16), P = 0.70), as were the rates of non-preventable deaths (IRR 1.06 (0.78-1.42), P = 0.72) and missed NFR deaths (IRR 1.1 (0.83-1.42), P = 0.56). CONCLUSION The rate of potentially preventable deaths has decreased by 47% per year over a 4-year period without any change in the overall rate of unexpected deaths. Distinguishing between potentially preventable deaths in contrast to total unexpected deaths enables more targeted evaluation of rapid response systems.
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Affiliation(s)
| | | | - Julie Wade
- Cabrini Health, Melbourne, Victoria, Australia
| | - John Reeves
- Cabrini Health, Melbourne, Victoria, Australia
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21
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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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22
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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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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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Tait PA, Pirone C, To THM. Providing high‐quality pharmaceutical care for the dying older person in hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paul A. Tait
- Southern Adelaide Palliative Services Division of Rehabilitation, Aged Care and Palliative Care Flinders Medical Centre Adelaide Australia
- Discipline of Palliative and Supportive Services College of Nursing and Health Sciences Flinders University Adelaide Australia
| | - Christy Pirone
- Clinical Governance Unit Flinders Medical Centre Adelaide Australia
| | - Timothy Hong Man To
- Southern Adelaide Palliative Services Division of Rehabilitation, Aged Care and Palliative Care Flinders Medical Centre Adelaide Australia
- Discipline of Palliative and Supportive Services College of Nursing and Health Sciences Flinders University Adelaide Australia
- Faculty of Health University of Technology Sydney Australia
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Afshar K, Feichtner A, Boyd K, Murray S, Jünger S, Wiese B, Schneider N, Müller-Mundt G. Systematic development and adjustment of the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE). BMC Palliat Care 2018; 17:27. [PMID: 29454343 PMCID: PMC5816386 DOI: 10.1186/s12904-018-0283-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/06/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Supportive and Palliative Care Indicators tool (SPICT) supports the identification of patients with potential palliative care (PC) needs. An Austrian-German expert group translated SPICT into German (SPICT-DE) in 2014. The aim of this study was the systematic development, refinement, and testing of SPICT-DE for its application in primary care (general practice). METHODS SPICT-DE was developed by a multiprofessional research team according to the TRAPD model: translation, review, adjudication, pretesting and documentation. In a pretest, five general practitioners (GPs) rated four case vignettes of patients with different PC needs. GPs were asked to assess whether each patient might benefit from PC or not (I) based on their subjective appraisal ("usual practice") and (II) by using SPICT-DE. After further refinement, two focus groups with 28 GPs (68% with a further qualification in PC) were conducted to test SPICT-DE. Again, participants rated two selected case vignettes (I) based on their subjective appraisal and (II) by using SPICT-DE. Afterwards, participants reflected the suitability of SPICT-DE for use in their daily practice routine within the German primary care system. Quantitative data were analysed with descriptive statistics and non-parametric tests for small samples. Qualitative data were analysed by conventional content analysis. Focus group discussion was analysed combining formal and conventional content analysis. RESULTS Compared to the spontaneous rating of the case vignettes based on subjective appraisal, participants in both the pretest and the focus groups considered PC more often as being beneficial for the patients described in the case vignettes when using SPICT-DE. Participants in the focus groups agreed that SPICT-DE includes all relevant indicators necessary for an adequate clinical identification of patients who might benefit from PC. CONCLUSIONS SPICT-DE supports the identification of patients who might benefit from PC and seems suitable for routine application in general practice in Germany. The systematic development, refinement, and testing of SPICT-DE in this study was successfully completed by using a multiprofessional and participatory approach.
