The duration of hospitalization before review by the rapid response team: A retrospective cohort study

The associations between rapid response systems and their components with patient outcomes: A scoping review

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.

Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews

BACKGROUND

Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making.

OBJECTIVES

To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews.

METHODS

Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4).

RESULTS

Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review.

CONCLUSIONS

Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.

Impact of hospitalization duration before medical emergency team activation: A retrospective cohort study

BACKGROUND

The rapid response system has been implemented in many hospitals worldwide and, reportedly, the timing of medical emergency team (MET) attendance in relation to the duration of hospitalization is associated with the mortality of MET patients. We evaluated the relationship between duration of hospitalization before MET activation and patient mortality. We compared cases of MET activation for early, intermediate, and late deterioration to patient characteristics, activation characteristics, and patient outcomes. We also aimed to determine the relationship, after adjusting for confounders, between the duration of hospitalization before MET activation and patient mortality.

MATERIALS AND METHODS

We retrospectively evaluated patients who triggered MET activation in general wards from March 2009 to February 2015 at the Asan Medical Center in Seoul. Patients were categorized as those with early deterioration (less than 2 days after admission), intermediate deterioration (2-7 days after admission), and late deterioration (more than 7 days after admission) and compared them to patient characteristics, activation characteristics, and patient outcomes.

RESULTS

Overall, 7114 patients were included. Of these, 1793 (25.2%) showed early deterioration, 2113 (29.7%) showed intermediate deterioration, and 3208 (45.1%) showed late deterioration. Etiologies of MET activation were similar among these groups. The clinical outcomes significantly differed among the groups (intensive care unit transfer: 34.1%, 35.6%, and 40.4%; p < 0.001 and mortality: 26.3%, 31.5%, and 41.2%; p < 0.001 for early, intermediate, and late deterioration, respectively). Compared with early deterioration and adjusted for confounders, the odds ratio of mortality for late deterioration was 1.68 (1.46-1.93).

CONCLUSIONS

Nearly 50% of the acute clinically-deteriorating patients who activated the MET had been hospitalized for more than 7 days. Furthermore, they presented with higher rates of mortality and ICU transfer than patients admitted for less than 7 days before MET activation and had mortality as an independent risk factor.

The association between hospital length of stay before rapid response system activation and clinical outcomes: a retrospective multicenter cohort study

Background

Rapid response system (RRS) is being increasingly adopted to improve patient safety in hospitals worldwide. However, predictors of survival outcome after RRS activation because of unexpected clinical deterioration are not well defined. We investigated whether hospital length of stay (LOS) before RRS activation can predict the clinical outcomes.

Methods

Using a nationwide multicenter RRS database, we identified patients for whom RRS was activated during hospitalization at 9 tertiary referral hospitals in South Korea between January 1, 2016, and December 31, 2017. All information on patient characteristics, RRS activation, and clinical outcomes were retrospectively collected by reviewing patient medical records at each center. Patients were categorized into two groups according to their hospital LOS before RRS activation: early deterioration (LOS < 5 days) and late deterioration (LOS ≥ 5 days). The primary outcome was 28-day mortality and multivariable logistic regression was used to compare the two groups. In addition, propensity score-matched analysis was used to minimize the effects of confounding factors.

Results

Among 11,612 patients, 5779 and 5883 patients belonged to the early and late deterioration groups, respectively. Patients in the late deterioration group were more likely to have malignant disease and to be more severely ill at the time of RRS activation. After adjusting for confounding factors, the late deterioration group had higher 28-day mortality (aOR 1.60, 95% CI 1.44–1.77). Other clinical outcomes (in-hospital mortality and hospital LOS after RRS activation) were worse in the late deterioration group as well, and similar results were found in the propensity score-matched analysis (aOR for 28-day mortality 1.66, 95% CI 1.45–1.91).

Conclusions

Patients who stayed longer in the hospital before RRS activation had worse clinical outcomes. During the RRS team review of patients, hospital LOS before RRS activation should be considered as a predictor of future outcome.

Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): A prospective multicentre observational study

AIM

To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge.

METHOD

Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged > 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL).

RESULTS

152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91-0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77-0.91; p < 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93-0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge.

CONCLUSION

The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.

Is There A Non-Essential Hospitalization Day In Inpatients With Diabetes Under Medical Insurance? Evidence From An Observational Study In China

PURPOSE

Non-essential hospitalization day of inpatient diabetes threatens health seriously and contributes to great economic burden on individuals and the society. Studying the essential utilization of hospitalization services is conducive to the reduction in the burden of diabetes. The purpose of this study is to identify the existence of non-essential hospitalization days during hospitalization in diabetic patients through exploring the use of health care in different types of insured patients.

PATIENTS AND METHODS

A sample of 6731 admission records from 5929 hospitalized patients was studied. Binary logistic regression was performed to estimate the adjusted effects of health insurance status on readmission. Multiple stepwise linear regression was performed to estimate the adjusted effects of health insurance status on length of stay (LOS), direct medical expenses (DME), out-of-pocket (OOP) expenditures, and percentage of individual payment after reimbursement (PIPAR). Adjusted odds ratios (with 95% CI) were reported as the results of logistic regression models and linear regression models, respectively.

RESULTS

Adjusted 7-day readmission rate and 30-day readmission rate were not significantly different between urban and rural resident basic medical insurance (URRBMI) and urban employee basic medical insurance (UEBMI). Compared with inpatients under URRBMI, the adjusted LOS and DME were significantly higher for UEBMI inpatients (adjusted OR of 2.6, 95% CI=1.9-3.2, adjusted OR of 1870.85, 95% CI=1370.97-2370.73, respectively). Adjusted OOP and PIPAR were significantly lower for UEBMI inpatients (adjusted OR of－970.86, 95% CI =-1111.63--830.10, adjusted OR of -0.19, 95% CI=-0.20--0.18, respectively).

CONCLUSION

There was a non-essential hospitalization day existing in the treatment of diabetes. Moral hazard has been found in UEBMI which would trigger overtreatment in hospitalization of diabetics, and the lower PIPAR of UEBMI was one of the main causes of moral hazard.

High Rate of Medical Emergency Team Activation in Children with Tracheostomy

Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p  < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.

National Early Warning Score vs Rapid Response Team criteria-Prevalence, misclassification, and outcome

PURPOSE

The purpose of this study was to examine the prevalence of deviating vital parameters in general ward patients using rapid response team (RRT) criteria and National Early Warning Score (NEWS), assess exam duration, correct calculation and classification of risk score as well as mortality and adverse events.

METHODS

Point prevalence study of vital parameters according to NEWS and RRT criteria of all adult patients admitted to general wards at a Scandinavian university hospital with a mature RRT.

PRIMARY OUTCOME

prevalence of at-risk patients fulfilling at least one RRT criteria, total NEWS of 7 or greater or a single NEWS parameter of 3 (red NEWS).

SECONDARY OUTCOMES

mortality in-hospital and within 30 days or adverse events within 24 hours.

RESULTS

We assessed 598 (75%) of 798 admitted patients and examiners captured a fulfilled RRT calling criterion in 50 patients (8.4%), 36 (6.0%) had NEWS ≥ 7, 34 with a red NEWS parameter. Red NEWS occurred in 112 patients (18.7%). Secondary outcomes were fulfilled in 49 patients (8.2%). Mortality overall was 6.5% within 30 days, 1.8% in hospital. In 134 patients (22.4%) the manual calculation of score for NEWS was incorrectly performed by examiner.

CONCLUSION

Even with a mature RRT in place, we captured patients with failing physiology in general wards reflecting afferent limb failure. Manual calculation of NEWS is frequently incorrect, possibly leading to misclassification of patients at risk.

Advance care planning in the context of clinical deterioration: a systematic review of the literature

Background:

A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of reviews involve a patient approaching the end-of-life. It is not well understood whether patients have pre-existing advance care plans at the time of significant clinical deterioration requiring Rapid Response Team review. Nor is it understood whether such critical events prompt patients, their families and treating teams to discuss advance care planning and consider referral to specialist palliative care services.

