RapidResponseTeamA.endancetoHospitalInpa4entswithaNot-for-

Resuscita4onOrder:Triggers,Interven4onsandOutcomes

A/ProfArthasFlabouris

StaffSpecialist,IntensiveCareUnitRoyalAdelaideHospital

AgeingPopula4on

RecognizingAcuteDeteriora4on

•  Recogni(onsystemsinacutehealthservicesshouldaimtoiden(fypa(entsatvariouscri(calpoints:– whenapa(entisnotexpectedtodiesoon,andepisodesofacuteclinicaldeteriora(onmaybereversible

– whenapa(entislikelytodiesoon,butepisodesofacuteclinicaldeteriora(onmaybereversible

– whenapa(entislikelytodiesoonerandclinicaldeteriora(onislikelytobeirreversible.

RapidResponseTeams

•  Respondtoacutephysiologicaldeteriora(oninpa(entswhoareatriskofadverseevents

•  ARRTcallismadewhenpa(entsmeetacuteandsignificantphysiologicaldeteriora(on

•  egheartorrespiratoryrate,hypotension,decreasedlevelofconsciousnessorstaffconcerns

•  HaveALS-trainedstaffandequippedforcri(calcareinterven(ons

RapidResponseTeams

•  RRTareverylikelytoprovidecri(calcaretypeinterven(onsduringRRTcall

•  RRTmorelikelytoaGendpa(entswithapre-exis(ngNFR

•  ResultinhighernumbersofNFRorderscomparedwithconven(onalcardiacarrestteams

TrajectorytoDeath•  Notalldeathshavethesametrajectory.•  Thelevelofprognos(cuncertaintyassociatedwithnon-

cancerdiseaseisamajorimpedimenttoendoflifedecisions.•  Poten(alcanusethefeaturesofaperson’sendoflife

trajectoryasadeterminantoftheirendoflifeneeds.

NotForResuscita4onOrders

•  FirsthospitalpoliciesregardingNFRin1976•  Ini(alinten(onwastoindicatethosenotforCPR

•  Nowencompassesmorebutconfusionremains

•  Doesnotprecludeallac(vetreatment•  50%aredischargedhomefromhospital•  approx20%aliveatoneyear

NotForResuscita4onOrders•  NFRpa(entsarelesslikelytoreceiveinterven(onsandinves(ga(ons

•  NFRpa(entsmuchlesslikelytobeadmiGedtoICU

•  90%ofallhospitaldeathswereassociatedwithapre-exis(ngNFR.

•  HospitalswithaRRThavehigherratesofnewNFRdocumenta(onduringanemergencycall

Unexpectedacutedeteriora4nginthedyingpa4ent

•  CommonlystatedreasonswhyprimarycarecliniciansdidnotdocumentNFRordersinclude

•  deteriora(onwasacuteorunexpected(22.5%),•  awai(ngfamilydiscussion(22.5%),•  ac(velytrea(ngthepa(entforareversiblecondi(on(17.1%),•  notknowingthepa(entwellenough(10.9%),•  resuscita(onstatusnotyetdiscussedbytheteam(10.9%).

•  ARRTmaybethetriggerthathelpsfocustheprimarycareclinicians,thepa(entandtheirfamilyonconsidera(onofendoflifeplanning.

Case1•  82yearoldmale

•  SevereCOPD,CCFadmiGedwithcommunityacquiredpneumonia

•  PriorNFRandNFICUorders•  RRTcallfortachypneaanddesatura(on

•  RR=34,SaO2=84%

•  RRTcall–Yes/No?

Case2

•  68yearoldmale•  Metasta(clungcancerandrecurrentpleuraleffusions•  AdmiGedunderpallia(vecare

•  PriorNFR•  Tachycardia

•  Pulse=150(newonsetAF)•  RR=32,SaO2=92%,SBP=120,GCS=14

•  RRTcall–Yes/No?

Case3

•  81yearoldfemale•  PriorNFR•  Acutedropinconsciousstate

•  GCS=5,RR=20,SaO2=84%,SBP=70mmHg,Pulse=96

•  RRTcall–Yes/No?

RapidResponseTeamCallstopa4entswithapre-exis4ngNotfor

Resuscita4onorder

•  ShouldRRT,whoseprincipleinten(onisto“save”pa(entswhobecomeacutelyunwellinthewardrespondtopa(entswithanNFRorder?