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Affiliation(s)
- Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Angelika Feichtner
- Paracelsus Medical University Salzburg, Strubergasse 21, 5020 Salzburg, Austria
| | - Kirsty Boyd
- Usher Institute of Population Health Sciences and Informatics, Old Medical School, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Scott Murray
- Usher Institute of Population Health Sciences and Informatics, Old Medical School, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Saskia Jünger
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health, University of Cologne, Albertus-Magnus-Platz, 50923 Cologne, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Gabriele Müller-Mundt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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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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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Crozier TM, Galt P, Wilson SJ, Wallace EM. Rapid response team calls to obstetric patients in a busy quaternary maternity hospital. Aust N Z J Obstet Gynaecol 2017; 58:47-53. [PMID: 28656602 DOI: 10.1111/ajo.12660] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/22/2017] [Indexed: 11/27/2022]
Abstract
AIMS There is limited published information regarding intensive care unit (ICU) led rapid response team (RRT) calls to obstetric patients. We examined the characteristics of RRT calls to obstetric patients at a tertiary teaching hospital. METHODS Details of calls to pregnant and postpartum patients between October 2010 and June 2014 were obtained from the hospital RRT database. Each was retrospectively examined for data on patient demographics, call trigger, interventions and outcomes. Local obstetric-specific escalation practices (Code Pink/Green) for obstetrical concerns (not mandating maternal instability/involvement of the ICU team), were excluded. RESULTS There were 106 RRT calls logged during 43 months, and 97 had data available for analysis. Women currently pregnant accounted for 33% of calls and postpartum women 67%, with nearly half of these occurring more than 24 h post-delivery. The most common reason (29% of calls) for calling the RRT was hypotension, followed by 'concern about patient' (21%) and decreased Glasgow Coma Score (GCS) (17%). An escalation in the environment of care occurred after 32% of calls, with approximately 11% of calls necessitating direct ICU admission. Twenty-three percent of all calls were to women who had an ICU admission during their hospital stay. Among the cohort who received an RRT call, there was one maternal and three neonatal deaths. CONCLUSION At our institution generic RRT calls are called to both pregnant and postpartum women, and frequently result in an escalation in the care environment. Further study is required to understand better the specific needs of this important population.
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Affiliation(s)
- Timothy M Crozier
- Intensive Care Unit, Monash Medical Centre, Clayton, Victoria, Australia.,The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,Monash Intensive Care Research Centre, Monash Medical Centre, Clayton, Victoria, Australia
| | - Pauline Galt
- Intensive Care Unit, Monash Medical Centre, Clayton, Victoria, Australia.,Monash Intensive Care Research Centre, Monash Medical Centre, Clayton, Victoria, Australia
| | - Stuart J Wilson
- Intensive Care Unit, Monash Medical Centre, Clayton, Victoria, Australia
| | - Euan M Wallace
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,Monash Women's Services, Monash Health, Clayton, Victoria, Australia
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Orford NR, Milnes S, Simpson N, Keely G, Elderkin T, Bone A, Martin P, Bellomo R, Bailey M, Corke C. Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study. BMJ Support Palliat Care 2017; 9:e21. [PMID: 28659433 DOI: 10.1136/bmjspcare-2016-001231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/16/2017] [Accepted: 05/17/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe the effect of a communication skills training programme on patient-centred goals of care documentation and clinical outcomes in critically ill patients with life-limiting illnesses (LLI) referred for intensive care management. METHODS Prospective before-and-after cohort study in a tertiary teaching hospital in Australia. The population was 222 adult patients with LLI referred to the intensive care unit (ICU). The study was divided into two periods, before (1 May to 31 July 2015) and after (15 September to 15December 2015) the intervention. The intervention was a 2-day, small group, simulated-patient, communication skills course, and process of care for patients with LLI. The primary outcome was documentation of patient-centred goals of care discussion (PCD) within 48 hours of referral to the ICU. Secondary outcomes included clinical outcomes and 90-day mortality. RESULTS The intervention was associated with increased documentation of a PCD from 50% to 69% (p=0.004) and 43% to 94% (p<0.0001) in patients deceased by day 90. A significant decrease in critical care as the choice of resuscitation goal (61% vs 42%, p=0.02) was observed. Although there was no decrease in admission to ICU, there was a significant decrease in medical emergency team call prevalence (87% vs 73%, p=0.009). The cancer and organ failure groups had a significant decrease in 90-day mortality (75% vs 44%, p=0.02; 42% vs 16%, p=0.01), and the frailty group had a significant decrease in 90-day readmissions (48% vs 19%, p=0.003). CONCLUSIONS The intervention was associated with increased PCD documentation and decrease in the choice of critical care as the resuscitation goal. Admissions to ICU did not decrease, and although limited by study design, condition-specific trajectory changes, clinical interventions and outcomes warrant further study.
