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Examining rapid response system treatments in the elderly patient population

This month’s column addresses the benefits of effectively using rapid response system calls for elderly patients who suffer from chronic illnesses.

Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCSEng(Hon), FRCSEd(Hon)

November 1, 2018

Rapid response system (RRS) calls are designed to identify and respond to seriously ill patients in acute hospital settings.1 Older patients, particularly those individuals nearing the end of their lives, may require care that includes intense treatment options—some of which happen after RRS calls are activated.1 But is this type of treatment beneficial to elderly patients in all circumstances? A study in the September 2018 issue of The Joint Commission Journal on Quality and Patient Safety examines the issue and measures the cost of hospitalization for older end-of-life inpatients subject to an RRS call.2

About the study

A study conducted at a teaching hospital in Sydney, Australia, sought to identify who benefits from aggressive RRS treatment near the end of life. The cohort study—led by Magnolia Cardona, PhD, MPH, associate professor, health systems research and translation, Centre for Research in Evidence-Based Practice, Bond University and Gold Coast Hospital and Health Service, Queensland, Australia, and colleagues—evaluated 733 adult inpatients for a three-month period, before and after their last-placed RRS call. The researchers also conducted a subgroup analysis of patients ages 80 and older. The authors uncovered the following findings:2

  • 8.9 percent of patients had a preexisting not-for-resuscitation (NFR) or not-for-RRS order, and none of these patients survived for three months.
  • Patients without an NFR or not-for-RRS order had a three-month survival probability of 71 percent.
  • Compared with survivors, RRS recipients who died were more likely to be:
    • Older
    • Admitted to a medical ward
    • Have a larger mean number of admissions before the RRS

The average cost of hospitalization for patients ages 80 years and older transferred to the intensive care unit (ICU) was higher than for those not requiring treatment in the ICU.

Findings

The authors concluded that the study strongly indicates that for patients 80 years of age or older with hospital admissions in the past three months and a history of two or more hospital admissions and an existing NFR or not-for-RRS order, “Clinicians could step back and consider drawing the line for aggressive/non-beneficial, futile management, as death in these cases is inevitable.”2

From a surgical standpoint, a study published in a 2013 issue of Health and Quality of Life Outcomes—“Effects of a rapid response system on quality of life: A prospective cohort study in surgical patients before and after implementing a rapid response system,” by Friede Simmes, RN, MScN, and colleagues—sought to assess an RRS call’s effect on a surgical patient’s health-related quality of life (HRQoL) at three and six months postoperation.3

The authors of this study assert quality of life outcomes “reflect a patient’s health perspective and are relevant to better understand and improve health care expenditure and resource utilisation,” and they hypothesized that an RRS system would “positively influence a patient’s quality of life.”3

The study measured the responses of surgical patients before the operation, as well as at three and six months postoperatively. Patients included in the study were given questionnaires that measured mobility, self-care, pain or discomfort, and anxiety or depression, and then asked the patient to rate his or her health on a scale of 0–100.3 The authors concluded that “the implementation of an RSS did not convincingly affect HRQoL as measured by the questionnaires, but noted that implementation of an RRS system did account for fewer problems at three to six months postoperatively in the areas of pain/discomfort and anxiety/depression—conversely seeing more problems with mobility and self-care.3

“The most important explanation for our lack of effect is most likely that other factors had a larger influence on HRQoL than merely the implementation of an RRS,” the authors wrote. “We found that pre-surgery HRQoL and [American Society of Anaesthesiologists physical status classification] were strongly associated with HRQoL following surgery.”3

With that in mind, what should one consider when determining if this practice is beneficial for patients nearing end of life—whether for their quality of life or financially?

Dr. Cardona, a co-author of The Joint Commission Journal on Quality and Patient Safety article, further expanded on the issue of how effectively to use RSS on elderly patients who have multiple chronic illnesses in a blog post for Quality Data Download.

“As difficult as it is to let go of a relative or a patient, people who do not benefit from aggressive and non-beneficial RRS interventions are likely to suffer physical disability and emotional distress without additional life expectancy,” Cardona wrote.4 “More often than not, the trajectories of very old patients with multiple chronic illnesses after ICU admission involve poor quality end of life postdischarge, and death within days or months of admission to critical care. Further, their families may harbor false hope of recovery; and whether or not very old patients survive the immediate treatment, long hospital stays are associated with increased infection risk, delirium, and high cost.”

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

References

  1. Downar J, Rodin D, Barua R, et al. Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: A multicenter retrospective study. J Critical Care. 2013;28(4):498-503.
  2. Cardona M, Turner RM, Chapman A, et al. Who benefits from aggressive rapid response system treatment near the end of life? A retrospective cohort study. Jt Comm J Qual Patient Saf. 2018;44(9):505-513.
  3. Simmes F, Schoonhoven L, Mintjes J, Fikkers BG, van der Hoeven JG. Effects of a rapid response system on quality of life: A prospective cohort study in surgical patients before and after implementing a rapid response system. Health Qual Life Outcomes. 2013;11:74.
  4. Cardona M. Who benefits from aggressive rapid response interventions near the end of life? The Joint Commission. Quality Data Download blog. August 31, 2018. Available at: www.jointcommission.org/quality_data_download/who_benefits_from_aggressive_rapid_response_interventions_near_the_end_of_life/. Accessed October 5, 2018.