1
|
Winters BD. Rapid Response Systems. Crit Care Clin 2024; 40:583-598. [PMID: 38796229 DOI: 10.1016/j.ccc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospital mortality, and facilitating triage and level of care escalations. The RRS is one of the first organized, and systematic, elements of the "ICU without walls" model. RRSs have been shown to be effective in preventing deterioration to cardiopulmonary arrest on general hospital wards and reducing total and unexpected hospital mortality. Recent studies have demonstrated that this benefit can be enhanced through targeted improvements and modifications of existing RRSs.
Collapse
Affiliation(s)
- Bradford D Winters
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 9127 Zayed 1800 Orealns Street, Baltimore, MD 21287, USA.
| |
Collapse
|
2
|
Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
Collapse
Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| |
Collapse
|
3
|
King L, Minyaev S, Grantham H, Clark RA. Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings. Jt Comm J Qual Patient Saf 2024; 50:269-278. [PMID: 38296749 DOI: 10.1016/j.jcjq.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system. METHODS A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis. RESULTS A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation. CONCLUSION Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.
Collapse
|
4
|
Baylis SR, Fletcher LR, Brown AJW, Hensman T, Serpa Neto A, Jones DA. Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department. Aust Crit Care 2024; 37:301-308. [PMID: 37716882 DOI: 10.1016/j.aucc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Medical emergency team (METs), activated by vital sign-based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting. OBJECTIVES The objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission. METHODS Retrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED. RESULTS Amongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50-3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17-3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08-6.70, p = 0.020) within 72 h. CONCLUSIONS ACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.
Collapse
Affiliation(s)
- Simon R Baylis
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Emergency Medicine, Austin Health, Melbourne, Australia; Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia.
| | - Luke R Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg Victoria, Australia; Data Analytics Research and Evaluation Centre (DARE), Austin Health and The University of Melbourne, Heidelberg, Victoria, Australia; Department of Critical Care, University of Melbourne, Australia
| | - Alastair J W Brown
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Intensive Care, Alfred Health, Melbourne, Australia; Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Tamishta Hensman
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Intensive Care, Royal Children's Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daryl A Jones
- Department of Intensive Care, Austin Health, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| |
Collapse
|
5
|
Douglas C, Alexeev S, Middleton S, Gardner G, Kelly P, McInnes E, Rihari-Thomas J, Windsor C, Morton RL. Transforming nursing assessment in acute hospitals: A cluster randomised controlled trial of an evidence-based nursing core assessment (the ENCORE trial). Int J Nurs Stud 2024; 151:104690. [PMID: 38237324 DOI: 10.1016/j.ijnurstu.2024.104690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Patient safety is threatened when early signs of clinical deterioration are missed or not acted upon. This research began as a clinical-academic partnership established around a shared concern of nursing physical assessment practices on general wards and delayed recognition of clinical deterioration. The outcome was the development of a complex intervention facilitated at the ward level for proactive nursing surveillance. METHODS The evidence-based nursing core assessment (ENCORE) trial was a pragmatic cluster-randomised controlled trial. We hypothesised that ward intervention would reduce the incidence of patient rescue events (medical emergency team activations) and serious adverse events. We randomised 29 general wards in a 1:2 allocation, across 5 Australian hospitals to intervention (n = 10) and usual care wards (n = 19). Skilled facilitation over 12 months enabled practitioner-led, ward-level practice change for proactive nursing surveillance. The primary outcome was the rate of medical emergency team activations and secondary outcomes were unplanned intensive care unit admissions, on-ward resuscitations, and unexpected deaths. Outcomes were prospectively collected for 6 months following the initial 6 months of implementation. Analysis was at the patient level using generalised linear mixed models to account for clustering by ward. RESULTS We analysed 29,385 patient admissions to intervention (n = 11,792) and control (n = 17,593) wards. Adjusted models for overall effects suggested the intervention increased the rate of medical emergency team activations (adjusted incidence rate ratio 1.314; 95 % confidence interval 0.975, 1.773), although the confidence interval was compatible with a marginal decrease to a substantial increase in rate. Confidence intervals for secondary outcomes included a range of plausible effects from benefit to harm. However, considerable heterogeneity was observed in intervention effects by patient comorbidity. Among patients with few comorbid conditions in the intervention arm there was a lower medical emergency team activation rate and decreased odds of unexpected death. Among patients with multimorbidity in the intervention arm there were higher rates of medical emergency team activation and intensive care unit admissions. CONCLUSION Trial outcomes have refined our assumptions about the impact of the ENCORE intervention. The intervention appears to have protective effects for patients with low complexity where frontline teams can respond locally. It also appears to have redistributed medical emergency team activations and unplanned intensive care unit admissions, mobilising higher rates of rescue for patients with multimorbidity. TRIAL REGISTRATION NUMBER ACTRN12618001903279 (Date of registration: 22/11/2018; First participant recruited: 01/02/2019).
Collapse
Affiliation(s)
- Clint Douglas
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia; Office of Nursing and Midwifery Services, Metro North Hospital and Health Service, Herston, QLD 4006, Australia.
| | - Sergey Alexeev
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2015, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Glenn Gardner
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia
| | - Patrick Kelly
- The University of Sydney, Faculty of Medicine and Health, Sydney School of Public Health, Camperdown, NSW 2006, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | | | - Carol Windsor
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2015, Australia
| |
Collapse
|
6
|
Al-Harbi S. Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests. Healthcare (Basel) 2024; 12:518. [PMID: 38470629 PMCID: PMC10931051 DOI: 10.3390/healthcare12050518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.
Collapse
Affiliation(s)
- Samah Al-Harbi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Pediatrics, King Abdulaziz University Hospital, Jeddah 22252, Saudi Arabia
| |
Collapse
|
7
|
Zhang Q, Lee K, Mansor Z, Ismail I, Guo Y, Xiao Q, Lim PY. Effects of a Rapid Response Team on Patient Outcomes: A Systematic Review. Heart Lung 2024; 63:51-64. [PMID: 37774510 DOI: 10.1016/j.hrtlng.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Despite the widespread adoption of the rapid response team (RRT) by many hospitals, questions remain regarding their effectiveness in improving several aspects of patient outcomes, such as hospital mortality, cardiopulmonary arrests, unplanned intensive care unit (ICU) admissions, and length of stay (LOS). OBJECTIVES To conduct a systematic review to understand the rapid response team's (RRT) effect on patient outcomes. METHODS A systematic search was conducted using PubMed, Cochrane, Embase, CINAHL, Web of Science, and two trial registers. The studies published up to May 6, 2022, from the inception date of the databases were included. Two researchers filtered the title, abstract and full text. The Version 2 of the Cochrane Risk of Bias tool and Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool were used separately for randomized and non-randomized controlled trials for quality appraisal. RESULTS Sixty-one eligible studies were identified, four randomized controlled trials(RCTs), four non-randomized controlled trials, six interrupted time-series(ITS) design , and 47 pretest-posttest studies. A total of 52 studies reported hospital mortality, 51 studies reported cardiopulmonary arrests, 18 studies reported unplanned ICU admissions and ten studies reported LOS. CONCLUSION This systematic review found the variation in context and the type of RRT interventions restricts direct comparisons. The evidence for improving several aspects of patient outcomes was inconsistent, with most studies demonstrating that RRT positively impacts patient outcomes.
Collapse
Affiliation(s)
- Qiuxia Zhang
- Department of Nursing, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia; Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China.
| | - Khuan Lee
- Department of Nursing, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia.
| | - Zawiah Mansor
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia.
| | - Iskasymar Ismail
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia; RESQ Stroke Emergency Unit, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang 43400, Malaysia.
| | - Yi Guo
- Department of General Practice and International Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China; Department of Neurology, Epilepsy Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China.
| | - Qiao Xiao
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia.
| | - Poh Ying Lim
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia.
| |
Collapse
|
8
|
Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Chandra Strobos N, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. Resuscitation 2024; 194:110041. [PMID: 37952578 PMCID: PMC10842078 DOI: 10.1016/j.resuscitation.2023.110041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which multiple RRS triggers occur together to activate RRS events are unknown. The purpose of this study was to identify these patterns (RRS trigger clusters) and determine their association with outcomes among hospitalized adult patients. METHODS RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n = 134,406). Cluster analysis methods were performed to identify RRS trigger clusters. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regressions were used to examine the associations between RRS trigger clusters and outcomes. RESULTS Six RRS trigger clusters were identified. Predominant RRS triggers for each cluster were: tachypnea, new onset difficulty in breathing, decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, mental status changes (Cluster 3); tachycardia, staff concern (Cluster 4); mental status changes (Cluster 5); hypotension, staff concern (Cluster 6). Significant differences in patient characteristics were observed across clusters. Patients in Clusters 3 and 6 had an increased likelihood of in-hospital cardiac arrest (p < 0.01). All clusters had an increased risk of mortality (p < 0.01). CONCLUSIONS We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and aiding in clinician decision-making during RRS events.