•  Astheliteraturesuggestthattheydo,whatpa(entbenefitdotheyprovide?

Results

•  1258pa(ents,198withpre-exis(ngNFRs(15.7%)

Pre-exis(ngNFRNopre-exis(ngNFR

Pre-exis4ngNFR NoPre-exis4ngNFR PValue

HospitalLengthofStayBeforeRRTCall(days,median,IQ)

6(3,14) 4(1,9) <0.01

HospitalLengthofStayAkerRRTCall(days,median,IQ)

5(1,11) 7(3,17) <0.01

TotalHospitalLengthofStay(days,median,IQ)

13(7,23) 14(7,26) 0.20

Pre-exis4ngNFR NoPre-exis4ngNFR PValue

Age(years,median,IQ) 81(72,87) 70(53,81) <0.01

Gender(%males) 56.4% 54.3% 0.55

CodeBLUEcall 9(4.5%) 134(12.6%) <0.01

TimeofMET(hrs,median,IQ) 11:00(7:23,16:42)

12:50(7:55,18:20)

0.06

Scene4me(mins,median,IQ) 17(6,33) 20(10,35) 0.02

Pulseonarrival(median,IQ) 99(79,125) 99(78,124) 0.96

RespiratoryRateonarrival(median,IQ)

24(18,30) 20(16,26) <0.01

SBPonarrival(mmHg)(median,IQ)

117(91,145) 120(90,148) 0.53

SaO2onarrival(median,IQ) 93(85,97) 97(93,99) <0.01

ArrivalGCS=15 41(24.3%) 479(51.7%) <0.01

0% 5% 10% 15% 20% 25% 30%

?3Observa(onsinRedzone

CardiacArrest

LevelofConsciousness/Seda(on

O2Satura(on<89%

PulseRate<40

PulseRate>140

RespiratoryArrest

RespiratoryRate<7

RespiratoryRate>30

SBP<90mm/Hg

SBP>200mm/Hg

SignificantBleeding

ThreatenedAirway

UnaGendedMDTReview

Unexpectedoruncontrolled

Worried

PriorNFR NoPriorNFR

ReasonsforRRTcall

Interven4ons

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-exis(ngNFR NoPre-exis(ngNFR

WardInterven(ons

Cri(calCareInterven(ons

ClinicalAssessmentOnly-1(1.0%)vs10(0.9%),p=0.93

P value= 0.61

P value= 0.63

Cri4calCareTypeInterven4onsInterven4on Pre-exis4ngNFR NoPre-exis4ngNFR PValue

Suc4on 17(8.6%) 41(3.9%) <0.01

Bagmask 10(5.1%) 188(8.0%) 0.15

Nasopharyngeal 9(4.5%) 12(1.1%) <0.01

Guedells 6(3.0%) 46(4.3%) 0.40

NIPPV 3(1.5%) 11(1.0%) 0.56

CPR 2(1.0%) 56(5.3%) 0.01

Arterial 2(1.0%) 4(0.4%) 0.24

LMA 0.0% 3(0.3%) 0.45

ETT 0.0% 27(2.5%) 0.02

Trachealinterven(on 0.0% 13(1.2%) 0.12

Defibrilla(on 0.0% 22(2.1%) 0.04

CVC 0.0% 7(0.7%) 0.25

Outcomes

NFRpa(entsweremorelikelytobelekontheward(92.4%vs80.3%,p<0.01)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LekonWard

ICU DiedonRRT

SDU OT CCU ED

Pre-exis(ngNFR

NoPre-exis(ngNFR

Outcomes

0%

10%

20%

30%

40%

50%

60%

70%

80%

DiedinHospital Discharged

Pre-exis(ngNFR

Nopre-exis(ngNFR

NFRpa(entshadmorelikelytodiehospital,111(56.6%)vs257(24.8%),p<0.01.

