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

Calvin J Lightbody; Jonathan N Campbell; G Peter Herbison; Heather K Osborne; Alice Radley; D Robin Taylor

doi:10.1136/bmjopen-2018-024264

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

Calvin J Lightbody, Jonathan N Campbell, G Peter Herbison, Heather K Osborne, Alice Radley, D Robin Taylor

Deanery of Molecular, Genetic and Population Health Sciences

Research output: Contribution to journal › Article › peer-review

Abstract / Description of output

OBJECTIVES: To 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.

DESIGN: A 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.

SETTING: Medical, surgical and intensive care units of a district general hospital.

OUTCOMES: The 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.

RESULTS: 289 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).

CONCLUSIONS: The 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.

Original language	English
Pages (from-to)	e024264
Journal	BMJ Open
Volume	8
Issue number	10
DOIs	https://doi.org/10.1136/bmjopen-2018-024264
Publication status	Published - 31 Oct 2018

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10.1136/bmjopen-2018-024264

Impact of a treatment escalation-limitation plan...
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Lightbody, C. J., Campbell, J. N., Herbison, G. P., Osborne, H. K., Radley, A., & Taylor, D. R. (2018). 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. BMJ Open, 8(10), e024264. https://doi.org/10.1136/bmjopen-2018-024264

@article{39fb896ebc6f4a6bb8b475774ecefdd7,

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",

abstract = "OBJECTIVES: To 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.DESIGN: A 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.SETTING: Medical, surgical and intensive care units of a district general hospital.OUTCOMES: The 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.RESULTS: 289 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).CONCLUSIONS: The 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.",

author = "Lightbody, {Calvin J} and Campbell, {Jonathan N} and Herbison, {G Peter} and Osborne, {Heather K} and Alice Radley and Taylor, {D Robin}",

note = "{\textcopyright} 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.",

year = "2018",

month = oct,

day = "31",

doi = "10.1136/bmjopen-2018-024264",

language = "English",

volume = "8",

pages = "e024264",

journal = "BMJ Open",

issn = "2044-6055",

publisher = "BMJ Publishing Group",

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Lightbody, CJ, Campbell, JN, Herbison, GP, Osborne, HK, Radley, A & Taylor, DR 2018, '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', BMJ Open, vol. 8, no. 10, pp. e024264. https://doi.org/10.1136/bmjopen-2018-024264

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. / Lightbody, Calvin J; Campbell, Jonathan N; Herbison, G Peter et al.
In: BMJ Open, Vol. 8, No. 10, 31.10.2018, p. e024264.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - 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

AU - Lightbody, Calvin J

AU - Campbell, Jonathan N

AU - Herbison, G Peter

AU - Osborne, Heather K

AU - Radley, Alice

AU - Taylor, D Robin

PY - 2018/10/31

Y1 - 2018/10/31

N2 - OBJECTIVES: To 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.DESIGN: A 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.SETTING: Medical, surgical and intensive care units of a district general hospital.OUTCOMES: The 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.RESULTS: 289 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).CONCLUSIONS: The 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.

AB - OBJECTIVES: To 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.DESIGN: A 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.SETTING: Medical, surgical and intensive care units of a district general hospital.OUTCOMES: The 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.RESULTS: 289 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).CONCLUSIONS: The 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.

U2 - 10.1136/bmjopen-2018-024264

DO - 10.1136/bmjopen-2018-024264

M3 - Article

C2 - 30385448

SN - 2044-6055

VL - 8

SP - e024264

JO - BMJ Open

JF - BMJ Open

IS - 10

ER -

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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