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Affiliation(s)
- Neil R Orford
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia.,Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia
| | - Sharyn Milnes
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia
| | - Nicholas Simpson
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia
| | - Gerry Keely
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Tania Elderkin
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Allison Bone
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Peter Martin
- School of Medicine, Deakin University, Geelong, Australia.,Palliative Care Unit, Barwon Health, Geelong, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia.,School of Medicine, The University of Melbourne, Parkville, Melbourne, Australia
| | - Michael Bailey
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia
| | - Charlie Corke
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,School of Medicine, Deakin University, Geelong, Australia
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Gooneratne M, Walker D. Rapid response systems and the deteriorating patient. Br J Hosp Med (Lond) 2017; 78:124-125. [PMID: 28277762 DOI: 10.12968/hmed.2017.78.3.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mevan Gooneratne
- Consultant, Anaesthetist, The Royal London Hospital, London E1 1BB
| | - David Walker
- Consultant Anaesthetist and Intensivist, University College Hospitals, London
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Hartin J, Walker J. Rapid response systems supporting end of life care: time for a new approach. Br J Hosp Med (Lond) 2017; 78:160-164. [PMID: 28277773 DOI: 10.12968/hmed.2017.78.3.160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rapid response systems have been implemented worldwide to support management of deteriorating patients outwith critical care units, and are increasingly required to support end of life care. These challenges require a new approach to supporting staff involved in do not attempt cardiopulmonary resuscitation decisions.
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Affiliation(s)
- Jillian Hartin
- Senior Nurse, Patient Emergency Response and Resuscitation Team (PERRT); Co-Chair Talking DNACPR Project Management Board, PERRT office, University College Hospital, London NW1 2BU
| | - Judy Walker
- Programme Director, Talking DNACPR, University College London Hospitals; Consultant, North and East London Commissioning Support Unit, London
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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: 13] [Impact Index Per Article: 1.9] [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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Cardona-Morrell M, Chapman A, Turner RM, Lewis E, Gallego-Luxan B, Parr M, Hillman K. Pre-existing risk factors for in-hospital death among older patients could be used to initiate end-of-life discussions rather than Rapid Response System calls: A case-control study. Resuscitation 2016; 109:76-80. [DOI: 10.1016/j.resuscitation.2016.09.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 09/18/2016] [Accepted: 09/25/2016] [Indexed: 01/26/2023]
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 925] [Impact Index Per Article: 115.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Coombs MA, Nelson K, Psirides AJ, Suter N, Pedersen A. Characteristics and dying trajectories of adult hospital patients from acute care wards who die following review by the rapid response team. Anaesth Intensive Care 2016; 44:262-9. [PMID: 27029659 DOI: 10.1177/0310057x1604400213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A third of patients reviewed by rapid response teams (RRT) require end-of-life care. However, little is known about the characteristics and management of these patients following RRT review. This paper presents results of a retrospective, descriptive audit that explored the dying trajectory of adult ward inpatients who died outside of intensive care following RRT review. The study setting was a 430-bed tertiary New Zealand hospital during 2013. RRT, inpatient databases and hospital notes were used to identify 100 consecutive adult inpatients who died subsequent to RRT review. Outcome measures included time from RRT review to death, place of death, pre-existing co-morbidities and frequency of medical review. Results demonstrated that patients were old (median 77 years, IQR 63-85years), emergency admissions (n=100) and admitted under a medical specialty (n=71). All but one of the cohort had pre-existing co-morbidities (mean 3.2, SD 1.7), almost a third (n=31) had cancer and 51% had 1-4 previous inpatient admissions within the previous 12 months. The mean length of stay prior to RRT review was 4.9 days (SD 5.5) during which patients were frequently reviewed by senior medical staff (mean 6.8 times, SD 6.9, range 0-44). Twenty per cent of patients died after their first RRT review with a further 40% receiving treatment limitation/palliation. Fifty-two per cent of patients had a pre-existing DNAR. Eighty per cent of patients died in hospital. Whilst the RRT fulfils an unmet need in decision-making at end of life, there is a need to understand what RRT, instead of ward-based or palliative care teams, offers dying patients.
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Affiliation(s)
- M A Coombs
- Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
| | - K Nelson
- Graduate School of Nursing Victoria University Wellington
| | - A J Psirides
- Capital and Coast District Health Board, Wellington Regional Hospital
| | - N Suter
- Wellington Hospital, Capital and Coast District Health Board
| | - A Pedersen
- Capital and Coast District Health Board, Wellington Regional Hospital
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Franklin J. Research roundup. Int J Palliat Nurs 2015. [DOI: 10.12968/ijpn.2015.21.4.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Synopses of a selection of recently published research articles of relevance to palliative care.
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Affiliation(s)
| | - Maureen Coombs
- Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand Capital & Coast District Health Board, Wellington, New Zealand
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