Aim and design:

This systematic review examined advance care planning with patients who experience significant clinical deterioration in hospital and require Rapid Response Team review. The prevalence of pre-existing advance directives, whether this event prompts end-of-life discussions, the provision of broader advance care planning and referral to specialist palliative care services was examined.

Data sources:

Three electronic databases up to August 2017 were searched, and a manual review of article reference lists conducted. Quality of studies was appraised by the first and fourth authors.

Results:

Of the 324 articles identified through database searching, 31 met the inclusion criteria, generating data from 47,850 patients. There was a low prevalence of resuscitation orders and formal advance directives prior to Rapid Response Team review, with subsequent increases in resuscitation and limitations of medical treatment orders, but not advance directives. There was high short- and long-term mortality following review, and low rates of palliative care referral.

Conclusions:

The failure of patients, their families and medical teams to engage in advance care planning may result in inappropriate Rapid Response Team review that is not in line with patient and family priorities and preferences. Earlier engagement in advance care planning may result in improved person-centred care and referral to specialist palliative care services for ongoing management.

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

BACKGROUND

Rapid response teams (RRTs) attend severely ill general ward patients whose average 30-day mortality is near 30%. A major part of RRT patients are over 75 years old, but there are no studies on the characteristics and outcome of this geriatric RRT population. We compared the characteristics and outcome of geriatric RRT sub-population with the RRT patients <75 years old. We further investigated, whether the accumulation of risk factors (RFs) for mortality among the general RRT population predicts a tenuous outcome among the geriatric sub-population.

METHODS

Prospective three-year observational cohort study of adult RRT patients in Tampere University Hospital, Finland. After identifying independent RFs for 30-day mortality among RRT patients with multivariate logistic regression, we further studied the impact of the accumulation of these RFs among geriatric RRT patients who had no limitations of medical treatment.

RESULTS

A total of 1372 patients were reviewed 1722 times. Geriatric patients (n = 449, 33%), when compared to non-geriatric patients, had higher 30-day (33% vs. 21%, respectively; p < 0.001) and one-year (54% vs. 35%, respectively; p < 0.001) mortality rates. Among the general RRT population, positive RRT criteria as measured by RRT during the review, high comorbidity index, age ≥ 75 years, non-elective hospital admission, medical reason for admission and afferent limb failure were identified as independent RFs for 30-day mortality and classified as feasible to obtain during a routine RRT review. The observed rates of these RFs among the geriatric RRT patients substantially affected their 30-day mortality (e.g. no RFs: 5.3%; one RF: 14%; two RFs: 27%; three RFs: 38%; four RFs: 52%; five RFs: 38%).

CONCLUSIONS

One-third of patients reviewed by RRT were ≥75 years old, and age statistics were comparable to previous RRT studies suggesting that this is the case globally. Outcome of geriatric RRT patients is poorer as compared with RRT patients <75 years. However, the outcome is substantially affected by the accruement (or lack) of RFs generally increasing the mortality of RRT patients. Considering these factors during a geriatric RRT review may aid with the decision to either escalate or de-escalate care.

Outcome of adult patients attended by rapid response teams: A systematic review of the literature

BACKGROUND

An abundance of studies have investigated the impact of rapid response teams (RRTs) on in-hospital cardiac arrest rates. However, existing RRT data appear highly variable in terms of both study quality and reported uses of limitations of care, patient survival and patient long-term outcome.

METHODS

A systematic electronic literature search (January, 1990-March, 2016) of the PubMed and Cochrane databases was performed. Bibliographies of articles included in the full-text review were searched for additional studies. A predefined RRT cohort quality score (range 0-17) was used to evaluate studies independently by two reviewers.