Collapse
Affiliation(s)
- Rebecca J Piasecki
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States.
| | - Elizabeth A Hunt
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Nancy Perrin
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Erin M Spaulding
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Bradford Winters
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Laura Samuel
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Patricia M Davidson
- University of Wollongong Australia, Northfields Ave., Wollongong, NSW 2522, Australia
| | | | - Matthew Churpek
- University of Wisconsin-Madison, Union South, 1308 W. Dayton St., Madison, WI 53715, United States
| | - Cheryl R Himmelfarb
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| |
Collapse
|
9
|
Axelsen MS, Baumgarten M, Egholm CL, Jensen JF, Thomsen TG, Bunkenborg G. A multi-facetted patient safety resource-A qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team. J Adv Nurs 2024; 80:124-135. [PMID: 37391909 DOI: 10.1111/jan.15770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/01/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
AIM To explore hospital managers' perceptions of the Rapid Response Team. DESIGN An explorative qualitative study using semi-structured individual interviews. METHODS In September 2019, a qualitative interview study including nineteen hospital managers at three managerial levels in acute care hospitals was conducted. Interview transcripts were analysed with an inductive content analysis approach, involving researcher triangulation in data collection and analysis processes. FINDINGS One theme, 'A resource with untapped potential, enhancing patient safety, high-quality nursing, and organisational cohesion' was identified and underpinned by six categories and 30 sub-categories. CONCLUSION The Rapid Response Team has an influence on the organization that goes beyond the team's original purpose. It strengthens the organization's dynamic cohesion by providing clinical support to nurses and facilitating learning, communication and collaboration across the hospital. Managers lack engagement in the team, including local key data to guide future quality improvement processes. IMPLICATIONS For organizations, nursing, and patients to benefit from the team to its full potential, managerial engagement seems crucial. IMPACT This study addressed possible challenges to using the Rapid Response Team optimally and found that hospital managers perceived this complex healthcare intervention as beneficial to patient safety and nursing quality, but lacked factual insight into the team's deliverances. The research impacts patient safety pointing at the need to re-organize managerial involvement in the function and development of the Rapid Response Team and System. REPORTING METHOD We have adhered to the COREQ checklist when reporting this study. "No Patient or Public Contribution".
Collapse
Affiliation(s)
| | - Mette Baumgarten
- Department of Anaesthesiology, Copenhagen University Hospital, Amager & Hvidovre, Hvidovre, Denmark
| | - Cecilie Lindström Egholm
- REHPA, Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janet Froulund Jensen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Holbaek Hospital, a Copenhagen University affiliated hospital, Holbaek, Denmark
| | - Thora Grothe Thomsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Gitte Bunkenborg
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Holbaek Hospital, a Copenhagen University affiliated hospital, Holbaek, Denmark
| |
Collapse
|
10
|
Hotta S, Ashida K, Tanaka M. Night-time detection and response in relation to deteriorating inpatients: A scoping review. Nurs Crit Care 2024; 29:178-190. [PMID: 37095606 DOI: 10.1111/nicc.12917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Although detection and response to clinical deterioration have been studied, the range and nature of studies focused on night-time clinical setting remain unclear. AIM This study aimed to identify and map existing research and findings concerning night-time detection and response to deteriorating inpatients in usual care or research settings. STUDY DESIGN A scoping review method was used. PubMed, CINAHL, Web of Science, and Ichushi-Web databases were systematically searched. We included studies focusing on night-time detection and response to clinical deterioration. RESULTS Twenty-eight studies were included. These studies were organized into five categories: night-time medical emergency team or rapid response team (MET/RRT) response, night-time observation using the early warning score (EWS), available resources for physicians' practice, continuous monitoring of specific parameters, and screening for night-time clinical deterioration. The first three categories were related to interventional measures in usual care settings, and relevant findings mainly demonstrated the actual situation and challenges of night-time practice. The final two categories were related to the interventions in the research settings and included innovative interventions to identify at-risk or deteriorating patients. CONCLUSIONS Systematic interventional measures, such as MET/RRT and EWS, could have been sub-optimally performed at night. Innovations in monitoring technologies or implementation of predictive models could be helpful in improving the detection of night-time deterioration. RELEVANCE TO CLINICAL PRACTICE This review provides a compilation of current evidence regarding night-time practice concerning patient deterioration. However, a lack of understanding exists on specific and effective practices regarding timely action for deteriorating patients at night.
Collapse
Affiliation(s)
- Soichiro Hotta
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kaoru Ashida
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Makoto Tanaka
- Department of Critical and Invasive-Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
11
|
Steitz BD, McCoy AB, Reese TJ, Liu S, Weavind L, Shipley K, Russo E, Wright A. Development and Validation of a Machine Learning Algorithm Using Clinical Pages to Predict Imminent Clinical Deterioration. J Gen Intern Med 2024; 39:27-35. [PMID: 37528252 PMCID: PMC10817885 DOI: 10.1007/s11606-023-08349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Early detection of clinical deterioration among hospitalized patients is a clinical priority for patient safety and quality of care. Current automated approaches for identifying these patients perform poorly at identifying imminent events. OBJECTIVE Develop a machine learning algorithm using pager messages sent between clinical team members to predict imminent clinical deterioration. DESIGN We conducted a large observational study using long short-term memory machine learning models on the content and frequency of clinical pages. PARTICIPANTS We included all hospitalizations between January 1, 2018 and December 31, 2020 at Vanderbilt University Medical Center that included at least one page message to physicians. Exclusion criteria included patients receiving palliative care, hospitalizations with a planned intensive care stay, and hospitalizations in the top 2% longest length of stay. MAIN MEASURES Model classification performance to identify in-hospital cardiac arrest, transfer to intensive care, or Rapid Response activation in the next 3-, 6-, and 12-hours. We compared model performance against three common early warning scores: Modified Early Warning Score, National Early Warning Score, and the Epic Deterioration Index. KEY RESULTS There were 87,783 patients (mean [SD] age 54.0 [18.8] years; 45,835 [52.2%] women) who experienced 136,778 hospitalizations. 6214 hospitalized patients experienced a deterioration event. The machine learning model accurately identified 62% of deterioration events within 3-hours prior to the event and 47% of events within 12-hours. Across each time horizon, the model surpassed performance of the best early warning score including area under the receiver operating characteristic curve at 6-hours (0.856 vs. 0.781), sensitivity at 6-hours (0.590 vs. 0.505), specificity at 6-hours (0.900 vs. 0.878), and F-score at 6-hours (0.291 vs. 0.220). CONCLUSIONS Machine learning applied to the content and frequency of clinical pages improves prediction of imminent deterioration. Using clinical pages to monitor patient acuity supports improved detection of imminent deterioration without requiring changes to clinical workflow or nursing documentation.
Collapse
Affiliation(s)
- Bryan D Steitz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA.
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| | - Siru Liu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| | - Liza Weavind
- Department of Anesthesiology, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| | - Kipp Shipley
- Department of Anesthesiology, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| | - Elise Russo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1475, Nashville, TN, 37203, USA
| |
Collapse
|
12
|
Jones D, Kishore K, Eastwood G, Sprogis SK, Glassford NJ. Breaches of pre-medical emergency team call criteria in an Australian hospital. CRIT CARE RESUSC 2023; 25:223-228. [PMID: 38234322 PMCID: PMC10790013 DOI: 10.1016/j.ccrj.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/03/2023] [Indexed: 01/19/2024]
Abstract
Objectives and outcomes To evaluate the 24hrs before medical emergency team (MET) calls to examine: 1) the frequency, nature, and timing of pre-MET criteria breaches; 2) differences in characteristics and outcomes between patients who did and didn't experience pre-MET breaches. Design Retrospective observational study November 2020-June 2021. Setting Tertiary referral Australian hospital. Participants Adults (≥18 years) experiencing MET calls. Results Breaches in pre-MET criteria occurred prior to 1886/2255 (83.6%) MET calls, and 1038/1281 (81.0%) of the first MET calls. Patients with pre-MET breaches were older (median [IQR] 72 [57-81] vs 66 [56-77] yrs), more likely to be admitted from home (87.8% vs 81.9%) and via the emergency department (73.0% vs 50.2%), but less likely to be for full resuscitation after (67.3% vs 76.5%) the MET. The three most common pre-MET breaches were low SpO2 (48.0%), high pulse rate (39.8%), and low systolic blood pressure (29.0%) which were present for a median (IQR) of 15.4 (7.5-20.8), 13.2 (4.3-21.0), and 12.6 (3.5-20.1) hrs before the MET call, respectively. Patients with pre-MET breaches were more likely to need intensive care admission within 24 h (15.6 vs 11.9%), have repeat MET calls (33.3 vs 24.7%), and die in hospital (15.8 vs 9.9%). Conclusions Four-fifths of MET calls were preceded by pre-MET criteria breaches, which were present for many hours. Such patients were older, had more limits of treatment, and experienced worse outcomes. There is a need to improve goals of care documentation and pre-MET management of clinical deterioration.
