Table 1.
Study type, methods and main findings.
| Study first author | Year | Hospital type (beds) | Country | Study design | Main findings |
|---|---|---|---|---|---|
| Austin24 | 2014 | Academic (800+) with specialist cancer centre (50) | The United States | Retrospective cohort | NFR orders created before, during and after the RRT review were low, at 9.6%, 3% and 13.3%, respectively. RRT activations were higher for oncology patients than general medical patients (37.34 v 20.86 per 1000 patient discharges) |
| Boniatti25 | 2010 | Academic (794) | Brazil | Retrospective observational | RRT review is associated with a high 30-day mortality, with NFR orders before and after the RRT review 5.1% and 3.3%, respectively |
| Calzavacca26 | 2010 | Tertiary (400) | Australia | Retrospective observational | 22.7% of patients had an NFR order prior to RRT review and an additional 8.5% after. Patients with multiple RRT reviews have increased risk of mortality |
| Calzavacca27 | 2010 | Tertiary (400) | Australia | Retrospective observational | 15% of patients had an NFR order prior to RRT review and further 9.5% after |
| Calzavacca28 | 2008 | Tertiary (NS) | Australia | Prospective observational | Presence of NFR orders was independently associated with mortality |
| Cardona-Morrell29 | 2016 | Teaching (NS) | Australia | Retrospective case-control analysis | Older patients requiring RRT with pre-existing LOMT or multiple indicators of chronic illness, cognitive impairment and frailty had a higher risk of death |
| Casamento30 | 2008 | General (NS) | Australia | Prospective audit and chart review | High in-hospital mortality following RRT review (32%) |
| Chen20 | 2008 | 23 hospitals | Australia | Cluster randomized control trial | NFR orders were uncommon for people receiving RRT review for cardiac arrest or unplanned ICU admission, due to limited time in which to discuss end-of-life wishes |
| Dargin31 | 2014 | Tertiary (350) | The United States | Retrospective | High in-hospital mortality for patients following RRT review. End-of-life care may be improved with better coordination between medical teams and palliative care |
| Downar32 | 2013 | 3 academic (NS) | Canada | Retrospective | In-hospital mortality for patients with an NFR order was high. RRTs frequently facilitate end-of-life discussions and decision making |
| Gouda and Alqahtani33 | 2016 | Tertiary (1200) | Saudi Arabia | Retrospective chart review | RRTs have a key role in addressing and initiating NFR orders |
| Jäderling34 | 2013 | Teaching (650) | Sweden | Observational cohort | In-hospital mortality for patients with NFR orders was high in the short- and long-term. Decisions about limitations of treatment are often made close to the time of the RRT review and did not preclude further RRT reviews |
| Jäderling35 | 2011 | 2 Teaching (650)/(400) | Sweden Australia |
Two-centre prospective observational study | Similarities in pre-existing LOMT (34.2% and 30.8%) and those implemented after RRT review (14.4% and 12.6%) were found between two different centres in Sweden and Australia, respectively |
| Jones11 | 2012 | 7 Academic | Australia (5) Canada (1) Sweden (1) |
Prospective audit | Approximately one-third of RRT reviews involved end-of-life and LOMT issues, highlighting a need for improved advance care planning |
| Medical Emergency Team End-of-Life Care investigators14 | 2013 | 7 Academic | Australia (5) Canada (1) Sweden (1) |
Prospective audit | Patients who required RRT review later in the admission (after day 7) were more likely to have a LOMT than patients receiving review on day 0 or 1 |
| Knott17 | 2011 | Tertiary teaching (450) | New Zealand | Retrospective cohort | LOMT and NFR documentation rates doubled after RRT review |
| O’Horo36 | 2015 | Tertiary (NS) | The United States | Retrospective chart review and prospective survey | Involvement of the primary treating team in RRT reviews was associated with significantly higher transfers to higher level care and discussion about code status |
| Parr37 | 2001 | Tertiary (580) | Australia | Retrospective cohort | The RRT can identify patient for whom an NFR should be considered |
| Psirides38 | 2016 | 11 (including 6 tertiary, 1 paediatric) | New Zealand | Prospective multicentre observational | RRT reviews resulted in new NFR orders (22.5%), altered early warning system calling criteria (10.8%) and other treatment limitations (8.8%) |
| Schneider39 | 2011 | Teaching (400) | Australia | Retrospective cohort | Atrial fibrillation was a trigger for approximately 10% of RRT activations |
| Silva40 | 2016 | Tertiary academic (600) | Portugal | Retrospective cohort | Prior to RRT activation, 5.1% of patients had an NFR order and 2.5% had a withhold therapy decision. An additional 24.1% had end-of-life decisions as part of the RRT actions |
| Smith41 | 2014 | Tertiary (300) | The United States | Retrospective audit (non-cardiac arrest events only) | NFR orders were in place before the RRT review for 11.01% of patients, with an additional 5.5% created at the time of the RRT review |
| Smith42 | 2015 | Academic teaching (400) | Australia | Retrospective cohort | NFR implemented by RRT during early reviews (<48 h of admission) in 3.91% of cases, 5.45% for intermediate cases (48<168 h after admission) and 8.39% in late cases (⩾168 h after admission) |
| Smith13 | 2014 | Tertiary (NS) | Australia | Retrospective, quasi-experimental | 28% of RRT reviews were associated with an NFR order. In 11.5% of instances, NFR was placed prior to the review |
| Stelfox21 | 2015 | 2 tertiary, 2 community (2883) | Canada | Retrospective database review | 2% of patients <50 years and 15% of patients >80 years had goals of care changed to exclude resuscitation following RRT review |
| Sulistio19 | 2015 | 3 hospitals (NS) | Australia | Retrospective cohort | 36.2% of patients had documented LOMT, 77.2% of these were instituted following the RRT review. Goals were changed to a more palliative intent in 28.5% of patients following RRT review |
| Sundararajan43 | 2014 | Tertiary (650) | Australia | Prospective study | Pre-existing LOMT orders were more likely to have been made in consultation with the patient or NOK (patient 50%, NOK 90%) compared with LOMT associated with an RRT review (patient 18%, NOK 58%) |
| Tam44 | 2014 | Tertiary (458) | Canada | Retrospective chart review | 6% of patients had their resuscitation status initiated or revisited by the RRT. Of these, 27% of patients had their status changed to NFR following the consultation |
| Tirkkonen45 | 2016 | University (NS) | Finland | Prospective observational | New LOMT were issued for 9.2% patients following RRT review following discussion with the patient in 19% or cases and discussion with relatives in 69% of cases |
| Tirkkonen46 | 2013 | Tertiary (769) | Finland | Prospective observational | NFR orders were associated with increased hospital mortality |
| Visser47 | 2014 | Sub-acute (NS) | Australia | Retrospective observational | LOMT were documented for 79.4% patients on admission. For 22.7% of the RRT reviews, there was an increase in LOMT following review by the RRT |
| White48 | 2016 | University teaching (780) | Australia | Prospective cohort | Few RRT activations were associated with a resuscitation order, with high mortality and transfers to ICU following RRT reviews |
LOMT, limitations of medical treatment; NFR, not for resuscitation; NOK, next of kin; RRT, Rapid Response Team.