Enhanced end‐of‐life care associated with deploying a rapid response team: A pilot study

Abstract

The authors have no financial or intellectual conflicts of interest relevant to this research. The research was not supported by external funding.HYPOTHESIS: Institution of a rapid response team (RRT) improves patients' quality of death (QOD). SETTING: A 425-bed community teaching hospital. PATIENTS: All medical-surgical patients whose end-of-life care was initiated on the hospital wards during the 8 months before (pre-RRT) and after (post-RRT) actuation.STUDY DESIGN: Retrospective cohort study. METHODS: Medical records of all patients were reviewed using a uniform data abstraction tool. Demographic information, diagnoses, physiologic and laboratory data, and outcomes were recorded. RESULTS:A total of 197 patients died in both the pre-RRT and post-RRT periods. There were no differences in age, sex, advance directives, ethnicity, or religion between groups. Restorative outcomes, including in-hospital mortality (27 vs. 30/ 1000 admissions), unexpected transfers to intensive care (17 vs. 19/1000 admissions) and cardiac arrests (3 vs. 2.5/1000 admissions) were similar during the 2 periods. Outcomes, including formal comfort care only orders (68 vs. 46%), administration of opioids (68 vs. 43%), pain scores (3.0 AE 3.5 vs. 3.7 AE 3.2), patient distress (26 vs. 62%), and chaplain visits (72 vs. 60%), were significantly better in the post-RRT period compared to the pre-RRT period (all P < 0.05). During the post-RRT period, 61 patients died with RRT care and 136 died without RRT care. End-of-life care outcomes were similar for these groups except more RRT patients had chaplain visits proximate to their deaths (80% vs. 68%; P ¼ 0.0001). CONCLUSIONS:Institution of an RRT in our hospital had negligible impact on outcomes of patients whose goal was restorative care. Deployment of the RRT was associated with generally improved end-of-life pain management and psychosocial care.

Part 8: Education, Implementation, and Teams

“…218 The other study demonstrated a significant difference between control wards and intervention wards (introduction of a critical care outreach service) with all patients (OR, 0.70; 95% CI, 0.50-0.97), and matched randomized patients (OR, 0.52; 95% CI, 0.32-0.85). 219 Of the 33 nonrandomized studies reporting mortality, no studies reported statistically significant worse outcomes for the intervention; 15 studies with no adjustment demonstrated no significant improvement [220][221][222][223][224][225][226][227][228][229][230][231][232][233][234] ; 6 studies with no adjustment demonstrated significant improvement [235][236][237][238][239][240] ; 1 study with no adjustment reported on rates, which improved with MET, but did not report on significance 241 ; 1 study with no adjustment demonstrated significant improvement for medical patients but not surgical patients (combined significance not reported) 242 ; 4 studies with adjustment demonstrated significant improvement both before and after adjustment 243,244,250,252 ; 2 studies with adjustment demonstrated no significant improvement both before and after adjustment 245,246 ; 2 studies with adjustment demonstrated significant improvement before adjustment but not after adjustment 247,251 ; 1 study with adjustment demonstrated significant improvement before adjustment but not after adjustment 27 ; 1 study that reported on both unexpected mortality and overall mortality showed significant improvement both before and after adjustment for unexpected mortality but no significant improvement both before and after adj...…”

“…220,221,224,225,[227][228][229][230][232][233][234][235][236][237][238][239][240][241][242][243][244][245][246][247]249,250,[253][254][255][256] For the 1 RCT, 218 no significant difference between control hospitals and intervention hospitals, both unadjusted (P=0.306; Diff, −0.208; 95% CI, −0.620 to 0.204) and adjusted (P=0.736; OR, 0.94; 95% CI, 0.79-1.13), was demonstrated. Of the 31 observational studies reporting on cardiac arrest rates, 1 before-after study using an aggregated weighted scoring system (Modified Early Warning Score [MEWS]) reported significantly higher cardiac arrest rates in MEWS bands 3 to 4 after intervention, but not in MEWS bands 0 to 2 or 5 to 15, and overall cardiac arrest rate significance was not reported 232 ; 7 studies with no adjustment demonstrated no significant improvement in cardiac arrest rates after the introduction of a MET system 224,225,[228][229][230]233,234 ; 15 studies with no adjustment demonstrated significant improvement in cardiac arrest rates after the introduction of a MET system 220,221,…”

Resource utilization and end‐of‐life care in a US hospital following medical emergency team‐implemented do not resuscitate orders

“…Vazquez et al reported improved quality of end-of-life care after implementation of a MET. 10 However, an inpatient palliative care service was not available in that study, and it is not clear whether or not a comfort care order set was available. Evidence suggests that utilization of palliative care resources improves end-of-life care in the ICU.…”

“…Finally, preliminary evidence suggests that METs may improve the quality of end-of-life care. 10 However, the use of end-of-life resources, including inpatient palliative care consultation and hospice care following MET activation has not been well studied.…”

Integration of Palliative Care in the Context of Rapid Response

“…An observational study in a community teaching hospital found that one year aft er deployment of an RRT staff ed by a critical care nurse, respiratory therapist, and second-year medical resident, signifi cantly more dying patients received opioids and had lower pain scores and distress than in the pre-intervention study period. 8 In general, opioids will be most eff ective for control of dyspnea as well as pain, with lower starting doses for dyspnea. 42 Expert recommendations are available regarding use of noninvasive ventilation for symptom palliation, which should always be preceded by a discussion of care goals with criteria for success or failure in relation to those goals.…”