Collapse
Affiliation(s)
- Daryl Jones
- Intensive Care Unit, Austin Hospital, Studley Road, Heidelberg, Victoria, 3084, Australia
- Monash Health, Clayton Road, Clayton, Australia
- Division of Acute and Critical Care, SPHPM, Monash University, Australia
| | - Kartik Kishore
- Bachelor of Technology - Computer Science & Engineering, Data Analytics Research and Evaluation (DARE) Centre, Austin Health, Australia
| | - Glenn Eastwood
- Intensive Care Research Manager, Austin Health, Studley Road, Heidelberg, Germany
- Senior Research Fellow SPHPM, Monash University, Australia
| | - Stephanie K. Sprogis
- School of Nursing and Midwifery & Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, 1 Gheringhap Street, Geelong, VIC, 3220, Australia
| | - Neil J. Glassford
- Austin Health, Melbourne, Victoria, Australia
- Monash Health, Clayton Road, Clayton, Australia
- Division of Acute and Critical Care, SPHPM, Monash University, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| |
Collapse
|
13
|
Piasecki RJ, Himmelfarb CRD, Gleason KT, Justice RM, Hunt EA. The associations between rapid response systems and their components with patient outcomes: A scoping review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2023; 5:100134. [PMID: 38125770 PMCID: PMC10732356 DOI: 10.1016/j.ijnsa.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background While rapid response systems have been widely implemented, their impact on patient outcomes remains unclear. Further understanding of their components-including medical emergency team triggers, medical emergency team member composition, additional roles in patient care beyond responding to medical emergency team events, and their involvement in "Do-Not-Resuscitate" order placement-may elucidate the relationship between rapid response systems and outcomes. Objective To explore how recent studies have examined rapid response system components in the context of relevant adverse patient outcomes, such as in-hospital cardiac arrests and hospital mortality. Design Scoping review. Methods PubMed, CINAHL, and Embase were searched for articles published between November 2014 and June 2022. Studies mainly focused on rapid response systems and associations with in-hospital cardiac arrests were considered. The following were extracted for analysis: study design, location, sample size, participant characteristics, system characteristics (including medical emergency team member composition, additional system roles outside of medical emergency team events), medical emergency team triggers, in-hospital cardiac arrests, and hospital mortality. Results Thirty-four studies met inclusion criteria. While most studies described triggers used, few analyzed medical emergency team trigger associations with outcomes. Of those, medical emergency team triggers relating to respiratory abnormalities and use of multiple triggers to activate the medical emergency team were associated with adverse patient outcomes. Many studies described medical emergency team member composition, but the way composition was reported varied across studies. Of the seven studies with dedicated medical emergency team members, six found their systems were associated with decreased incidence of in-hospital cardiac arrests. Six of seven studies that described additional medical emergency team roles in educating staff in rapid response system use found their systems were associated with significant decreases in adverse patient outcomes. Four of five studies that described proactive rounding responsibilities reported found their systems were associated with significant decreases in adverse patient outcomes. Reporting of rapid response system involvement in "Do-Not-Resuscitate" order placement was variable across studies. Conclusions Inconsistencies in describing rapid response system components and related data and outcomes highlights how these systems are complex to a degree not fully captured in existing literature. Further large-scale examination of these components across institutions is warranted. Development and use of robust and standardized metrics to track data related to rapid response system components and related outcomes are needed to optimize these systems and improve patient outcomes.
Collapse
Affiliation(s)
- Rebecca J. Piasecki
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Kelly T. Gleason
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Elizabeth A. Hunt
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| |
Collapse
|
14
|
Veerappa S, Orosz J, Bailey M, Pilcher D, Jones D. Epidemiology of in-hospital cardiac arrest patients admitted to the intensive care unit in Australia: a retrospective observational study. Intern Med J 2023; 53:2216-2223. [PMID: 36620904 DOI: 10.1111/imj.16007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/29/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) affects approximately 3000 patients annually in Australia. Introduction of the National Standard for Deteriorating Patients in 2011 was associated with reduced IHCA-related intensive care unit (ICU) admissions and reduced in-hospital mortality of such patients. AIMS To assess whether the reduction in IHCA-related ICU admissions from hospital wards seen following the implementation of the national standard (baseline period 2013-2014) was sustained over the follow-up period (2015-2019) in Australia. METHODS A multi-centre retrospective cohort study to compare the characteristics and outcomes of IHCA admitted to the ICU between baseline and follow-up periods. The primary outcome was the proportion of patients admitted to ICU from the ward following IHCA. Secondary outcomes included ICU and hospital mortality of IHCA-related ICU admissions. Data were analysed using hierarchical multivariable logistic regression. RESULTS The proportion of cardiac arrest-related admissions from the ward was lower in the follow-up period when compared to baseline (4.1 vs 3.8%; P = 0.04). Such patients had lower illness severity and were more likely to have limitations of medical treatment at admission. However, after adjustment for severity of illness, the likelihood of being admitted to ICU following cardiac arrest on the ward increased in the follow-up period (odds ratio (OR) 1.13 (1.05-1.22); P = 0.001). Hospital mortality was lower in the follow-up period (50.3 vs 46.3%; P = 0.02), but after adjustment the likelihood of death did not differ between the periods (OR 1.0 (0.86-1.17); P = 0.98). CONCLUSION After adjustment for the severity of illness, the likelihood of being admitted to ICU after IHCA slightly increased in the follow-up period.
Collapse
Affiliation(s)
- Shilpa Veerappa
- Intensive Care and Hyperbaric Services, Alfred Health, Melbourne, Victoria, Australia
| | - Judit Orosz
- Intensive Care and Hyperbaric Services, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resources Evaluation, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Critical Care Network, Safer Care Victoria, Melbourne, Victoria, Australia
- Donate Life in Victoria, Melbourne, Victoria, Australia
| | - Daryl Jones
- Austin Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Victoria, Australia
| |
Collapse
|
15
|
van Mourik N, Oomen JJ, van Vught LA, Biemond BJ, van den Bergh WM, Blijlevens NMA, Vlaar APJ, Müller MCA. The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy - A multicenter observational study. Intensive Crit Care Nurs 2023; 79:103486. [PMID: 37441816 DOI: 10.1016/j.iccn.2023.103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES The modified early warning score (MEWS) is used to detect clinical deterioration of hospitalized patients. We aimed to investigate the predictive value of MEWS and derived quick Sequential Organ Failure Assessment (qSOFA) scores for intensive care unit admission in patients with a hematologic malignancy admitted to the ward. DESIGN Retrospective, observational study in two Dutch university hospitals. SETTING Data from adult patients with a hematologic malignancy, admitted to the ward over a 2-year period, were extracted from electronic patient files. MAIN OUTCOME MEASURES Intensive care admission. RESULTS We included 395 patients with 736 hospital admissions; 2% (n = 15) of admissions resulted in admission to the intensive care unit. A higher MEWS (OR 1.5; 95 %CI 1.3-1.80) and qSOFA (OR 4.4; 95 %CI 2.1-9.3) were associated with admission. Using restricted cubic splines, a rise in the probability of admission for a MEWS ≥ 6 was observed. The AUC of MEWS for predicting admission was 0.830, the AUC of qSOFA was 0.752. MEWS was indicative for intensive care unit admission two days before admission. CONCLUSIONS MEWS was a sensitive predictor of ICU admission in patients with a hematologic malignancy, superior to qSOFA. Future studies should confirm cut-off values and identify potential additional characteristics, to further enhance identification of critically ill hemato-oncology patients. IMPLICATIONS FOR CLINICAL PRACTICE The Modified Early Warning Score (MEWS) can be used as a tool for healthcare providers to monitor clinical deterioration and predict the need for intensive care unit admission in patients with a hematologic malignancy. Yet, consistent application and potential reevaluation of current thresholds is crucial. This will enable bedside nurses to more effectively identify patients needing adjunctive care, facilitating timely interventions and improved outcome.
Collapse
Affiliation(s)
- Niels van Mourik
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.
| | - Jesse J Oomen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
16
|
Kuklina EV, Ewing AC, Satten GA, Callaghan WM, Goodman DA, Ferre CD, Ko JY, Womack LS, Galang RR, Kroelinger CD. Ranked severe maternal morbidity index for population-level surveillance at delivery hospitalization based on hospital discharge data. PLoS One 2023; 18:e0294140. [PMID: 37943788 PMCID: PMC10635479 DOI: 10.1371/journal.pone.0294140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Severe maternal morbidity (SMM) is broadly defined as an unexpected and potentially life-threatening event associated with labor and delivery. The Centers for Disease Control and Prevention (CDC) produced 21 different indicators based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) hospital diagnostic and procedure codes to identify cases of SMM. OBJECTIVES To examine existing SMM indicators and determine which indicators identified the most in-hospital mortality at delivery hospitalization. METHODS Data from the 1993-2015 and 2017-2019 Healthcare Cost and Utilization Project's National Inpatient Sample were used to report SMM indicator-specific prevalences, in-hospital mortality rates, and population attributable fractions (PAF) of mortality. We hierarchically ranked indicators by their overall PAF of in-hospital mortality. Predictive modeling determined if SMM prevalence remained comparable after transition to ICD-10-CM coding. RESULTS The study population consisted of 18,198,934 hospitalizations representing 87,864,173 US delivery hospitalizations. The 15 top ranked indicators identified 80% of in-hospital mortality; the proportion identified by the remaining indicators was negligible (2%). The top 15 indicators were: restoration of cardiac rhythm; cardiac arrest; mechanical ventilation; tracheostomy; amniotic fluid embolism; aneurysm; acute respiratory distress syndrome; acute myocardial infarction; shock; thromboembolism, pulmonary embolism; cerebrovascular disorders; sepsis; both DIC and blood transfusion; acute renal failure; and hysterectomy. The overall prevalence of the top 15 ranked SMM indicators (~22,000 SMM cases per year) was comparable after transition to ICD-10-CM coding. CONCLUSIONS We determined the 15 indicators that identified the most in-hospital mortality at delivery hospitalization in the US. Continued testing of SMM indicators can improve measurement and surveillance of the most severe maternal complications at the population level.