RESULTS

Twenty-nine studies with a total of 157,383 RRT activations were included in this review. The quality of data reporting related to RRT patients was assessed as modest, with a median quality score of 8 (range 2-11). Data from the included studies indicate that a median 8.1% of RRT reviews result in limitations of medical treatment (range 2.1-25%) and 23% (8.2-56%) result in a transfer to intensive care. A median of 29% (6.9-35%) of patients transferred to intensive care died during that admission. The median hospital mortality of patients reviewed by RRT is 26% (12-60%), and the median 30-day mortality rate is 29% (8-39%). Data on long-term survival is minimal. No data on functional outcomes was identified.

CONCLUSIONS

Patients reviewed by rapid response teams have a high and variable mortality rate, and limitations of care are commonly used. Data on the long-term outcomes of RRT are lacking and needed.

Frequency and survival pattern of in-hospital cardiac arrests: The impacts of etiology and timing

OBJECTIVE

Define the frequency and survival pattern of cardiac arrests in relation to the hospital day of event and etiology of arrest.

SUBJECT AND METHODS

Retrospective cohort study of adult in-hospital cardiac arrests between July 1, 2005, and June 30, 2013, that were classified by etiology of deterioration. Arrests were divided based on hospital day (HD) of event (HD1, HD2-7, HD>7 days), and analysis of frequency was performed. The primary outcome of survival to discharge and secondary outcomes of return of spontaneous circulation (ROSC) and favorable neurological outcomes were compared using multivariable logistic regression analysis.

RESULTS

A total of 627 cases were included, 193 (30.8%) cases in group HD1, 206 (32.9%) in HD2-7, and 228 (36.4%) in HD>7. Etiology of arrest demonstrated variability across the groups (p<0.001). Arrests due to ventilation issues increased in frequency with longer hospitalization (p<0.001) while arrests due to dysrhythmia had the opposite trend (p=0.014). Rates of survival to discharge (p=0.038) and favorable neurological outcomes (p=0.002) were lower with increasing hospital days while ROSC was not different among the groups (p=0.183). Survival was highest for HD1 (HD1: 38.9% [95% CI, 32.0-45.7%], p=0.002 vs HD2-7: 34.0% [95% CI, 27.5-40.4%], p<0.001 vs HD>7: 27.2% [95% CI, 21.4-33.0%], p<0.001).

CONCLUSIONS

The etiology of cardiac arrests varies in frequency as length of hospitalization increases. Survival rates and favorable neurological outcomes are lower for in-hospital arrests occurring later in the hospitalization, even when adjusted for age, sex, and location of event. Understanding these issues may help with focusing therapies and accurate prognostication.

Rapid Response Team activation in New Zealand hospitals—a multicentre prospective observational study

We aimed to describe the epidemiology of Rapid Response Team (RRT) activation in New Zealand public hospitals. We undertook a prospective multicentre observational study of RRT activations in 11 hospitals for consecutive 14-day periods during October–December 2014. A standardised case report form was used to collect data on patient demographics, RRT activation criteria and timing, vital signs on RRT arrival, team composition and intervention, treatment limitation and patient outcome at day 30. Three hundred and thirteen patients received 351 RRT calls during the study period. Patients were admitted under a medical specialty in 177 (56.5%) instances. Median duration from hospital admission to first RRT call was two days. Eighty-six percent of RRT calls were to inpatient wards. A total of 43.4% of RRT calls occurred between 0800 and 1700 hours (38% of the day) and 75.5% of RRT calls were activated by ward nurses. A median of three staff attended each call. Common triggers for RRT activation were increased Early Warning Score (56.2%) and staff concern (25.7%). During the RRT call, 2.8% of patients died; 19.8% died by day 30. New ‘Not For Resuscitation’ orders were written in 22.5% of RRT calls. By day 30, 56.2% of patients had been discharged home alive. In conclusion, RRTs in New Zealand are multidisciplinary, mostly nurse-activated and predominantly respond to deteriorating medical (rather than surgical) patients. Most patients remain on the ward. The RRT frequently implements treatment limitations. Given almost one in five patients die within 30 days, over half of whom die within 72 hours of RRT review, surviving the RRT call may provide false reassurance that the patient will subsequently do well.