title: Analysis of the impact of limitation of medical treatment orders during unplanned transfers from sub-acute care to Emergency Departments.
abstract: BACKGROUND
  The impact of limitation of medical treatment orders (LOMT) on patient outcomes following transfer from sub-acute care to the Emergency Department remains unclear.
  
  
  METHODS
  Retrospective medical record review of 431 adult in-patients who required ambulance transfer following clinical deterioration during a sub-acute care admission during 2010.
  
  
  RESULTS
  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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety, Geelong, Victoria, Australia; Eastern Health - Deakin University Nursing & Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia. Electronic address: maryann.street@deakin.edu.au.
authors.forename: Maryann
authors.initials: M
authors.lastname: Street
authors.affiliation: Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety, Geelong, Victoria, Australia; Eastern Health - Deakin University Nursing & Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia.
authors.forename: Julie
authors.initials: J
authors.lastname: Considine
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D010360:Patient Transfer; D012189:Retrospective Studies; D012307:Risk Factors; D019467:Subacute Care / Q000706:statistics & numerical data*; D014739:Victoria; D028761:Withholding Treatment
keywords: Advance Directives; Clinical deterioration; Do-not-resuscitate orders; Emergency Departments; Patient transfer; Sub-acute care