Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments

Abstract

The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear. Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010. Common reasons for transfer were respiratory (18.9%) or neurological (19.0%) conditions; 35.7% (154/431) were transferred within one week of sub-acute care admission. LOMT orders were in place for 37.8% (n=163) patients who were older (p<0.001), with more comorbidities (p<0.005), specifically cardiac, renal and pulmonary disease than patients without LOMT. Patients with LOMT orders had more physiological abnormalities before transfer; tachypnoea (43.7% vs 28.6%), hypoxaemia (63.5% vs 48.4%) and severe hypoxaemia (27.6% vs 14.5%). There were no differences in rates of admission, cardiac arrest, Medical Emergency Team activation or ICU admission. For admitted patients, those with LOMT orders had significantly (p≤0.005) higher mortality: in-hospital (21.9% vs 11.3%); 30 days (23.9% vs 12.3%) and 60 days (28.2% vs 13.4%). Patients with LOMT had higher levels of comorbidity and were more acutely ill during their sub-acute care admission. Once transferred those with a LOMT had similar rates of cardiac arrest, MET activation and unplanned ICU admission, but higher mortality.