Collapse
Affiliation(s)
- Elena V. Kuklina
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Alexander C. Ewing
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Glen A. Satten
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - William M. Callaghan
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - David A. Goodman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Cynthia D. Ferre
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jean Y. Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, United States of America
| | - Lindsay S. Womack
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, United States of America
| | - Romeo R. Galang
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Charlan D. Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| |
Collapse
|
17
|
Tan SC, Hayes L, Cross A, Tacey M, Jones D. Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration. Aust Crit Care 2023; 36:1078-1083. [PMID: 37076387 DOI: 10.1016/j.aucc.2023.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/31/2023] [Accepted: 03/01/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.
Collapse
Affiliation(s)
- Sing Chee Tan
- Faculty of Engineering and Information Technology, The University of Melbourne, Parkville, VIC 3010, Australia; Department of Intensive Care, Northern Health, Epping, Victoria, Australia; Division of Digital Health, Northern Health, Epping, Victoria, Australia.
| | - Lachlan Hayes
- Division of Digital Health, Northern Health, Epping, Victoria, Australia
| | - Anthony Cross
- Department of Intensive Care, Northern Health, Epping, Victoria, Australia; Centre for Integrated Critical Care, University of Melbourne, Carlton, Victoria, Australia
| | - Mark Tacey
- Office of Research, Northern Health, Epping, Victoria, Australia; Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Daryl Jones
- Department of Surgery, University of Melbourne, Carlton, Victoria, Australia; Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| |
Collapse
|
18
|
O'Connell A, Flabouris A, Edwards S, Tang D, Lavrencic K, Brook E, Shih-Teng Kao S, Thompson C. Predictive value of a tiered escalation response system: A case control study. Aust Crit Care 2023; 36:1067-1073. [PMID: 37028974 DOI: 10.1016/j.aucc.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/29/2023] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVE Rapid response systems designed to detect and respond to clinical deterioration often incorporate a multitiered, escalation response. We sought to determine the 'predictive strength' of commonly used triggers, and tiers of escalation, for predicting a rapid response team (RRT) call, unanticipated intensive care unit admission, or cardiac arrest (events). DESIGN This was a nested, matched case-control study. SETTING The study setting involved a tertiary referral hospital. PARTICIPANTS Cases experienced an event, and controls were matched patients without an event. OUTCOME MEASURES Sensitivity and specificity and area under the receiver operating characteristic curve (AUC) were measured. Logistic regression determined the set of triggers with the highest AUC. RESULTS There were 321 cases and 321 controls. Nurse triggers occurred in 62%, medical review triggers in 34%, and RRT triggers 20%. Positive predictive value of nurse triggers was 59%, that of medical review triggers was 75%, and that of RRT triggers was 88%. These values were no different when modifications to triggers were considered. The AUC was 0.61 for nurses, 0.67 for medical review, and 0.65 for RRT triggers. With modelling, the AUC was 0.63 for the lowest tier, 0.71 for next highest, and 0.73 for the highest tier. CONCLUSION For a three-tiered system, at the lowest tier, specificity of triggers decreases, sensitivity increases, but the discriminatory power is poor. Thus, there is little to be gained by using a rapid response system with more than two tiers. Modifications to triggers reduced the potential number of escalations and did not affect tier discriminatory value.
Collapse
Affiliation(s)
- Alice O'Connell
- Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia. Alice.O'
| | - Arthas Flabouris
- Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Doris Tang
- Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia
| | | | - Emma Brook
- Central Adelaide Palliative Care, Adelaide, South Australia, Australia
| | | | - Campbell Thompson
- Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
19
|
Smith D, Aitken LM. Rethinking the problem of clinically deteriorating patients: Time for theory-informed solutions. Aust Crit Care 2023; 36:925-927. [PMID: 37716883 DOI: 10.1016/j.aucc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/02/2023] [Indexed: 09/18/2023] Open
Affiliation(s)
- Duncan Smith
- City, University of London, School of Health & Psychological Sciences, Northampton Square, London, EC1V 0HB, UK; Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, Euston Road, London, NW1 2BU, UK.
| | - Leanne M Aitken
- City, University of London, School of Health & Psychological Sciences, Northampton Square, London, EC1V 0HB, UK; School of Nursing and Midwifery, Griffith University, Nathan, QLD, 4111, Australia.
| |
Collapse
|
20
|
Hall C, Samanta R, Trivedi M. Would your hospital benefit from a dedicated rapid response doctor? J Intensive Care Soc 2023; 24:9. [PMID: 37928091 PMCID: PMC10621510 DOI: 10.1177/1751143720903234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
| | - Romit Samanta
- Department of Anaesthesia, Addenbrookes Hospital, Cambridge, UK
| | - Monica Trivedi
- Department of Anaesthesia, Addenbrookes Hospital, Cambridge, UK
| |
Collapse
|
21
|
Jones PD. Deteriorating patients in Australian hospitals - Current issues and future opportunities. Aust Crit Care 2023; 36:928-930. [PMID: 37620214 DOI: 10.1016/j.aucc.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Affiliation(s)
- Prof Daryl Jones
- Intensive Care Unit Austin Hospital, Studley Road Heidelberg, Victoria, 3084, Australia
| |
Collapse
|
22
|
Jones D, Pound MG, Serpa-Neto A, Hodgson CL, Eastwood G, Bellomo R. Antecedents to and outcomes for in-hospital cardiac arrests in Australian hospitals with mature medical emergency teams: A multicentre prospective observational study. Aust Crit Care 2023; 36:1059-1066. [PMID: 37059632 DOI: 10.1016/j.aucc.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND The epidemiology and predictability of in-hospital cardiac arrests (IHCAs) in hospitals with established medical emergency teams (METs) is underinvestigated. OBJECTIVES We categorised IHCAs into three categories: "possible suboptimal end-of-life planning" (possible SELP), "potentially predictable", or "sudden and unexpected" using age, Charlson Comorbidity Index, place of residence, functional independence, along with documented vital signs, K+ and HCO3 in the period prior to the IHCA. We also described the differences in characteristics and outcomes amongst these three categories of IHCAs. METHODS This was a prospective observational study (1st July 2017 to 9th August 2018) of adult (18 years) IHCA patients in wards of seven Australian hospitals with well-established METs. RESULTS Amongst 152 IHCA patients, 145 had complete data. The number (%) classified as possible SELP, potentially predictable, and sudden and unexpected IHCA was 50 (34.5%), 52 (35.8%), and 43 (29.7%), respectively. Amongst the 52 potentially predictable patients, six (11.5%) had missing vital signs in the preceding 6 hr, 18 (34.6%) breached MET criteria in the prior 24 hr but received no MET call, and 6 (11.5%) had a MET call but remained on the ward. Abnormal K+ and HCO3 was present in 15 of 51 (29.5%) and 13 of 51 (25.5%) of such patients, respectively. The 43 sudden and unexpected IHCA patients were mostly (97.6%) functionally independent and had the lowest median Charlson Comorbidity Index. In-hospital mortality for IHCAs classified as possible SELP, potentially predictable, and sudden and unexpected was 76.0%, 61.5%, and 44.2%, respectively (p = 0.007). Only four of 12 (33.3%) possible SELP survivors had a good functional outcome. CONCLUSIONS In seven Australian hospitals with mature METs, only one-third of IHCAs were sudden and unexpected. Improving end-of-life care in elderly comorbid patients and enhancing the response to objective signs of deterioration may further reduce IHCAs in the Australian context.
