Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2016

Open Access 01-12-2016 | Research

Unexpected versus all-cause mortality as the endpoint for investigating the effects of a Rapid Response System in hospitalized patients

Authors: Anja H. Brunsveld-Reinders, Jeroen Ludikhuize, Marcel G. W. Dijkgraaf, M. Sesmu Arbous, Evert de Jonge, for the COMET study group

Published in: Critical Care | Issue 1/2016

Login to get access

Abstract

Background

The purpose of this study was to assess the effect of replacing all-cause mortality by death without limitation of medical treatments (LOMT) as the endpoint in a study of rapid response teams (RRTs) in hospitalized patients. We also described the time course of LOMT orders in patients dying on a general ward and the influence of RRTs on such orders.

Methods

This study is a secondary analysis of the COMET trial, a pragmatic prospective Dutch multicenter before-after study. We repeated the original analysis of the influence of RRTs on death before hospital discharge by replacing all-cause mortality by death without an LOMT order. In a subgroup of all patients dying before hospital discharge, we documented patient demographics, admission characteristics and LOMT orders of each patient. Patients age 18 years or above were included.

Results

In total, 166,569 patients were included in the study. The unadjusted ORs were 0.865 (95 % CI 0.77-0.98) in the original analysis using all-cause mortality and 0.557 (95 % CI 0.40-0.78) when choosing death without LOMT as the endpoint. In total, 3408 patients died before discharge. At time of death, 2910 (85 %) had an LOMT order. Median time from last change in LOMT status and death was 2 days (IQR 1–5) in the before-phase and median time after introduction of the RRT was 1 day (IQR 1–4) (p value not significant).

Conclusions

The improvement in survival of hospitalized patients after introduction of a rapid response team in the COMET study was more pronounced when choosing death without limitation of medical treatment, rather than all deaths as the endpoint. Most patients who died during hospitalization had limitation of medical treatments ordered, often shortly before death. Rapid response teams did not influence the institution of limitation of medical treatments.
Literature
1.
2.
3.
Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091–7.CrossRefPubMed
4.
Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, Smorenburg SM, de Rooij SE, Adams R, et al. Outcomes associated with the nationwide introduction of rapid response systems in The Netherlands. Crit Care Med. 2015;43:2544–51.CrossRefPubMed
5.
Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J, et al. Introducing critical care outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;30:1398–404.CrossRefPubMed
6.
Ludikhuize J, Dijkgraaf MGW, Smorenburg SM, de Rooij SEJA, Brunsveld-Reinders AH, Tangkau P, et al. Cost and Outcome of Medical Emergency Teams (COMET) study. Design and rationale of a Dutch multi-center study. Br J Med Med Res. 2013;3:13–28.CrossRef
7.
De MK, Verspuy M, Monsieurs KG, Van BP. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Resuscitation. 2013;84:1192–6.CrossRef
8.
Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S. The medical emergency team system and not-for-resuscitation orders: results from the MERIT study. Resuscitation. 2008;79(3):391–7.
9.
Hillman K, Chen J, May E. Complex intensive care unit interventions. Crit Care Med. 2009;37:S102–6.CrossRefPubMed
10.
Marrie TJ, Fine MJ, Kapoor WN, Coley CM, Singer DE, Obrosky DS. Community-acquired pneumonia and do not resuscitate orders. J Am Geriatr Soc. 2002;50:290–9.CrossRefPubMed
11.
Wenger NS, Pearson ML, Desmond KA, Brook RH, Kahn KL. Outcomes of patients with do-not-resuscitate orders. Toward an understanding of what do-not-resuscitate orders mean and how they affect patients. Arch Intern Med. 1995;155:2063–8.CrossRefPubMed
12.
Al-Qahtani S, Al-Dorzi HM, Tamim HM, Hussain S, Fong L, Taher S, et al. Impact of an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Crit Care Med. 2013;41:506–17.CrossRefPubMed
13.
Jones DA, McIntyre T, Baldwin I, Mercer I, Kattula A, Bellomo R. The medical emergency team and end-of-life care: a pilot study. Crit Care Resusc. 2007;9:151–6.PubMed
14.
Vazquez R, Gheorghe C, Grigoriyan A, Palvinskaya T, Amoateng-Adjepong Y, Manthous CA. Enhanced end-of-life care associated with deploying a rapid response team: a pilot study. J Hosp Med. 2009;4:449–52.CrossRefPubMed
15.
Jones D, Moran J, Winters B, Welch J. The rapid response system and end-of-life care. Curr Opin Crit Care. 2013;19:616–23.CrossRefPubMed
16.
Micallef S, Skrifvars MB, Parr MJ. Level of agreement on resuscitation decisions among hospital specialists and barriers to documenting do not attempt resuscitation (DNAR) orders in ward patients. Resuscitation. 2011;82:815–8.CrossRefPubMed
17.
Smith RL, Hayashi VN, Lee YI, Navarro-Mariazeta L, Felner K. The medical emergency team call: a sentinel event that triggers goals of care discussion. Crit Care Med. 2014;42:322–7.CrossRefPubMed
18.
Casamento AJ, Dunlop C, Jones DA, Duke G. Improving the documentation of medical emergency team reviews. Crit Care Resusc. 2008;10:29.PubMed
19.
Jones DA, Bagshaw SM, Barrett J, Bellomo R, Bhatia G, Bucknall TK, et al. The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Crit Care Med. 2012;40:98–103.CrossRefPubMed
20.
Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003;290:790–7.CrossRefPubMed
Metadata
Title
Unexpected versus all-cause mortality as the endpoint for investigating the effects of a Rapid Response System in hospitalized patients
Authors
Anja H. Brunsveld-Reinders
Jeroen Ludikhuize
Marcel G. W. Dijkgraaf
M. Sesmu Arbous
Evert de Jonge
for the COMET study group
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-016-1339-9

Other articles of this Issue 1/2016

Critical Care 1/2016 Go to the issue

Editorial

Do we need new prokinetics to reduce enteral feeding intolerance during critical illness?

Research

The involvement of regulatory non-coding RNAs in sepsis: a systematic review

Letter

Response to: influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation

Letter

Response to a trial on reversal of Death by Neurologic Criteria

Research

Liver function predicts survival in patients undergoing extracorporeal membrane oxygenation following cardiovascular surgery

Review

Acute kidney injury: short-term and long-term effects