Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

ObjectivesTo assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.DesignA retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a...

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Published in:BMJ open 2018-10, Vol.8 (10), p.e024264-e024264
Main Authors: Lightbody, Calvin J, Campbell, Jonathan N, Herbison, G Peter, Osborne, Heather K, Radley, Alice, Taylor, D Robin
Format: Article
Language:English
Subjects:
Advance directives
Clinical decision making
Decision making
Emergency medical care
Hospitals
Illnesses
Intervention
Mortality
Palliative care
Patient safety
Patient-Centred Medicine
Physicians
Systematic review
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description ObjectivesTo assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.DesignA retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as ‘expected’ or ‘unexpected’ using the Gold Standard Framework Prognostic Indicator Guidance.SettingMedical, surgical and intensive care units of a district general hospital.OutcomesThe primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical ‘problems’ identified using the Structured Judgement Review Method.Results289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were ‘expected’. Among patients with ‘expected’ deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p
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Patient deaths were classified retrospectively as ‘expected’ or ‘unexpected’ using the Gold Standard Framework Prognostic Indicator Guidance.SettingMedical, surgical and intensive care units of a district general hospital.OutcomesThe primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical ‘problems’ identified using the Structured Judgement Review Method.Results289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were ‘expected’. Among patients with ‘expected’ deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for ‘problems’, 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and ‘problems’ were significantly lower in the group with a TELP/DNACPR compared with ‘DNACPR only’ and ‘neither’: harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and ‘problems’: 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).ConclusionsThe use of a TELP was associated with a significant reduction in harms, NBIs and ‘problems’ in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.]]></description><identifier>ISSN: 2044-6055</identifier><identifier>EISSN: 2044-6055</identifier><identifier>DOI: 10.1136/bmjopen-2018-024264</identifier><identifier>PMID: 30385448</identifier><language>eng</language><publisher>England: BMJ Publishing Group LTD</publisher><subject>Advance directives ; Clinical decision making ; Decision making ; Emergency medical care ; Hospitals ; Illnesses ; Intervention ; Mortality ; Palliative care ; Patient safety ; Patient-Centred Medicine ; Physicians ; Systematic review</subject><ispartof>BMJ open, 2018-10, Vol.8 (10), p.e024264-e024264</ispartof><rights>Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</rights><rights>2018 Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. 2018</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-b3874-e57523d45721971a83992b7e7200a141a50eea79ab2d5c95356d233a286a6b993</citedby><cites>FETCH-LOGICAL-b3874-e57523d45721971a83992b7e7200a141a50eea79ab2d5c95356d233a286a6b993</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.proquest.com/docview/2128549739/fulltextPDF?pq-origsite=primo$$EPDF$$P50$$Gproquest$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.proquest.com/docview/2128549739?pq-origsite=primo$$EHTML$$P50$$Gproquest$$Hfree_for_read</linktohtml><link.rule.ids>112,113,230,314,727,780,784,885,3194,25753,27549,27550,27924,27925,37012,37013,44590,53791,53793,75126,77594,77595,77601,77632</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30385448$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Lightbody, Calvin J</creatorcontrib><creatorcontrib>Campbell, Jonathan N</creatorcontrib><creatorcontrib>Herbison, G Peter</creatorcontrib><creatorcontrib>Osborne, Heather K</creatorcontrib><creatorcontrib>Radley, Alice</creatorcontrib><creatorcontrib>Taylor, D Robin</creatorcontrib><title>Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method</title><title>BMJ open</title><addtitle>BMJ Open</addtitle><description><![CDATA[ObjectivesTo assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.DesignA retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as ‘expected’ or ‘unexpected’ using the Gold Standard Framework Prognostic Indicator Guidance.SettingMedical, surgical