Characteristics and outcome of rapid response team patients >= 75 years old: a prospective observational cohort study

ORIGINAL RESEARCH Open Access Cha ac e is ics and ou come o apid esponse eam pa ien s ≥75 yea s old: a p ospec i e obse a ional coho s udy Joonas Ti kkonen 1*† , Pi i a Se älä 2† and Sanna Hoppu 3 Abs ac Backg ound: Rapid esponse eams (RRTs) a end se e ely ill gene al wa d pa ien s whose a e age 30-day mo ali y is nea 30%. A majo pa o RRT pa ien s a e o e 75 yea s old, bu he e a e no s udies on he cha ac e is ics and ou come o his ge ia ic RRT popula ion. We compa ed he cha ac e is ics and ou come o ge ia ic RRT sub-popula ion wi h he RRT pa ien s <75 yea s old. We u he in es iga ed, whe he he accumula ion o isk ac o s (RFs) o mo ali y among he gene al RRT popula ion p edic s a enuous ou come among he ge ia ic sub-popula ion. Me hods: P ospec i e h ee-yea obse a ional coho s udy o adul RRT pa ien s in Tampe e Uni e si y Hospi al, Finland. A e iden i ying independen RFs o 30-day mo ali y among RRT pa ien s wi h mul i a ia e logis ic eg ession, we u he s udied he impac o he accumula ion o hese RFs among ge ia ic RRT pa ien s who had no limi a ions o medical ea men . Resul s: A o al o 1372 pa ien s we e e iewed 1722 imes. Ge ia ic pa ien s (n= 449, 33%), when compa ed o non-ge ia ic pa ien s, had highe 30-day (33% s. 21%, espec i ely; p< 0.001) and one-yea (54% s. 35%, espec i ely; p< 0.001) mo ali y a es. Among he gene al RRT popula ion, posi i e RRT c i e ia as measu ed by RRT du ing he e iew, high como bidi y index, age ≥75 yea s, non-elec i e hospi al admission, medical eason o admission and a e en limb ailu e we e iden i ied as independen RFs o 30-day mo ali y and classi ied as easible o ob ain du ing a ou ine RRT e iew. The obse ed a es o hese RFs among he ge ia ic RRT pa ien s subs an ially a ec ed hei 30-day mo ali y (e.g. no RFs: 5.3%; one RF: 14%; wo RFs: 27%; h ee RFs: 38%; ou RFs: 52%; i e RFs: 38%). Conclusions: One- hi d o pa ien s e iewed by RRT we e ≥75 yea s old, and age s a is ics we e compa able o p e ious RRT s udies sugges ing ha his is he case globally. Ou come o ge ia ic RRT pa ien s is poo e as compa ed wi h RRT pa ien s <75 yea s. Howe e , he ou come is subs an ially a ec ed by he acc uemen (o lack) o RFs gene ally inc easing he mo ali y o RRT pa ien s. Conside ing hese ac o s du ing a ge ia ic RRT e iew may aid wi h he decision o ei he escala e o de-escala e ca e. Keywo ds: Rapid esponse eam, Medical eme gency eam, Rapid esponse sys em, Ge ia ic, Ou come * Co espondence: [email p o ec ed] † Equal con ibu o s 1 Depa men o In ensi e Ca e Medicine, Tampe e Uni e si y Hospi al, Depa men o Anaes hesiology and In ensi e Ca e Medicine, Seinäjoki Cen al Hospi al, Uni e si y o Tampe e, PO Box 2000, FI-33521 Tampe e, Finland Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2017 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 DOI 10.1186/s13049-017-0423-8 Backg ound The apid esponse sys em (RRS) is a pi o al link in he ‘chain o su i al’o an in-hospi al ca diac a es [1]. In cases o in-hospi al pa ien de e io a ion, apid esponse eams (RRTs) o m he e e en limb o he RRSs, p o i- ding pa