Background: Do not resuscitate (DNR) order is an important aspect of medical practice. Since the implementation of critical care response team (CCRT), frequently we have encountered with patients in the wards that should have been made DNR. Initiating DNR became an important part of CCRT activity. We were obliged to extended the role of CCRT - beyond managing seriously ill patients - in addressing the code status for patients after discussion with the managing teams.
Purpose: We compare the trend of initiation of DNR orders in the regular ward before and after implementing CCRT.
Methods: Our hospital is 1200 bed tertiary care center. CCRT has been launched in January 1, 2008. The CCRT is 24/7 service led by in-house North American certified intensivists. Cohort analysis of prospectively collected data of 5406 CCRT activation from January 1, 2008, to September 30, 2013. Data before implementation of CCRT was available for 299 patients from the period of June 1, 2007, to December 31, 2007. A comparison made between the two groups (before and after implementation of CCRT) for demographic data and percentage of patients in whom DNR order initiated.
Results: Before CCRT implementation, 299 patients were attended by Intensive Care Unit physician for regular consultation, 41.1% were females and 52.4% were males with mean of age 58.44 ± 18.47 standard deviation (SD). DNR was initiated in 2.7% of patients. After CCRT implementation, 5904 CCRT activations, 47.6% females and 52.4% males with mean of age 59.17 ± 20.07 SD DNR initiated in 468 (7.9%) of cases. There was 5.2% increase in DNR orders initiation and completion after CCRT introduced to our institute.
Conclusion: CCRT plays an important role in addressing and initiating DNR.
Hillman K. Critical care without walls. Curr Opin Crit Care 2002;8:594-9.
Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA. Institute for Healthcare Improvement. Available from: http://www.ihi.org. [Last updated on 2010 Aug 16; Last cited on 2013 May 04].
Gao H, McDonnell A, Harrison DA, Moore T, Adam S, Daly K, et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007;33:667-79.
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.
Gouda A, Al-Jabbary A, Fong L. Compliance with DNR policy in a tertiary care center in Saudi Arabia. Intensive Care Med 2010;36:2149-53.
Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: A systematic review and meta-analysis. Arch Intern Med 2010;170:18-26.
Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S; MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The medical emergency team system and not-for-resuscitation orders: Results from the MERIT study. Resuscitation 2008;79:391-7.
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.
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: Preliminary study. BMJ 2002;324:387-90.
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.
Devita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006;34:2463-78.
Jones DA, DeVita M, Bellomo R. Current concepts: Rapid-response teams. N Engl J Med 2011;365:139-46.
Downar J, Rodin D, Barua R, Lejnieks B, Gudimella R, McCredie V, et al. Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: A multicentre retrospective study. J Crit Care 2013;28:498-503.
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.
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.
Gibbins J, McCoubrie R, Alexander N, Kinzel C, Forbes K. Diagnosing dying in the acute hospital setting - Are we too late? Clin Med (Lond) 2009;9:116-9.
Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, et al. A systematic review of physicians′ survival predictions in terminally ill cancer patients. BMJ 2003;327:195-8.
Finucane TE. How gravely ill becomes dying: A key to end-of-life care. JAMA 1999;282:1670-2.