Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem.

PURPOSE: To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES: English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION: All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION: A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS: Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION: This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.

A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients.

AIM: To determine whether the introduction of a multi-faceted intervention (newly designed ward observation chart, a track and trigger system and an associated education program, COMPASS) to detect clinical deterioration in patients would decrease the rate of predefined adverse outcomes. METHODS: A prospective, controlled before-and-after intervention of trial was conducted in all consecutive adult patients admitted to four medical and surgical wards during a 4 month period, 1157 and 985, respectively. A sub-group of patients underwent vital sign and medical review analysis pre-intervention (427) and post-intervention (320). The outcome measures included: number of unplanned admissions to the intensive care unit (ICU), Medical Emergency Team (MET) reviews and unexpected hospital deaths, vital sign documentation frequency and incidence of a medical review following clinical deterioration. This study is registered, ACTRN12609000808246. RESULTS: Reductions were seen in unplanned admissions to ICU (21/1157 [1.8%] vs. 5/985 [0.5%], p=0.006) and unexpected hospital deaths (11/1157 [1.0%] vs. 2/985 [0.2%], p=0.03) during the intervention period. Medical reviews for patients with significant clinical instability (58/133 [43.6%] vs. 55/79 [69.6%] p<0.001) and number of patients receiving a MET review increased (25/1157 [2.2%] vs. 38/985 [3.9%] p=0.03) during the intervention period. Mean daily frequency of documentation of all vital signs increased during the intervention period (3.4 [SE 0.22] vs. 4.5 [SE 0.17], p=0.001). CONCLUSION: The introduction of a multi-faceted intervention to detect clinical deterioration may benefit patients through increased monitoring of vital signs and the triggering of a medical review following an episode of clinical instability.

Re-wiring an arterial line. A novel technique.

In cases where the loss of a small volume of blood is critical to the patient's welfare, the technique of re-wiring intra-arterial and intravenous catheters that minimize the amount of blood lost is important. A simple technique is described using the needleless systems which are now widely employed throughout hospitals.

Comparison of Fluorescent Antibody with Cultural Technique for Isolation of Enteropathogenic Escherichia coli from Swine.

In an investigation of hogs as possible reservoirs of human strains of enteropathogenic Escherichia coli (EEC), 92 six-month-old grain- and garbage-fed hogs were examined on the farm and again at the packing plant. Of the 331 specimens obtained by swabbing the rectum, cecum, and edible meat carcass of these hogs, 125 were presumptively positive for EEC when screened by the fluorescent-antibody (FA) technique. These "presumptive positive" specimens then underwent extensive bacteriological examination and complete serological typing. The FA technique proved to be an easier, simpler, and more economical procedure than culture when a large number of specimens were examined for possible EEC serogroups. It was found especially valuable for identification of multiple serogroups of EEC within a single specimen. It also appeared to be more sensitive than cultural examination, since results were not dependent on the presence of large numbers of organisms in the specimen, or even on their viability. However, the FA technique was found to be less specific than culture because of cross-reactivity with antigenically related Enterobacteriaceae when fluorescein-labeled antisera were used. Therefore, any specimen found positive on FA examination should be considered as presumptive positive until confirmed by bacteriological examination and complete serological study.