ien assessmen , bedside in e en ion, and apid escala ion o ca e i deemed app op ia e [2]. On he o he hand, RRTs ini ia e limi a ions o medical ea - men (LOMT) in a median o 8% o he e iews, and a end pa ien s wi h p e-exis ing LOMT egula ly [3, 4]. The a e age RRT pa ien is gene ally a ound 59–65 yea s old, p esen ed ei he as means (± s anda d de ia ions) o medians (qua iles) in he RRT li e a u e [4–12]. This sug- ges s ha many RRT pa ien s a e ≥75 yea s old. Mo ali y among he elde ly c i ically ill pa ien s is high, and age is an independen isk ac o o wo se ou come, al hough como bidi ies, o a lack o hem, subs an ially a ec he p ognosis [13, 14]. The e o e, high age alone does no equal u ili y o u he ea men s no mo e han young age alone equals be e ou come. To assis wi h RRT e- iews in which he ini ia ion o ea men goals, a he han he escala ion o ca e, migh be app op ia e, Ca dona-Mo ell and Hillman ha e de eloped he C iSTAL ool [15]. The C iSTALs p emise is ha he RRT pa ien is ≥65 yea s old, a e which igo ous as- sessmen on pa ien backg ound is conduc ed. While he C iSTAL ool seems p o icien , s a is ically in in- cludes on a e age, hal o RRT pa ien s. The e is no da a on cha ac e is ics and ou come o ge ia ic (≥75 yea s) RRT pa ien s. I is unknown, whe he hei p ognosis is subs an ially wo se o no as compa ed wi h RRT pa ien s <75 yea s old. Fu he , i has no been in es iga ed how he acc uemen o known isk ac o s o mo ali y among he gene al RRT popu- la ion, o lack o hem, in luence on he p ognosis o ge ia ic RRT pa ien s. Me hods Aim and design We aimed o compa e he cha ac e is ics and ou comes o RRT pa ien s ≥75 yea s old wi h younge adul RRT pa ien s in a h ee-yea p ospec i e obse a ional single cen e coho s udy. We u he in es iga ed he inde- penden isk ac o s o ixed 30-day mo ali y among he whole s udy coho and hen es ed he hypo hesis, ha he acc uemen o hese isk ac o s a ec he ou - come o ge ia ic RRT pa ien s wi hou p eceding LOMT. E hics The E hics Commi ee o he Tampe e Uni e si y Hospi al (Tays) app o ed he s udy p o ocol (App o al no: R10111). Pa ien consen was wai ed as no in e en ions we e conduc ed. Hospi al and RRT Tays is one o i e e ia y e e al cen es in Finland, wi h 71,000 soma ic admissions annually. I has a closed model, mixed su gical-medical in ensi e ca e uni (ICU) wi h 24 beds and app oxima ely 2100 admissions pe yea . Tays has a RRS ha includes egula aining o he wa ds’RRS- esponsible nu ses, who, in u n, dis ibu e his knowledge o hei homewa d colleagues. The wa ds use dicho omised RRT ac i a ion c i e ia (hea a e < 40/ min o >140/min, sys olic blood p essu e < 90 mmHg, pe iphe al a e iola oxygen sa u a ion < 90%, espi a- o y a e < 5/min o >24/min and dec ease in s a e o consciousness), in addi ion o he subjec i e ‘nu se wo - ied’c i e ion (no objec i e c i e ia a e equi ed in case a nu se is wo ied ha a pa ien is de e io a ing). The RRT comp ises an ICU physician ( eam leade ) and wo ICU nu ses. The RRT has a wo- ie app oach when ig- ge ed; i he e iew is no assessed as immedia ely li e- h ea ening, he wo RRT nu ses may i s a end he pa ien be o e epo ing o he RRT leade . De ini ions The e m ‘RRT pa ien ’ e e s o a hospi alised indi idual equi ing one o se e al RRT a endances. Regula ollow-up isi s a e some imes issued o discha ged ICU pa ien s; in his s udy, hese scheduled ‘ou each isi s’we e no conside ed RRT ac i a ions. The age limi o a pa ien o be de ined as ‘ge ia ic’o ‘aged’ a ies subs an ially in he in ensi e ca e and esusci a- ion li e a u e (≥60–80 yea s) [13–19]. The Eu opean Union Ge ia ic Medicine Socie y e e s o pa ien s >60 as aged [20]. De ining pa ien s 60–65 yea s old as ‘ge ia ic’ did no seem app op ia e in his s udy, conside ing he age dis ibu ion o he gene al RRT coho s [4–12] and me e he ac ha he s a u o y lexible pension age in Finland is 63–68 yea s. The e o e, we de ined RRT pa ien s ≥75 yea s old as ‘ge ia ic’RRT pa ien s in his s udy. Da a collec ion Be ween 1 May 2012 and 30 Ap il 2015, we collec ed da a p ospec i ely on RRT ac i a ions pe he U s ein S yle. This collec ion was pa o an ongoing p ojec o RRT da a ga he ing ( he hi d componen o he RRSs, Jones e al. 2011) [2, 21]. Speci ic pa ien da a we e ob- ained om pa ien eco ds, da a on a e en limb ailu e (documen ed posi i e MET ac i a ion c i e ia 20– 360 min be o e he RRT ac i a ion) we e ob ained om elec onic nu sing eco ds, and long- e m mo ali y da a we e e ie ed om he Finnish Popula ion Regis e Cen e [22]. Exclusion c i e ia RRT ac i a ions o paedia ic pa ien s (< 18 yea s) and hos- pi al isi o s (ou pa ien s) we e excluded. RRT ac i a ions Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 Page 2 o 8 o he ICU, ope a ion ooms and eme gency depa men we e also excluded. Finally, RRT e iews in ol ing ca diac a es s and epea RRT e iews we e excluded. S a is ical analysis Da a a e p esen ed as numbe s (pe cen ages) unless o he wise indica ed. Chi-squa e and Mann–Whi ney U- es s we e used o compa isons be ween g oups. Mul i a ia e logis ic eg ession was applied wi h he ‘ENTER’me hod o in es iga e hose ac o s independ- en ly associa ed wi h wo se ou comes wi hin he en i e RRT popula ion. Age was inpu ed as a dicho omised a iable o e lec he s udy’shypo hesis.AHosme - Lemeshow es was conduc ed o p esen he goodness- o - i o he model. The iden i ied isk ac o s ha would be easible o ob ain du ing ou ine RRT e iew we e hen es ed as dicho omized a iables among he no-LOMT ge ia ic sub-popula ion. Tes s we e wo-sided; p< 0.05 was conside ed signi i- can and 95% con idence in e als we e epo ed whe e app op ia e. SPSS e sion 20 o Windows (SPSS Inc., Chicago, IL, USA) was used. Resul s S udy coho Du ing he s udy pe iod, 1914 RRT e iews mee ing he inclusion c i e ia we e obse ed. In 192 o hese, he pa- ien su e ed a ca diac a es ; hese e iews we e excluded om u he analysis. The inal coho comp ised 1372 RRT pa ien s who we e a ended a o al o 1722 imes (Fig. 1). Figu e 2 p esen s he age dis ibu ion o he co- ho : 1003 (73%) RRT pa ien s we e ≥60 yea s old, and 632 (48%) ≥70 yea s old. The median age o he RRT pa- ien s was 69 (59, 78), and he mean age was 67 ± 16 (bo h skewness and ku osis be ween −1.0 and +1.0). Ge ia ic RRT pa ien s s. non-ge ia ic RRT pa ien s E e y hi d RRT pa ien was conside ed ge ia ic pa- ien (449, 33%) (Fig. 1). Ge ia ic pa ien s we