Collapse
|
23
|
Jones D, Pearsell J, Wadeson E, See E, Bellomo R. Rapid Response System Components and In-Hospital Cardiac Arrests Rates 21 Years After Introduction Into an Australian Teaching Hospital. J Patient Saf 2023; 19:478-483. [PMID: 37493361 DOI: 10.1097/pts.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVES The aims of the study are: (1) to evaluate the epidemiology of in-hospital cardiac arrests (IHCAs) 21 years after implementing a rapid response teams (RRTs); and (2) to summarize policies, procedures, and guidelines related to a national standard pertaining to recognition of and response to clinical deterioration in hospital. METHODS The study used a prospective audit of IHCA (commencement of external cardiac compressions) in ward areas between February 1, 2021, and January 31, 2022. Collation, summary, and presentation of material related to 8 "essential elements" of the Australian Commission for Safety and Quality in Health Care consensus statement on clinical deterioration. RESULTS There were 3739 RRT calls and 244 respond blue calls. There were 20 IHCAs in clinical areas, with only 10 occurring in general wards (0.36/1000 admissions). The median (interquartile range) age was 69.5 years (60-77 y), 90% were male, and comorbidities were relatively uncommon. Only 5 patients had a shockable rhythm. Survival was 65% overall, and 80% and 50% in patients on the cardiac and general wards, respectively. Only 4 patients had RRT criteria in the 24 hours before IHCA. A detailed summary is provided on policies and guidelines pertaining to measurement and documentation of vital signs, escalation of care, staffing and oversight of RRTs, communication for safety, education and training, as well as evaluation, audit, and feedback, which underpinned such findings. CONCLUSIONS In our mature RRT, IHCAs are very uncommon, and few are preventable. Many of the published barriers encountered in successful RRT use have been addressed by our policies and guidelines.
Collapse
Affiliation(s)
- Daryl Jones
- From the Department of Intensive Care and Deteriorating Patient Committee, Austin Health, Victoria, Australia
| | | | | | | | | |
Collapse
|
24
|
Jones D, Orosz J, Psirides A, Pilcher D. Potential metrics for rapid response systems in Australia and New Zealand. CRIT CARE RESUSC 2023; 25:116-117. [PMID: 37876372 PMCID: PMC10581264 DOI: 10.1016/j.ccrj.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Daryl Jones
- Intensive Care Unit Austin Health, Australia
- Austin Department of Intensive Care, Warringal hospital, Australia
- University Melbourne, Australia
- DEPM Monash, Australia
- Critical Care Outreach Austin Hospital, Australia
- International Society of Rapid Response Systems, Australia
| | - Judit Orosz
- Departmentt of Intensive Care, Alfred Health, Commercial Road, Prahran 3004, Australia
| | - Alex Psirides
- Wellington Regional Hospital, New Zealand
- Chair, National Critical Care Advisory Group, Te Whatu Ora, New Zealand
| | - David Pilcher
- DEPM Monash, Australia
- Departmentt of Intensive Care, Alfred Health, Commercial Road, Prahran 3004, Australia
- ANZICS Centre for Outcome and Resource Evaluation, 101 High Str, Prahran 3004, Australia
| |
Collapse
|
25
|
Lambert C, Wiencek C, Francis-Parr J. Effect of Simulation-Based Training on the Self-Confidence of New Nurses in the Care of Patients With Acute Deterioration and Activation of the Rapid Response Team. J Contin Educ Nurs 2023; 54:367-376. [PMID: 37531656 DOI: 10.3928/00220124-20230711-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
BACKGROUND New nurses report feeling unprepared and having low levels of self-confidence. High-fidelity simulation (HFS) is frequently used to increase confidence and improve patient safety. This study assessed whether HFS training increased new nurses' self-confidence and activation of the rapid response team (RRT) when caring for patients with clinical deterioration. METHOD A quality improvement design was used. New nurses on two units at a Level I trauma center completed a 70-minute HFS. The change in self-confidence was measured by Grundy's C-Scale, and the change in percentage of staff-initiated RRT calls versus auto-triggered calls was calculated 3 months after HFS. RESULTS All 12 nurses who participated in the HFS showed improved self-confidence immediately after simulation. A Wilcox-on signed-rank paired data test showed statistically significantly improved confidence scores for all five items of the C-Scale from preintervention to immediately postintervention as well as 5 months later. One unit showed an increase in percentage of staff-initiated RRT calls 3 months postsimulation, and the other unit showed a decline in staff-initiated versus auto-triggered RRT calls. DISCUSSION The HFS increased self-confidence scores from preintervention to immediately postintervention, with the increase sustained 5 months later. However, how this increase translated into practice when activating RRT calls cannot be determined because many factors can influence RRT call patterns. CONCLUSION The literature review and study results suggest that HFS training embedded into an existing nurse residency program can build self-confidence in caring for patients with clinical deterioration. [J Contin Educ Nurs. 2023;54(8):367-376.].
Collapse
|
26
|
Lykins V JD, Freedman MT, Zemore Z, Sedhai YR, Lubin S, Sessler CN, Hogan C, Kashiouris MG. Patients Who Decompensate and Trigger Rapid Response Immediately Upon Hospital Admission Have Higher Mortality Than Equivalent Patients Without Rapid Responses. J Patient Saf 2023; 19:300-304. [PMID: 37310865 DOI: 10.1097/pts.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Rapid response teams (RRTs) have impacted the management of decompensating patients, potentially improving mortality. Few studies address the significance of RRT timing relative to hospital admission. We aimed to identify outcomes of adult patients who trigger immediate RRT activation, defined as within 4 hours of admission and compare with RRT later in admission or do not require RRT activation, and identify risk factors that predispose toward immediate RRT activation. METHODS A retrospective case-control study was performed using an RRT activation database, comprising 201,783 adult inpatients at an urban, academic, tertiary care hospital. This group was subdivided by timing of RRT activation regarding admission: within the first 4 hours (immediate RRT), between 4 and 24 hours (early RRT), and after 24 hours (late RRT). The primary outcome was 28-day all-cause mortality. Individuals triggering an immediate RRT were compared with demographically matched controls. Mortality was adjusted for age, Quick Systemic Organ Failure Assessment score, intensive care unit admission, and Elixhauser Comorbidity Index. RESULTS Patients with immediate RRT had adjusted 28-day all-cause mortality of 7.1% (95% confidence interval [CI], 5.6%-8.5%) and death odds ratio of 3.27 (95% CI, 2.5-4.3) compared with those who did not (mortality, 2.9%; 95%CI, 2.8%-2.9%; P < 0.0001). Patients triggering an immediate RRT were more likely to be Black, be older, and have higher Quick Systemic Organ Failure Assessment scores than those who did not trigger RRT activation. CONCLUSIONS In this cohort, patients who require immediate RRT experienced higher 28-day all-cause mortality, potentially because of evolving or unrecognized critical illness. Further exploring this phenomenon may create opportunities for improved patient safety.
Collapse
Affiliation(s)
| | | | | | - Yub Raj Sedhai
- Division of Hospital Medicine, Department of Internal Medicine
| | | | - Curtis N Sessler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine
| | | | - Markos G Kashiouris
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine
| |
Collapse
|
27
|
Ko JP, Ng LS, Goh KJ, Chai HZ, Phua GC, Tan QL. Staff perception and attitudes towards a medical rapid response team with a multi-tiered response. Singapore Med J 2023; 64:527-533. [PMID: 34911185 PMCID: PMC10476913 DOI: 10.11622/smedj.2021223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joanna Phone Ko
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Lit Soo Ng
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Hui Zhong Chai
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Ghee Chee Phua
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Qiao Li Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
28
|
Visovatti SH. Pulmonary Embolism Center of Excellence: Putting It All Together. Interv Cardiol Clin 2023; 12:393-398. [PMID: 37290842 DOI: 10.1016/j.iccl.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Center of excellence (COE) designations are generally used to identify programs with expertise in a specific area of medicine. Meeting criteria for a COE may result in advantages including improved clinical outcomes, marketing advantages, and improved financial performance. However, criteria for COE designations are highly variable, and they are granted by a wide variety of entities. The diagnosis and treatment of both acute pulmonary emboli and chronic thromboembolic pulmonary hypertension are disciplines that require multidisciplinary expertise, highly coordinated care, specialized technology and advanced skillsets gained through high patient volumes.
Collapse
Affiliation(s)
- Scott H Visovatti
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Davis Heart and Lung Research Institute, 473 West 12th Avenue, Columbus, OH 43210, USA.
| |
Collapse
|
29
|
Kritz EM, Thomas JK, Alawa NS, Hadad EB, Guffey DM, Bavare AC. Rapid response events with multiple triggers are associated with poor outcomes in children. Front Pediatr 2023; 11:1208873. [PMID: 37388290 PMCID: PMC10303937 DOI: 10.3389/fped.2023.1208873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023] Open
Abstract
Objective We describe the characteristics and outcomes of pediatric rapid response team (RRT) events within a single institution, categorized by reason for RRT activation (RRT triggers). We hypothesized that events with multiple triggers are associated with worse outcomes. Patients and Methods Retrospective 3-year study at a high-volume tertiary academic pediatric hospital. We included all patients with index RRT events during the study period. Results Association of patient and RRT event characteristics with outcomes including transfers to ICU, need for advanced cardiopulmonary support, ICU and hospital length of stay (LOS), and mortality were studied. We reviewed 2,267 RRT events from 2,088 patients. Most (59%) were males with a median age of 2 years and 57% had complex chronic conditions. RRT triggers were: respiratory (36%) and multiple (35%). Transfer to the ICU occurred after 1,468 events (70%). Median hospital and ICU LOS were 11 and 1 days. Need for advanced cardiopulmonary support was noted in 291 events (14%). Overall mortality was 85 (4.1%), with 61 (2.9%) of patients having cardiopulmonary arrest (CPA). Multiple RRT trigger events were associated with transfer to the ICU (559 events; OR 1.48; p < 0.001), need for advanced cardiopulmonary support (134 events; OR 1.68; p < 0.001), CPA (34 events; OR 2.36; p = 0.001), and longer ICU LOS (2 vs. 1 days; p < 0.001). All categories of triggers have lower odds of need for advanced cardiopulmonary support than multiple triggers (OR 1.73; p < 0.001). Conclusions RRT events with multiple triggers were associated with cardiopulmonary arrest, transfer to ICU, need for cardiopulmonary support, and longer ICU LOS. Knowledge of these associations can guide clinical decisions, care planning, and resource allocation.