and intensive care units of a district general hospital.OutcomesThe primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical ‘problems’ identified using the Structured Judgement Review Method.Results289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were ‘expected’. Among patients with ‘expected’ deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for ‘problems’, 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and ‘problems’ were significantly lower in the group with a TELP/DNACPR compared with ‘DNACPR only’ and ‘neither’: harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and ‘problems’: 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).ConclusionsThe use of a TELP was associated with a significant reduction in harms, NBIs and ‘problems’ in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.]]></description><subject>Advance directives</subject><subject>Clinical decision making</subject><subject>Decision making</subject><subject>Emergency medical care</subject><subject>Hospitals</subject><subject>Illnesses</subject><subject>Intervention</subject><subject>Mortality</subject><subject>Palliative care</subject><subject>Patient safety</subject><subject>Patient-Centred Medicine</subject><subject>Physicians</subject><subject>Systematic review</subject><issn>2044-6055</issn><issn>2044-6055</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><sourceid>9YT</sourceid><sourceid>PIMPY</sourceid><recordid>eNqNUstu1DAUjRCIVqVfgIQssWFBWseO89ggoYpHURESj7V1E9-ZeJTYwXYG8Yd8FjedoSqs8MaW7znnHl-fLHta8IuikNVlN-38jC4XvGhyLkpRlQ-yU8HLMq-4Ug_vnU-y8xh3nFapWqXE4-xEctmosmxOs1_X0wx9Yn7DgKWAkCZ0iWHsYYRkvbsc7WTT7ZHNIzhGu_Mu79DhxvYWRmZdwrAnGmEiA2fYAGGKdM9mIlIhMrME67YsDWgDGyEmBmayMa6yHW58QILng48zNRuZISPDS7bEI4l9SWHp0xLQsA-L2d6a_Ix7iz_YR0yDN0-yRxsYI54f97Ps29s3X6_e5zef3l1fvb7JO9nUZY6qVkKaUtWiaOsCGtm2oquxFpxDURagOCLULXTCqL5VUlVGSAmiqaDq2laeZa8OuvPSTWh6MhJg1HOwE4Sf2oPVf1ecHfTW73UllKgaRQIvjgLBf18wJk1z6HGk2aJfohaFoLYtF4Kgz_-B7vwSHD1vRdEPtrVcHckDqg8-xoCbOzMF12tY9DEseg2LPoSFWM_uv-OO8ycaBLg4AIj9X4q_ASNAz8Q</recordid><startdate>20181031</startdate><enddate>20181031</enddate><creator>Lightbody, Calvin J</creator><creator>Campbell, Jonathan N</creator><creator>Herbison, G Peter</creator><creator>Osborne, Heather K</creator><creator>Radley, Alice</creator><creator>Taylor, D Robin</creator><general>BMJ Publishing Group LTD</general><general>BMJ Publishing Group</general><scope>9YT</scope><scope>ACMMV</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>88G</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>BTHHO</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>K9-</scope><scope>K9.</scope><scope>KB0</scope><scope>M0R</scope><scope>M0S</scope><scope>M1P</scope><scope>M2M</scope><scope>NAPCQ</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>PSYQQ</scope><scope>Q9U</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20181031</creationdate><title>Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method</title><author>Lightbody, Calvin J ; 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(2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as ‘expected’ or ‘unexpected’ using the Gold Standard Framework Prognostic Indicator Guidance.SettingMedical, surgical and intensive care units of a district general hospital.OutcomesThe primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical ‘problems’ identified using the Structured Judgement Review Method.Results289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were ‘expected’. Among patients with ‘expected’ deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for ‘problems’, 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and ‘problems’ were significantly lower in the group with a TELP/DNACPR compared with ‘DNACPR only’ and ‘neither’: harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and ‘problems’: 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).ConclusionsThe use of a TELP was associated with a significant reduction in harms, NBIs and ‘problems’ in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.]]></abstract><cop>England</cop><pub>BMJ Publishing Group LTD</pub><pmid>30385448</pmid><doi>10.1136/bmjopen-2018-024264</doi><oa>free_for_read</oa></addata></record>
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subjects Advance directives
Clinical decision making
Decision making
Emergency medical care
Hospitals
Illnesses
Intervention
Mortality
Palliative care
Patient safety
Patient-Centred Medicine
Physicians
Systematic review
title Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method
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