e mo e likely o be emale, o be admi ed as su gical pa ien s and o p esen como bidi y bu den han pa ien s <75 yea s old (Table 1). RRT e iew cha ac e is ics we e o he wise ela i ely compa able, hough ge ia ic pa ien s we e mo e likely o ecei e a new LOMT and we e seldom admi ed o in ensi e ca e. Among he pa ien s admi ed o in ensi e ca e, su i al a es and leng h o s ay we e equal o ge ia ic and non- ge ia ic pa ien s. Table 2 p esen s he ou comes o he s udy popula ion. Ge ia ic pa ien s had highe 24 h and hospi al mo ali y, we e a ely discha ged home and had highe ixed mo - ali y o up o one yea when compa ed o non-ge ia ic pa ien s. Independen isk ac o s o 30-day mo ali y among he s udy coho Table 3 p esen s he esul s o he mul i a ia e eg es- sion analysis o he ac o s independen ly associa ed wi h 30-day mo ali y among he 1322 RRT pa ien s. P eced- ing LOMT, posi i e RRT c i e ia as measu ed by RRT du ing he e iew, high como bidi y index, age ≥75 yea s, non-elec i e hospi al admission, medical eason o ad- mission and a e en limb ailu e we e iden i ied as inde- penden isk ac o s. Fig. 1 S udy coho . RRT, apid esponse eam Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 Page 3 o 8 E ec o he accumula ion o he isk ac o s on he ou come o ge ia ic RRT pa ien s wi hou p eceding ea men limi a ions The abo e-men ioned isk ac o s we e es ed in he ge- ia ic sub popula ion wi hou p eceding LOMT (n= 411). By de ini ion, he ac o s o age ≥75 yea s and p eceding LOMT we e no applied, and he Cha lson como bidi y sco e was dicho omised o <5 and ≥5 ( he la e indica ing se e e como bidi y). Figu e 3 p esen s he impac o he acc uemen o hese isk ac o s (o lack o hem). Ge ia ic pa ien s wi h none o hese ac o s had a ixed 30-day mo - ali y o jus 5.3%, whe eas pa ien s wi h ou o hese ac- o s had a 52% 30-day mo ali y (p< 0.001). Only eigh ge ia ic pa ien s had all i e isk ac o s. Discussion Key indings This p ospec i e obse a ional coho s udy e ealed ha e e y hi d RRT pa ien is ≥75 yea s old. Since he median (and mean) age o he coho was compa able o o he s udies a ound he wo ld, i seems ha RRTs globally a e aced wi h he same challenges ela ed o ageing popula ions. As may be expec ed, he ge ia ic sub popula ion was, in gene al, mo e p one o wo se ou comes. Howe e , ad anced age alone does no pe se equal u ili y o ad anced ea men s, hough i is an independen isk ac o o 30-day mo ali y. In- deed, he possible u ili y and e hics o escala ing ge- ia ic RRT pa ien s’ca e should be ca e ully weighed when hese pa ien s p esen mul iple known isk ac- o s o 30-day mo ali y among he gene al RRT popula ion. On he o he hand, lack o hese isk ac- o s du ing a ge ia ic RRT e iew indica e ha ge i- a ic pa ien ’sp ognosismaybesubs an iallybe e han RRT pa ien s’p ognosis in gene al. Age o RRT pa ien s RRT s udies om Aus alia, New Zealand, he Uni ed S a es o Ame ica and Sweden epo he median o mean age o RRT pa ien s o ange be ween 66 and 74, and hese alues a e in line wi h ou indings [4, 5, 7–9, 11, 12]. One s udy om B azil epo ed a lowe mean age o 63 yea s, while one s udy om he Uni ed Kingdom epo ed a highe median age o 76 yea s indica ing ha some a i- abili y exis