Mortality outcomes in hospitalized oncology patients after rapid response team activation
Background The prognosis of hospitalized oncology patients varies widely, and physicians are poor at predicting outcomes in cancer patients. Discrete signifiers of prognosis in hospitalized oncology patients are widely sought.
Objective To test the hypothesis that oncology patients who have had rapid response team (RRT) activations would have high rates of in-hospital and 100-day mortality, and that these might differ based on malignancy type and other clinical factors.
Methods A retrospective study was performed at a single, 900+ bed academic center in the northeastern United States during a 2-year study period using an RRT-specific database. We included patients 18 years or older with a cancer diagnosis, including solid tumor and hematologic malignancy, as well as those who were status post-bone marrow transplantation, who required RRT activation. Surgical and intensive care unit patients were excluded. Primary outcome variables of interest were inpatient and 100-day mortality post-RRT activation as well as the clinical variables leading up to RRT activation.
Results RRT activation was associated with a high inpatient mortality in patients with solid tumor and hematologic malignancies (43% and 35%, respectively) and a 100-day mortality (solid tumors, 78%; hematologic malignancies, 55%). In multivariate analysis, female sex was associated with significantly higher inpatient and 100-day mortality.
Limitations This retrospective review of a single center's data on oncology patients may not apply to all hospitals.
Conclusions These findings demonstrate high inpatient and 100-day mortality in a selected population of oncology patients. The event of an RRT activation may be a useful predictor of prognosis in oncology patients and can be used to help patients and families improve advance care and end-of-life planning.
Funding Cancer Center Support Grant 5P30CA056036-17 and the Biostatistics Shared Resource of Thomas Jefferson University
Accepted for publication November 20, 2018
Correspondence Neil D Palmisiano MD; Neil.palmisiano@jefferson.edu
Disclosures: The authors report no disclosures/conflicts of interest.
©2018 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0439
Results
A total of 179 hospitalized oncology patients had an RRT activation during the 2-year study period during October 2014 through November 2016. During that time, 4,654 medical oncology patients were admitted to the hospital, resulting in a rate of RRT activation of 38.4 events per 1,000 admissions. In all, 179 patients were included in the analyses for inpatient mortality, and 175 patients were included for 100-day mortality post-RRT. Patients with unknown mortality status (n = 4) at 100 days after RRT were excluded from the analyses.
The average age of the study patients was 62.3 years (standard deviation [SD], 13.3; Table 1). They comprised equal proportions of men (52%) and women (48%). Just more than half (52%) of the patients carried a diagnosis of solid malignancy, 39% of hematologic malignancy, and 9% status post-BMT. Most of the patients were full code (80%) at the time of RRT activation. The average number of days from admission to RRT event was 9.5 days (SD, 12.1). Equal proportions of RRT events took place during the daytime (52%) and nighttime (48%), and more than half of the study patients (56%) were transferred to the ICU within 24 hours of the RRT activation. Of all the study patients, 11.7% were discharged to hospice after the RRT event, and 53% required RRT evaluation for increased work of breathing. Forty-nine percent of the total study patients had peri-RRT lactate levels ≥2 mmol/L (reference range, 0.5-2.0 mmol/L), and 58% had peri-RRT INR levels ≥1.2 (reference range, 0.85-1.15). The average SIRS score was 2.8 (SD, 1.1), and the qSOFA score was 1.4 (SD, 0.8) in the 24 hours preceding the RRT activation.
Over the 2-year study period, the inpatient mortality rate for all admitted oncology patients was 2.3% (108 deaths in 4,654 oncology inpatients), according to claims data. By comparison, of the 179 patients who required an RRT activation, 39% did not survive to discharge. When those patients were categorized based on their cancer type, 43% of the solid malignancy patients died within the same hospital stay after an RRT event, 35% of the hematologic malignancy patients died, and 25% of the status post-BMT patients died. Of the 175 patients with known mortality status at 100 days after RRT, 65% of total patients had died within that time compared with only 15.7% (347 deaths in 2,217 patients) of all admitted patients with cancer who did not experience an RRT event. When categorized based on their cancer type, significantly more patients (78%) with solid tumors had died within 100 days after RRT activation, whereas only 55% of those with a hematologic malignancy and 50% of those who were post-BMT died within the same time period.
Tables 2 and 3 present major findings from regression models with a moderate to strong level of prediction. The characteristics associated with increased odds of inpatient mortality among solid tumor patients after an RRT event were female sex (OR, 4.91; 95% CI, 1.45-16.6), increased work of breathing as the reason for the RRT activation (OR, 5.53; 95% CI, 1.69-18.1), having no lactate level ordered (OR, 5.12; 95% CI, 1.05-25.1), each unit increase in SIRS score (OR, 1.92; 95% CI, 1.01-3.66), each unit increase in qSOFA score (OR, 3.32; 95% CI, 1.45-7.56), and each unit increase in peri-RRT blood products being given (OR, 1.74; 95% CI, 1.03-2.94). Among hematologic malignancy patients, ICU transfer within 24 hours of the RRT (OR, 3.85; 95% CI, 1.14-13.0) was associated with increased inpatient mortality, whereas having no lactate level ordered (OR, 0.09; 95% CI, 0.01-0.96) was associated with lower odds of inpatient mortality.
The characteristics associated with increased odds of 100-day mortality in patients with solid tumors were female sex (OR, 4.99; 95% CI, 1.22-20.3), increase in each day from admission to RRT event (OR, 1.14; 95% CI, 1.01-1.18), and each unit increase in SIRS score (OR, 2.04; 95% CI, 1.02-4.07). For hematologic malignancy patients, being do not resuscitate (DNR) or do not intubate (DNI) (OR, 7.65; 95% CI, 1.21-48.2) was associated with increased odds of 100-day mortality.