Conclusions•  RRTcallsforpa(entswithNFRordersarenotinfrequent

•  NFRpa(entswerejustaslikelytoreceivesomeinterven(on(ward,cri(calcareorboth)duringaRRTcall

•  NFRpa(entsare:•  Older,respiratorydistress,shorterscene(me•  InhospitalforlongerbeforeRRT•  MorelikelytohaveRRTcallfordesatura(on,respiratoryorconsciouslevel

•  MorelikelytodieduringRRT•  Morelikelytodieinhospital•  LesslikelyadmiGedtoICU/SDU

•  NFRpa(entshavealargertendencytobemadeNF-RRTakerRRTcall

Case1•  82yearoldmale

•  SevereCOPD,CCFadmiGedwithcommunityacquiredpneumonia

•  PriorNFRandNFICUorders•  RRTcallfortachypneaanddesatura(on

•  RR=34,SaO2=84%

•  RRTcall,respondedtotreatmentandlekonward

Case2

•  68yearoldmale•  Metasta(clungcancerandrecurrentpleuraleffusions•  AdmiGedunderpallia(vecare

•  PriorNFR•  Tachycardia

•  Pulse=150(newonsetAF)•  RR=32,SaO2=92%,SBP=120,GCS=14

•  RRTcall,treatment,controlledAFrate,andlekonward

Case3

•  81yearoldfemale•  CCF,frail,admiGedwithmalaena

•  PriorNFR•  Acutedropinconsciousstate

•  GCS=5,RR=20,SaO2=84%,SBP=70mmHg,Pulse=96

•  RRTcall,treatmentwithnarco(candlekonward.NotforfurtherRRTcalls

Case4

•  84year-oldman,admiGedakeramechanicalfall

•  PriorNFR•  RRTcall7daysakeradmissionforrespiratoryarrestakeraspira(on

•  CPRini(atedaspa(entwasnotflaggedas‘NFR’bywardstaff

Case4

•  CPRwasceasedaker6minuteswhennoteswerelocated

•  Rhythmreturnedandanasopharyngealairwaywasinserted

•  Pa(entwasthendocumentedasNF-RRTandNF-ICU

•  CPRwaslaterdeemed‘appropriate’inthenotesasthere‘wasaneasilyreversiblecauseofdeteriora(on’.

TheDecisionforaNotForResuscita4onorderatthe4meofaRapidResponseTeama.endance

BackgroundLittle is known about the timing and circumstances surrounding the issuing of an NFR order during a RRT call. This is important because in contrast to other NFR decisions these orders may be made by doctors who encounter the patient for the first time, during an acute event, and may be made at a time the patient is not competent A significant proportion of RRT calls occur after hours

Case5•  89yearoldfemale

•  Residesinhighlevelnursinghome•  Demen(a,metasta(clungcancer,chronicpain

•  PriorNFRorder•  SaO2=92%onroomair•  RR=32•  SBP=220mmHg•  GCS=10•  Seizure

StudyDesignandPa4ents•  Prospec(velyiden(fiedpa(entsandretrospec(vemedicalrecordanddatabasereview.

•  Wardinpa(entswithaNFR/NFRRT/NFICUorderdocumentedatthe(meofaRRTcall and

•  Wardinpa(entswhodieduringtheirhospitaladmissionandhadadocumentedNFR/NFRRT/NFICUorder.

•  48RRTini(atedOrderpa(ents•  50“control”Orderpa(ents

•  8.3%ofRRTini(atedOrders,basicand/oradvancedlifesupportwascommenced

•  Similarmedian–  Age, 78.5vs80.5years(p=0.31)–  TimeofOrder, 15:55vs15:30hrs(p=0.52)–  HospLOSpriortoOrder, 2vs1day(p=0.38)– Weekdayorder, 64.6%vs68.0%(p=0.44)–  HourssincepriorRRTcall, 8:32vs8:32(p=0.64)

TypeofOrders

•  RRTdocumentedfewer–– NFRorders, 64.6%vs98.6%(p<0.01)– NFICUorders, 37.5%vs82.0%(p<0.01)

•  RRTdocumentedmore–– NFRRTorders, 64.6%vs44.0%(p=0.04)– ModifiedRRTcalls,8.3%vs0%(p=0.04)

DocumentedReasonsforanOrder

0

10

20

30

40

50

60

70

80

Fu(lityexis(ng Fu(lityacute Chronicillness Pa(entwishes NOKwishes Exis(nglimitsexpanded

%

ReasonsforOrders

Control RRTini(ated

Whodocumentedthedecision

•  RRTini(atedorders– 96%byRRTDoctor– 12.5%Homeclinicregistrar– 0%anyConsultant

•  Controlorders– 98%byRegistrar– 0%anyConsultant

Documentedastowhowasinformed

Documenta4onofwhowasinformedofdecision

RRTini4ated Control Pvalue Overall

Pa4ent 18.8% 50% <0.01 34.7%Pa(entnotcompetent 22.9% 6.0% 0.02 14.3%NextofKin 58.3% 90.0% <0.01 74.5%AdmitConsultant 47.9% 6.0% <0.01 26.5%OtherConsultant 8.3% 0% 0.04 4.1%ICUConsultant 18.8% 8.0% 0.12 13.3%Wardnurses 2.1% 0% 0.31 1%Nomen(on 2.1% 0% 0.31 1%