s [6, 10]. Ne e heless, i may be concluded ha , in gene al, a majo pa o RRT pa ien s a e o uly ad anced age (≥75 yea s). The e o e, ou indings can be gene alised o he challenges ela ed o ageing RRT pa- ien s a ound he wo ld. Fu he mo e, he pe cen age o he RRT pa ien popula ion ha is ge ia ic can only be expec ed o inc ease wi h he ageing popula ions in Wes e n coun ies; his has al eady been obse ed among ICU pa ien s [19]. Compa ison o ge ia ic RRT pa ien s wi h younge RRT pa ien s The como bidi y bu den was no subs an ially highe among he ge ia ic RRT pa ien s, al hough he di e ence was s a is ically signi ican . The esul s sugges ha youn- ge RRT pa ien s o en ha e mode a e o se e e como bi- dies as well. RRT igge easons we e compa able, and i al signs we e documen ed as o en abno mal in bo h sub coho s. Pe haps he mos impo an inding was, ha he sho - e m ou comes o pa ien s admi ed o ICU did no di e be ween he ge ia ic and younge RRT pa ien s. Thus, he RRT seemed o conduc well- ounded pa ien selec ion despi e o en ope a ing du ing on-call hou s, du ing which he suppo om he pa en uni is limi ed. Long- e m ixed mo ali y a es we e highe in ge ia ic sub coho , bu i should be acknowledged ha mo ali y a es among younge RRT pa ien s we e high as well. Fig. 2 Dis ibu ion o he 1372 RRT pa ien s acco ding o age. RRT, apid esponse eam Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 Page 4 o 8 Table 1 Cha ac e is ics o RRT pa ien s and hei i s RRT e iews, ≥75 yea s s. < 75 yea s old ≥75 yea s (n= 449) < 75 yea s (n= 923) p- alue Pa ien cha ac e is ics Age (median; Q 1 ,Q 3 ) 82 (78, 85) 63 (52, 69) < 0.001 Sex (male) 240 (54) 581 (63) 0.001 Medical pa ien 155 (35) 405 (44) 0.001 CCI (median; Q 1 ,Q 3 ) 2.0 (1.0, 4.0) 2.0 (0.0, 3.0) < 0.001 Co ona y a e y disease 108 (24) 102 (11) < 0.001 Ch onic hea ailu e 124 (28) 99 (11) < 0.001 Pe iphe al a e y disease 55 (12) 83 (9.0) 0.063 Ce eb o ascula disease 86 (19) 108 (12) < 0.001 Diabe es 112 (25) 218 (24) 0.620 Ch onic obs uc i e pulmona y disease 55 (12) 100 (11) 0.449 Renal insu iciency 48 (11) 77 (8.4) 0.162 Malignancy 117 (26) 227 (25) 0.579 Elec i e hospi al admission 345 (77) 698 (76) 0.621 Leng h o hospi al admission (days, median; Q 1 ,Q 3 ) 8 (4, 14) 11 (6, 23) < 0.001 P eceding ICU admission 52 (12) 198 (22) < 0.001 P eceding LOMT 38 (8.5) 48 (5.2) 0.019 Su ge y 0–24 h be o e he e iew 73 (16) 107 (12) 0.016 RRT e iew cha ac e is ics Days in hospi al be o e he e iew (median; Q 1 ,Q 3 ) 2 (1, 5) 2 (1, 7) 0.001 Re iew du ing on-call ime a 340 (76) 700 (76) 0.963 A e en limb ailu e b 128 (37) 273 (36) 0.650 Leng h o RRT e iew (min) (median; Q 1 ,Q 3 ) 27 (20, 39) 30 (20, 41) 0.044 Reason o RRT ac i a ion •Respi a o y 156 (45) 304 (40) •Ci cula o y 69 (20) 142 (19) •Neu ologic 47 (14) 128 (17) 0.297 •Mul iple 14 (4.1) 38 (5.0) •O he c 59 (17) 153 (20) Vi als documen ed by RRT •AVPU ≤3 o GCS ≤13 129 (29) 233 (25) 0.176 •Hea a e < 40 o >140 /min 42 (9.4) 75 (8.1) 0.452 •Sys olic blood p essu e < 90 mmHg 61 (13) 126 (14) 0.962 •Respi a o y a e < 5 o >24 /min 175 (39) 351 (38) 0.757 •SpO 2 < 90% 139 (31) 238 (26) 0.047 •None o he abo e 118 (26) 246 (27) 0.866 RRT in e en ion •Fluids 165 (37) 305 (33) 0.175 •Oxygen o In uba ion 20 (4.5) 48 (5.2) o CPAP 42 (9.4) 105 (11) 0.300 o Mask 226 (50) 417 (45) •Medica ions 100 (29) 239 (31) 0.450 New LOMT 57 (13) 43 (4.7) < 0.001 Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 Page 5 o 8 Risk ac o s o 30-day mo ali y The p e iously iden i ied associa ion o se e al inde- penden isk ac o s wi h hospi al mo ali y o 30-day mo ali y was con i med o 30-day mo ali y in his s udy [6, 7]. In addi ion, he cumula i e impac o basic diseases was inpu ed as con inuous a iable, he Cha lson como bidi y index sco e, o he mul i a ia e logis ic e- g ession model, and i was shown o be independen ly as- socia ed wi h wo se ou come [23]. Finally, as a majo pa o he RRT calls a e igge ed o non-physiological ea- sons (e.g. he ‘nu se wo ied’c i e ion), we also included whe he he pa ien ul illed he RRT ac i a ion c i e ia du ing he e iew as a a iable in he model. Posi i e ac i- a ion c i e ia eco ded by he RRT we e also associa ed wi h wo se ou comes, as could be expec ed. Iden i ied isk ac o s as ou come p edic o s o ge ia ic pa ien s Measu ed a any gi en poin , om 24 h o one yea a e he isi , ge ia ic pa ien s had highe mo ali y a es. This, howe e , did no e eal any hing abou he p og- nosis o an indi idual ge ia ic pa ien . We ound ha he p ognosis o ge ia ic pa ien s a ied subs an ially, depending on he acc uemen o isk ac o s known o be associa ed wi h poo p ognosis among RRT pa ien s. In ac , he ge ia ic RRT pa ien s wi h ze o o one isk ac o had lowe 30-day mo ali y a e han he RRT pa- ien s <75 yea s old despi e hei median age was jus 63 yea s. Wo h discussing is also ha a e en limb ai- lu e, also known as delayed RRT ac i a ion, was included as one o he i e ac o s es ed he e. While his ac o ep- esen s a clea sys em ailu e, un o una ely pa ien ’sp og- nosis is indispu ably wo se i his/he condi ion has been allowed o de e io a e o hou s wi hou in e en ions. In some cases ICU physicians a e o ced o e alua e, whe he a pa ien has al eady de e io a ed beyond sal a ion. All i e isk ac o s a e easibly and quickly ob ained om he wa d nu ses o ecen pa ien eco ds du ing a RRT e iew. The e o e, hese ac o s could also be aken in o conside a ion du ing on-call hou s, which ha e limi ed esou ces and ime bu comp ise o e h ee hi ds o RRT ac i a ions. In ac , he C iSTAL in es iga o s hemsel es ound in hei ecen e o- spec i e case-con ol analysis ha se e al ac o s no - mally conside ed impo an when ini ia ing LOMT discussions (disabili y, p e ious hospi al admissions, p o einu ia, e c.) we e no a ailable e en in a s udy se - ing, whe e he lack o ime o ho ough e iew o Table 1 Cha ac e is ics o RRT pa ien s and hei i s RRT e iews, ≥75 yea s s. < 75 yea s old (Con inued) T ans e o ICU 69 (15) 265 (29) < 0.001 •ICU LOS (days, median; Q 1 ,Q 3 ) 2 (1, 3) 3 (1, 5) 0.053 •Died in in ensi e ca e 9/69 (13) 31/265 (12) 0.759 Da a a e p esen ed as numbe s (pe cen ages) i no o he wise indica ed. RRT apid esponse eam, CCI Cha lson como bidi y index; Malignancy, malignan solid umo o hema ologic malignancy; ICU in ensi e ca e uni , LOMT limi a ions o medical ea men , AVPU ale , oice, pain, un esponsi e, GCS