Collapse
Affiliation(s)
- Erin M. Kritz
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Jenilea K. Thomas
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Nawara S. Alawa
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Elit B. Hadad
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Danielle M. Guffey
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
| | - Aarti C. Bavare
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| |
Collapse
|
30
|
Jones D. The medical emergency team - current status and future directions: a perspective for acute care physicians. Intern Med J 2023; 53:888-891. [PMID: 37349279 DOI: 10.1111/imj.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 03/28/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Daryl Jones
- Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
31
|
Young AM, Strobel RJ, Rotar E, Norman A, Henrich M, Mehaffey JH, Brady W, Teman NR. Implementation of a non-intensive-care unit medical emergency team improves failure to rescue rates in cardiac surgery patients. J Thorac Cardiovasc Surg 2023; 165:1861-1872.e5. [PMID: 36038381 PMCID: PMC9887097 DOI: 10.1016/j.jtcvs.2022.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/22/2022] [Accepted: 07/09/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Failure to rescue (FTR) is an emerging measure in cardiac surgery, defined as mortality after a postoperative complication. We hypothesized that establishing a medical emergency team (MET) reduced rates of FTR in adults undergoing cardiac surgery. METHODS All patients (N = 11,218) undergoing a The Society of Thoracic Surgeons index operation at our center (1994-2018) were stratified by pre-MET or MET era based on the 2009 institutional implementation of a MET to respond to clinical decompensation in non-intensive-care patients. Patients missing The Society of Thoracic Surgeons predicted risk of mortality were excluded from all cohorts. Risk adjusted multivariable regression analyzed the association of postoperative complications, operative mortality, and FTR by era. Nearest neighbor propensity score matching utilizing patients' The Society of Thoracic Surgeons predicted risk of mortality was performed to create balanced control and exposure groups for secondary subgroup analysis. RESULTS In the risk-adjusted multivariable analysis, surgery during the MET era was associated with decreased mortality (odds ratio [OR], 0.51; 95% CI, 0.45-0.77; P < .001), postoperative renal failure (OR, 0.57; 95% CI, 0.46-0.70; P < .001), reoperation (OR, 0.75; 95% CI, 0.59-0.95; P = .017), and deep sternal wound infection (OR, 0.16; 95% CI, 0.04-0.45; P = .002). Surgery performed during the MET era was associated with a decreased rate of FTR in the risk-adjusted analysis (OR, 0.46; 95% CI, 0.34-0.70; P < .001). CONCLUSIONS The development of an institutional MET program was associated with a decrease in major complications and FTR. These findings support the development of MET programs to improve FTR after cardiac surgery.
Collapse
Affiliation(s)
- Andrew M Young
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Raymond J Strobel
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Evan Rotar
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Anthony Norman
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Matt Henrich
- Department of Emergency Medicine, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - William Brady
- Department of Emergency Medicine, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va.
| |
Collapse
|
32
|
Greenberg JM, Schmidt A, Chang TP, Rake A. Qualitative Study on Safe and Effective Handover Information during a Rapid Response Team Encounter. Pediatr Qual Saf 2023; 8:e650. [PMID: 38571734 PMCID: PMC10990382 DOI: 10.1097/pq9.0000000000000650] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 04/01/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction A rapid response team (RRT) evaluates and manages patients at risk of clinical deterioration. There is limited literature on the structure of the rapid response encounter from the floor to the intensive care unit team. We aimed to define this encounter and examine provider experiences to elucidate what information healthcare staff need to safely manage patients during an RRT evaluation. Methods This phenomenological qualitative study included 6 focus groups (3 in-person and 3 virtually) organized by provider type (nurses, residents, fellows, attendings), which took place until thematic saturation was reached. Two authors inductively coded transcripts and used a quota sampling strategy to ensure that the focus groups represented key stakeholders. Transcripts were then analyzed to identify themes that providers believe influence the RRT's quality, efficacy, and efficiency and their ability to manage and treat the acutely decompensating pediatric patient on the floor. Results Transcript coding yielded 38 factors organized into 8 themes. These themes are a summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. Conclusions The principal themes of utmost importance at our institution during an RRT encounter are preparation, a brief and concise handoff from the floor team, and a summary statement from the intensive care unit team with contingency planning at the end of the encounter. Our data suggest that some standardization may be beneficial during the handoff.
Collapse
Affiliation(s)
- Justin M. Greenberg
- From the Department of Anesthesia and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| | - Anita Schmidt
- Department of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| | - Todd P. Chang
- Department of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| | - Alyssa Rake
- From the Department of Anesthesia and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| |
Collapse
|
33
|
Levkovich BJ, Orosz J, Bingham G, Cooper DJ, Dooley M, Kirkpatrick C, Jones DA. Medication-related Medical Emergency Team activations: a case review study of frequency and preventability. BMJ Qual Saf 2023; 32:214-224. [PMID: 35790383 DOI: 10.1136/bmjqs-2021-014185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 06/08/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Despite recognition of clinical deterioration and medication-related harm as patient safety risks, the frequency of medication-related Rapid Response System activations is undefined. We aimed to estimate the incidence and preventability of medication-related Medical Emergency Team (MET) activations and describe the associated adverse medication events. METHODS A case review study of consecutive MET activations at two acute, academic teaching hospitals in Melbourne, Australia with mature Rapid Response Systems was conducted. All MET activations during a 3-week study period were assessed for a medication cause including identification of the contributing adverse medication event and its preventability, using validated tools and recognised classification systems. RESULTS There were 9439 admissions and 628 MET activations during the study period. Of these, 146 (23.2%) MET activations were medication related: an incidence of 15.5 medication-related MET activation per 1000 admissions. Medication-related MET activations occurred a median of 46.6 hours earlier (IQR 22-165) in an admission than non-medication-related activations (p=0.001). Furthermore, this group also had more repeat MET activations during their admission (p=0.021, OR=1.68, 95% CI 1.09 to 2.59). A total of 92 of 146 (63%) medication-related MET activations were potentially preventable. Tachycardia due to omission of beta-blocking agents (10.9%, n=10 of 92) and hypotension due to cumulative toxicity (9.8%, n=9 of 92) or inappropriate use (10.9%, n=10 of 92) of antihypertensives were the most common adverse medication events leading to potentially preventable medication-related MET activations. CONCLUSIONS Medications contributed to almost a quarter of MET activations, often early in a patient's admission. One in seven MET activations were due to potentially preventable adverse medication events. The most common of these were omission of beta-blockers and clinically inappropriate antihypertensive use. Strategies to prevent these events would increase patient safety and reduce burden on the MET.
Collapse
Affiliation(s)
- Bianca J Levkovich
- Centre for Medicines Use and Safety, Monash University, Clayton, Victoria, Australia
- Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Judit Orosz
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | | | - D James Cooper
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
- Australia and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia
| | - Michael Dooley
- Centre for Medicines Use and Safety, Monash University, Clayton, Victoria, Australia
- Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Carl Kirkpatrick
- Centre for Medicines Use and Safety, Monash University, Clayton, Victoria, Australia
| | - Daryl A Jones
- Australia and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| |
Collapse
|
34
|
Abstract
BACKGROUND Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established. AREAS OF UNCERTAINTY Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions. THERAPEUTIC ADVANCES Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions. CONCLUSIONS There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.
Collapse
|
35
|
Orosz J, Jones DA. Improving risk stratification and decision support for deteriorating hospital patients. BMJ Qual Saf 2023:bmjqs-2022-015881. [PMID: 36849249 DOI: 10.1136/bmjqs-2022-015881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Judit Orosz
- Intensive Care Unit, Alfred Health, Prahran, Victoria, Australia
| | - Daryl A Jones
- The Austin Hospital, Austin Health, Heidelberg, Victoria, Australia
| |
Collapse
|
36
|
Olsen SL, Nedrebø BS, Strand K, Søreide E, Kvaløy JT, Hansen BS. Reduction in omission events after implementing a Rapid Response System: a mortality review in a department of gastrointestinal surgery. BMC Health Serv Res 2023; 23:179. [PMID: 36810005 PMCID: PMC9945730 DOI: 10.1186/s12913-023-09159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent 'events of omission', including failure to monitor patients' vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates. METHODS We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates. RESULTS Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, P = 0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), P = 0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, P = 0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, P = 0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92-0.98) and 0.97 (95% CI: 0.95-0.99)). CONCLUSION The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement. TRIAL REGISTRATION Retrospectively registered.