OrderandDocumenta4onofwhowasinformed

ControlNFR

ControlNFRRT

ControlNFICU

RRTNFR

RRTNFRRT

RRTNFICU

Pa(ent 51.0% 36.4% 61.0% 22.6% 19.4% 27.8%

Pa(entnotcompetent

6.1% 9.1% 7.3% 22.6% 25.8% 22.2%

NextofKin 89.8% 90.9% 90.2% 58.1% 64.5% 55.6%

AdmitConsultant 4.1% 4.5% 4.9% 58.1% 45.2% 50.0%

Case5•  89yearoldfemale

•  Residesinhighlevelnursinghome•  Demen(a,metasta(clungcancer,chronicpain

•  SaO2=92%onroomair,RR=32,SBP=220mmHg,GCS=10

•  Seizure•  RRTcallforseizure

•  RRTtreatmentofseizure,hypertensionandmodifiedRRTcriteria

Conclusions

•  RRTdocumentedordersareforpa(entswithsimilarcharacteris(csandreasonsasnonRRTdocumentedorders

•  However– LesslikelytobeanNFRoraNFICU– MorelikelytobeaNFRRTandmodifiedcriteria– Noless/morelikelytobeprecededbyapriorRRT

Conclusions•  RRTOrdersarelesslikelytodocumentpa(ent/NOKinvolvement

•  Par(cularlyforNFRRTandmodifiedcriteria

•  ButmorelikelytodocumentConsultantinvolvement

•  ConsultantsrarelydocumentOrdersandtheirdocumentedinvolvementinthedecisionmakingisinfrequent

Conclusions•  Documenta(onisweakforpa(ent/NOK,nursingandspecialistmedicalinvolvement

•  “Teams”documentwithintheirown“domain”,thatisRRTforNFRRT,admitteamsforNFR,ICUforNFICU,etc–needaholis(capproach

•  Poten(allytheremaybepoorcommonunderstandingaboutthemerits,andapplica(on,ofthevarious“orders/limits”

RapidResponseTeamsandtheDyingpa4ent

ANZSPM-FiveDomainsofEnd-of-LifeCare RapidResponseSystems

Symptommanagement(holis(c&mul(disciplinary)–especiallyfocusingonpain,shortnessofbreath,anxietyanddepression,plusmanagingspiritualand/orexisten(aldistress.

SupportacutesymptommanagementResponsive,ALStrained(butlesssoforpallia(vetypecare)

AdvanceCarePlanning–especiallyiden(fyingpa(ent-selectedSubs(tuteDecisionMakers,documen(ngshared‘goals-of-care’andpa(entpreferences

Notwellplacedtoini(ateAdvanceCarePlanningCansupportplanningbeyondjust“NFR”orders

CareerSupport

Notwellplacedtosupportcareersoutsideofcareerini(ated“Calls”

Coordina(onandIntegra(onofCare

Supportwardstafftodeliver(melycare,resuscita(veorpallia(ve

TerminalPhase(last7-10daysoflife)-(melyrecogni(onofthe“dyingphase”anddevelopingdocumentedTerminalPhasePlanstoadequatelymanagepa(entsandsupporttheirfamilies

Wellplaced,okenthefirsttorecognizeirretrievabledeteriora(on

Implica4ons•  TheRRTcanrelieveacutedeteriora(onandprolonglife,evenfor

thoseindecline•  TheRRTcanimprovethequalityofendoflifecareplanning,and

supportwardstaffandthepa(ent’sfamily.•  Poten(allypreventorreducetheuseofinappropriateacutecare

interven(ons•  RRTcouldbebeGerintegratedintosuppor(ngpa(entswith

advancedcareplans•  TheeraoftheRRShasredefinedthegapbetween“NFR”orders

anddeath.NeedtobringaGen(onofthatgaptoadmiungteamsandpallia(vecareproviders

•  NeedtobeGerdefine“NFRRT”anddeveloptransparentpoliciesastohowtodocumentit,communicateit,andimplica(onstopa(entsandcareers

•  Whoshouldtakeresponsibilityforacutedeteriora(oninthepost“NFR”period?

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