Glasgow coma scale, CPAP con inuous posi i e ai way p essu e, LOS leng h o s ay a On-call ime: O he han Monday −F iday 8.00 a.m. o 3.00 p.m. b Documen ed posi i e MET ac i a ion c i e ia 20–360 min be o e he RRT ac i a ion c Includes he calls igge ed by ‘s a wo ied’c i e ion Table 2 Ou come o RRT pa ien s ≥75 yea s s. < 75 yea s old Pa ien ou come ≥75 yea s (n= 449) < 75 yea s (n= 923) p- alue New RRT e iew 49 (11) 177 (19) < 0.001 24 h mo ali y 37 (8.2) 46 (5.0) 0.018 Hospi al mo ali y 104 (23) 158 (17) 0.008 Discha ged ali e o •Home a 52 (15) 296 (39) •O he hospi al b 175 (51) 302 (40) < 0.001 •P ima y ca e wa d 118 (34) 167 (39) 30-day mo ali y 148 (33) 193 (21) < 0.001 180-day mo ali y 206 (46) 281 (31) < 0.001 One yea mo ali y 242 (54) 323 (35) < 0.001 Da a a e p esen ed as numbe s (pe cen ages) i no o he wise indica ed. RRT apid esponse eam a Includes discha ge o nu sing home i his was pa ien ’s esidence be o e he hospi al admission b Includes local dis ic hospi als Table 3 Mul i a ia e logis ic eg ession analysis o ac o s independen ly associa ed wi h 30-day mo ali y, whole coho (n= 1372) Mul i a ia e analysis Odds a io 95% CI p- alue P eceding LOMT 3.84 2.38–6.20 < 0.001 Posi i e RRT c i e ia measu ed by RRT 2.24 1.58–3.16 < 0.001 CCI 1.18 1.11–1.26 < 0.001 Age > 75 yea s 1.75 1.33–2.30 < 0.001 Non-elec i e hospi al admission 1.99 1.40–2.83 < 0.001 P eceding ICU admission 0.64 0.44–0.95 0.025 Medical pa ien 1.37 1.04–1.80 0.026 A e en limb ailu e 1.31 1.00–1.71 0.049 Su ge y wi hin 24 h 0.74 0.48–1.15 0.180 Sex (male) 1.16 0.88–1.52 0.278 The Hosme -Lemeshow goodness-o - i Chi-squa e (8) wi h p= 0.335 indica ed a good i o he model. RRT apid esponse eam, LOMT limi a ions o medical ea men , CI con idence in e al, CCI Cha lson como bidi y index, ICU in ensi e ca e uni Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 Page 6 o 8 pa ien eco ds is no a ac o [16]. Pe haps adding up he known isk ac o s o wo se ou come in ou s udy could also assis he RRT physician when a RRT e iew wi h e hical conside a ions ega ding a ge ia ic pa- ien ’s bes in e es s is u gen ly needed. On he o he hand, lack o hese isk ac o s should sugges ha es- cala ing ca e o a de e io a ing ge ia ic RRT pa ien is no u ile a all. Limi a ions This s udy is o p ospec i e design, bu i was con- duc ed in a single cen e in a No dic uni e si y hos- pi al. While we sugges ha he majo pa o RRT ac i a ions conce n ge ia ic pa ien s ac oss all con i- nen s, cul u al di e ences in clinical p ac ices and RRT usage, including LOMT, may a y subs an ially. In ac , he whole RRS concep a ies subs an ially be ween cen es and coun ies [4–12]. The me ho- dology o iden i ying isk ac o s om a la ge RRT popula ion and hen es ing hem in a small sub- popula ion de i ed om he same p ima y coho has se e al limi a ions, so ou esul s should only be con- side ed p elimina y. Mo eo e , esul s o a mul i a i- a e eg ession model can ne e dic a e he apies, me ely p o ide sugges ions o clinicians. Howe e , he iden i ied isk ac o s we e compa able o hose p e iously epo ed and p obably apply in o he ins i- u ions oo. Conclusions E e y hi d RRT pa ien was ≥75 yea s old in his s udy, and