Collapse
Affiliation(s)
- Siri Lerstøl Olsen
- Department of Quality and Health Technology, Faculty of Health Sciences, SHARE-Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 43, 4036, Stavanger, Norway. .,Department of Emergency Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Bjørn S Nedrebø
- grid.412008.f0000 0000 9753 1393Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kristian Strand
- grid.412835.90000 0004 0627 2891Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- grid.18883.3a0000 0001 2299 9255Faculty of Health Sciences, University of Stavanger, Stavanger, Norway ,grid.412835.90000 0004 0627 2891Section for Quality and Patient Safety, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- grid.18883.3a0000 0001 2299 9255Department of Mathematics and Physics, Faculty of Science and Technology, University of Stavanger, Stavanger, Norway ,grid.412835.90000 0004 0627 2891Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Britt Sætre Hansen
- grid.18883.3a0000 0001 2299 9255Department of Quality and Health Technology, Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 43, 4036 Stavanger, Norway ,grid.412835.90000 0004 0627 2891The Research Group for Nursing and Health Care Science, Stavanger University Hospital, Stavanger, Norway
| |
Collapse
|
37
|
Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Strobos NC, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.06.23285560. [PMID: 36798369 PMCID: PMC9934794 DOI: 10.1101/2023.02.06.23285560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which RRS triggers co-occur to activate the medical emergency team (MET) to respond to RRS events is unknown. The purpose of this study was to identify and describe the patterns (RRS trigger clusters) in which RRS triggers co-occur when used to activate the MET and determine the association of these clusters with outcomes using a sample of hospitalized adult patients. Methods RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n=134,406). A combination of cluster analyses methods was performed to group patients into RRS trigger clusters based on the triggers used to activate their RRS events. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regression was used to examine the associations between RRS trigger clusters and outcomes following RRS events. Results Six RRS trigger clusters were identified in the study sample. The RRS triggers that predominantly identified each cluster were as follows: tachypnea, new onset difficulty in breathing, and decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, and staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, and mental status changes (Cluster 3); tachycardia and staff concern (Cluster 4); mental status changes (Cluster 5); hypotension and staff concern (Cluster 6). Significant differences in patient characteristics were observed across RRS trigger clusters. Patients in Clusters 3 and 6 were associated with an increased likelihood of in-hospital cardiac arrest (IHCA [p<0.01]), while Cluster 4 was associated with a decreased likelihood of IHCA (p<0.01). All clusters were associated with an increased risk of mortality (p<0.01). Conclusions We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes following RRS events. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and may aid in clinician decision-making during RRS events.
Collapse
|
38
|
Raff L, Moore C, Raff E. The role of language barriers on efficacy of rapid response teams. Hosp Pract (1995) 2023; 51:29-34. [PMID: 36400063 DOI: 10.1080/21548331.2022.2150416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Rapid response (RR) systems are associated with decreased hospital mortality. Systemic biases and inequities can negatively impact RR outcomes. Language barriers between patients and providers are associated with worse outcomes, but it is unknown if language barriers are associated with RR outcomes. METHODS We analyzed all adult hospitalized patients who experienced a RR over one year (January 2020 to December 2020) at a tertiary care academic medical center. We used an objective scoring system to establish disease severity at the time of the event. We then compared disease severity and outcomes for patients who are primary language Spanish (PLS) and primary language English (PLE) using both univariable and multivariable analyses. RESULTS Of 1133 patients, 42 identified as PLS and 1091 as PLE. In multivariable analyses, PLS patients had significantly higher disease severity scores, as measured by deterioration index score (8.2, p = 0.021) at the time of their rapid responses. PLS patients also had 18.5% increase in length of stay (LOS) after RRs and this disparity was not mitigated when controlling for disease severity at the time of RRs. PLS was not a significant predictor for hospital mortality after RRs. CONCLUSIONS Our study found that PLS patients had increased disease severity at the time of RRs and increased LOS after RRs. However, the disparity in LOS was not mitigated when controlling for disease severity at the time of RRs. These findings suggest that language barriers may cause both delays in activation of RR systems, as well as the care provided during and after RRs.
Collapse
Affiliation(s)
- Lauren Raff
- Division of Trauma and Acute Care Surgery, University of North Carolina at Chapel Hill Department of Surgery, Chapel Hill, NC, US
| | - Carlton Moore
- Division of Hospital Medicine, University of North Carolina at Chapel Hill Department of Medicine, Chapel Hill, NC, US
| | - Evan Raff
- Division of Hospital Medicine, University of North Carolina at Chapel Hill Department of Medicine, Chapel Hill, NC, US.,Division of Hospital Medicine, University of North Carolina at Chapel Hill Department of Medicine, 101 Manning Drive, 27599, Chapel Hill, NC, US
| |
Collapse
|
39
|
Majeed J, Chawla S, Bondar E, Chimonas S, Martin SC, O'Sullivan M, Jones D. Rapid Response Team Activations in Oncologic Ambulatory Sites: Characteristics, Interventions, and Outcomes. JCO Oncol Pract 2022; 18:e1961-e1970. [PMID: 36306480 PMCID: PMC9750547 DOI: 10.1200/op.22.00436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/14/2022] [Accepted: 09/13/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Patients with cancer are vulnerable to clinical deterioration. Rapid response teams (RRTs) identify and manage patients with acute changes in clinical status. Although RRTs have been well studied in the hospital setting, there are limited data on patients who require support in the ambulatory or outpatient oncologic settings. Describe baseline characteristics, reasons for activations, interventions, and outcomes of ambulatory oncologic patients receiving RRT activation in a tertiary cancer center. METHODS We conducted a retrospective review of adult (age ≥ 18 years) patients requiring RRT activation at multiple ambulatory sites between July 2020 and June 2021. Demographic and clinical data captured include age, sex, race, ethnicity, do not resuscitate status, vital signs, receipt of active cancer treatment within 30 days, and cancer type. Using Kaplan-Meier survival analysis and multivariable Cox proportion hazard ratio regression models, outcomes of 90-day mortality and hospitalization were assessed. RESULTS There were 322 RRT activations among 427,734 visits to 10 ambulatory sites (0.75 RRTs/1,000 visits). The most frequent reasons were syncope (25.2%), fall (24.5%), and adverse reaction to cancer therapy or intravenous contrast (16.5%). One hundred thirty-seven (42.5%) required transfer to an emergency department, of which 81 (59.1%) required hospital admission. At 90 days, 51 (15.8%) had died, with 44 (86.3%) receiving comfort measures. Kaplan-Meier survival analysis and multivariable Cox proportional hazard ratio regression showed that heart rate > 100 at RRT presentation and hospitalization after a RRT event were significantly associated with 90-day mortality. CONCLUSION Although uncommon, patients with cancer undergoing care at ambulatory sites can suffer acute clinical deterioration needing RRT review. The rates of hospitalization and mortality among such patients are high, suggesting the need for improved end-of-life care.
Collapse
Affiliation(s)
- Jibran Majeed
- Advanced Practice Provider, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ellen Bondar
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven C. Martin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Daryl Jones
- University Melbourne, Victoria, Parkville, Australia
- DEPM Monash University, Victoria, Prahran, Australia
- Austin Department of Intensive Care, Victoria, Heidelberg, Australia
- Critical Care Outreach Austin Hospital, Victoria, Heidelberg, Australia
- International Society of Rapid Response Systems, London, United Kingdom
| |
Collapse
|
40
|
Chalam JN, Noble J, DeLaroche AM, Ehrman RR, Cashen K. Characteristics of Adult Rapid Response Events in a Freestanding Children's Hospital. Hosp Pediatr 2022; 12:1058-1065. [PMID: 36377402 DOI: 10.1542/hpeds.2022-006748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe nonhospitalized adult rapid response events (adult RREs) in a freestanding children's hospital and examine the relationship between various demographic and clinical factors with the final patient disposition. METHODS We retrospectively reviewed records for nonhospitalized patients ≥18 years of age from events that occurred in a freestanding pediatric hospital between January 2011 through December 2020. We examined the relationship between adult RREs and patient demographic information, medical history, interventions, and patient disposition following an adult RRE. RESULTS Four hundred twenty-nine events met inclusion criteria for analysis. Most events (69%) occurred in females, 49% of events occurred in family members of patients, and 47% occurred on inpatient floor and ICU areas. The most common presenting complaint was syncope or dizziness (36%). Delivery of bad news or grief response was associated with 14% of adult RREs. Overall, 46% (n = 196) of patients were transferred to the pediatric emergency department (ED). Patients requiring acute intervention or with cardiac or neurologic past medical histories were more likely to be transferred to the pediatric ED. Acute advanced cardiac life support interventions were infrequent but, of the patients taken to the pediatric ED, 1 died, and 3 were admitted to the ICU. CONCLUSIONS Adult RREs are common in freestanding children's hospitals and, although rare, some patients required critical care. Expertise in adult critical care management should be available to the rapid response team and additional training for the pediatric rapid response team in caring for adult nonpatients may be warranted.