in he ligh o p e ious s udies, his seems o be he case globally. Ge ia ic RRT pa ien s ha e poo e sho - and long- e m ou comes when compa ed o RRT pa ien s <75 yea s old and age is an independen isk ac o o mo ali y. Howe e , he cumula i e impac o he ac o s independen ly associa ed wi h wo se ou - comes among he gene al RRT popula ion subs an ially in luences ou comes among ge ia ic RRT pa ien s. Ge i- a ic pa ien s wi h none o hese isk ac o s had sub- s an ially be e ou come han RRT pa ien s in gene al. Abb e ia ions C iSTAL: C i e ia o Sc eening and T iaging o App op ia e aL e na i e ca e; ICU: In ensi e ca e uni ; LOMT: Limi a ions o medical ea men ; RF: Risk ac o ; RRS: Rapid esponse sys em; RRT: Rapid esponse eam; Tays: Tampe e Uni e si y Hospi al Acknowledgemen s No applicable. Funding This s udy was inancially suppo ed by he Compe i i e Resea ch Funding o he Tampe e Uni e si y Hospi al (G an 9S009). A ailabili y o da a and ma e ials The da a o he cu en s udy a e no publicly a ailable because mo ali y da a we e e ie ed om he Finnish Popula ion Regis e Cen e unde a licence o his s udy. Howe e , he da a a e a ailable om he co esponding au ho upon easonable eques and wi h pe mission om he Finnish Popula ion Regis e Cen e. Au ho s’con ibu ions JT and SH designed he s udy. JT collec ed and analyzed he da a unde he supe ision and guidance o PS and SH. All au ho s con ibu ed o he in e p e a ion o he esul s. JT p epa ed he manusc ip , which was hen e ised c i ically o impo an in ellec ual con en by PS and SH. All o he au ho s ha e ead and app o ed he inal manusc ip . E hics app o al and consen o pa icipa e The E hics Commi ee o he Tampe e Uni e si y Hospi al (Tays) app o ed he s udy p o ocol (App o al no: R10111). Pa ien consen was wai ed as no in e en ions we e conduc ed. Consen o publica ion No applicable. Fig. 3 The cumula i e impac o isk ac o s ound in mul i a ia e eg ession model on 30-day mo ali y o RRT pa ien s ≥75 yea s old and wi hou ea men limi a ions (n= 411). Risk ac o s we e iden i ied as posi i e RRT c i e ia measu ed by RRT, Cha lson como bidi y sco e ≥5, non-elec i e hospi al admission, medical eason o admission, and a e en limb ailu e. RRT, apid esponse eam Ti kkonen e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2017) 25:77 Page 7 o 8 Compe ing in e es s The au ho s decla e ha hey ha e no compe ing in e es s. Publishe ’sNo e Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. Au ho de ails 1 Depa men o In ensi e Ca e Medicine, Tampe e Uni e si y Hospi al, Depa men o Anaes hesiology and In ensi e Ca e Medicine, Seinäjoki Cen al Hospi al, Uni e si y o Tampe e, PO Box 2000, FI-33521 Tampe e, Finland. 2 Eme gency Medical Se ice, FinnHEMS 30, Tampe e Uni e si y Hospi al, Uni e si y o Tampe e, PO Box 2000, FI-33521 Tampe e, Finland. 3 Depa men o In ensi e Ca e Medicine, Tampe e Uni e si y Hospi al, Uni e si y o Tampe e, PO Box 2000, FI-33521 Tampe e, Finland. Recei ed: 16 May 2017 Accep ed: 31 July 2017 Re e ences 1. Soa J, Nolan JP, Bö ige BW, Pe kins GD, Lo C, Ca li P, e al. Eu opean esusci a ion council guidelines o esusci a ion 2015: sec ion 3. 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