Collapse
Affiliation(s)
- Jennifer N Chalam
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Jennifer Noble
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.,Central Michigan University School of Medicine, Mount Pleasant, Michigan
| | - Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.,Central Michigan University School of Medicine, Mount Pleasant, Michigan
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center, Sinai-Grace Hospital, Detroit, Michigan
| | - Katherine Cashen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Children's Hospital, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
41
|
Bunkenborg G, Barfod O'Connell M, Jensen HI, Bucknall T. Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse. J Clin Nurs 2022; 31:3560-3572. [PMID: 34985170 PMCID: PMC9787103 DOI: 10.1111/jocn.16183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/30/2022]
Abstract
AIM AND OBJECTIVE To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT). BACKGROUND For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction. DESIGN Qualitative focus group interviews. METHODS A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist. RESULTS One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'. CONCLUSION Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses. RELEVANCE TO CLINICAL PRACTICE Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.
Collapse
Affiliation(s)
- Gitte Bunkenborg
- Department of Intensive Care and AnaesthesiologyHolbæk HospitalHolbækDenmark,Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
| | | | - Hanne Irene Jensen
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark,Department of Intensive Care and AnaesthesiologyLillebaelt HospitalUniversity Hospital of Southern DenmarkKoldingDenmark
| | - Tracey Bucknall
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark,Alfred Health Centre for Quality and Patient Safety ResearchInstitute of Health TransformationDeakin UniversityBurwoodVictoriaAustralia
| |
Collapse
|
42
|
Allen J, Currey J, Jones D, Considine J, Orellana L. Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission. Crit Care Med 2022; 50:1588-1598. [PMID: 35866655 DOI: 10.1097/ccm.0000000000005621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. DESIGN Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. SETTING A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. PATIENTS A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. MEASUREMENTS AND MAIN RESULTS The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. CONCLUSIONS Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.
Collapse
Affiliation(s)
- Joshua Allen
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, VIC, Australia
| | - Judy Currey
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, VIC, Australia
| | - Daryl Jones
- DEPM Monash University, Level 6 The Alfred Centre (Alfred Hospital), Melbourne, VIC, Australia
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Research-Eastern Health Partnership, VIC, Australia
| | - Liliana Orellana
- Biostatistics Unit, Faculty of Health, Deakin University, Geelong, VIC, Australia
| |
Collapse
|
43
|
Arora V, Juneja D, Singh O, Singh A, Tiwari D, Gupta A. The epidemiology and outcomes of adult rapid response team patients in a tertiary care hospital in India. Med Intensiva 2022; 46:577-580. [PMID: 36155680 DOI: 10.1016/j.medine.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/16/2021] [Indexed: 06/16/2023]
Affiliation(s)
- V Arora
- Attending Consultant, Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - D Juneja
- Director, Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India.
| | - O Singh
- Principal Director, Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - A Singh
- Senior Consultant, Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - D Tiwari
- Deputy Medical Superintendent, Max Super Speciality Hospital, New Delhi 110017, India
| | - A Gupta
- Consultant, Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| |
Collapse
|
44
|
Hyun DG, Lee SY, Ahn JH, Huh JW, Hong SB, Koh Y, Lim CM, Oh DK, Suh GY, Jeon K, Ko RE, Cho YJ, Lee YJ, Lim SY, Park S, Heo J, Lee JM, Kim KC, Lee YJ, Chang Y, Jeon K, Lee SM, Hong SK, Cho WH, Kwak SH, Lee HB, Ahn JJ, Seong GM, Lee SI, Park S, Park TS, Lee SH, Choi EY, Moon JY. Mortality of patients with hospital-onset sepsis in hospitals with all-day and non-all-day rapid response teams: a prospective nationwide multicenter cohort study. Crit Care 2022; 26:280. [PMID: 36114545 PMCID: PMC9482246 DOI: 10.1186/s13054-022-04149-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT’s operating hours on in-hospital mortality in inpatient patients with sepsis. Methods We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups. Results Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35–0.93; P = 0.024). Conclusions In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04149-z.
Collapse
|
45
|
Tohme S, Newman JS, Gasparis C, Manetta F. Massive Embolism: Knife versus PCI. Int J Angiol 2022; 31:179-187. [PMID: 36157101 PMCID: PMC9507597 DOI: 10.1055/s-0042-1755573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Pulmonary embolism is the third most common cardiovascular syndrome with an estimated up to 25% of patients presenting with sudden death. For those who survive, a mainstay of management for patients with hemodynamic stability is anticoagulation; however, recommendations and options are rapidly changing for patients with submassive or massive pulmonary embolism with hemodynamic instability. Catheter-based and surgical approaches offer efficacious management options for unstable patients or patients with contraindications to anticoagulation; however, both approaches have inherent benefits and risk. This article seeks to offer a brief review on the recommendations and options for management of pulmonary embolism from both surgical and catheter-based perspectives.
Collapse
Affiliation(s)
- Scarlett Tohme
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Joshua S. Newman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Christopher Gasparis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| |
Collapse
|
46
|
Raff L, Reilly K, Ratner S, Moore C, Raff E. Building High-Performance Team Dynamics for Rapid Response Events in a US Tertiary Hospital: A Quality Improvement Model for Sustainable Process Change. Am J Med Qual 2022; 37:413-421. [PMID: 35404304 DOI: 10.1097/jmq.0000000000000057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hospital rapid response systems are designed to reduce unmet patient needs and prevent clinical deterioration. Rapid response teams are the principal component of a rapid response system and require teamwork to function optimally; poor communication among team members can result in substandard patient care. The authors describe a process for developing and implementing standardized communication and a teamwork structure for rapid response events (RREs) at a large academic hospital. The multidisciplinary team developed a project charter and key driver diagram, developed a "communication bundle," used quality improvement methodology, monitored adherence to the changes, and reported these data to key stakeholders on a weekly basis. By project end, the team met the goal of having 70% or more of adult RREs include the use of the "communication bundle." The balancing measure demonstrated that the introduction of a formalized communication framework did not significantly increase the duration of RREs.
Collapse
Affiliation(s)
- Lauren Raff
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kelly Reilly
- Institute for Healthcare Quality and Improvement, University of North Carolina Health Care, Chapel Hill, NC
| | - Shana Ratner
- Institute for Healthcare Quality and Improvement, University of North Carolina Health Care, Chapel Hill, NC
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Carlton Moore
- Institute for Healthcare Quality and Improvement, University of North Carolina Health Care, Chapel Hill, NC
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan Raff
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
47
|
Challenges of practicing neuro-endovascular interventions in a resource-limited country; Ghana in focus. Neurol Sci 2022; 43:5451-5457. [DOI: 10.1007/s10072-022-06222-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/15/2022] [Indexed: 10/18/2022]
|
48
|
Veldhuis LI, Woittiez NJC, Nanayakkara PWB, Ludikhuize J. Artificial Intelligence for the Prediction of In-Hospital Clinical Deterioration: A Systematic Review. Crit Care Explor 2022; 4:e0744. [PMID: 36046062 PMCID: PMC9423015 DOI: 10.1097/cce.0000000000000744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
To analyze the available literature on the performance of artificial intelligence-generated clinical models for the prediction of serious life-threatening events in non-ICU adult patients and evaluate their potential clinical usage.
Collapse
|
49
|
Shiell A, Fry M, Elliott D, Elliott R. Exploration of a rapid response team model of care: A descriptive dual methods study. Intensive Crit Care Nurs 2022; 73:103294. [PMID: 36031517 DOI: 10.1016/j.iccn.2022.103294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/01/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration. OBJECTIVE To explore the characteristics of a collaborative rapid response team model. DESIGN Dual methodology was used for this descriptive study. SETTING The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia). PARTICIPANTS Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards. METHODS A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically. RESULTS The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation. CONCLUSIONS Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.
Collapse
Affiliation(s)
- Alexandra Shiell
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| | - Margaret Fry
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| | - Doug Elliott
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| | - Rosalind Elliott
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| |
Collapse
|
50
|
Jones DA. Long term mortality of medical emergency team patients in regional Australia. CRIT CARE RESUSC 2022; 24:100-101. [PMID: 38045603 PMCID: PMC10692635 DOI: 10.51893/2022.2.e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Daryl A. Jones
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Warringal Hospital, Melbourne, VIC, Australia
- Department of Surgery, University Melbourne, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Critical Care Outreach, Austin Hospital, Melbourne, VIC, Australia
- International Society for Rapid Response Systems, Sunderland, UK
| |
Collapse
|