Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

RATIONALE

Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients.

OBJECTIVES

To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.

PANEL DESIGN

The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines.

METHODS

We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).

RESULTS

The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system.

CONCLUSIONS

The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Effects of a Rapid Response Team on Patient Outcomes: A Systematic Review

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.

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning

A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.

Increasing the Number of Medical Emergency Calls Does Not Improve Hospital Mortality

OBJECTIVES

Medical emergency teams were established to rescue patients experiencing clinical deterioration thus preventing cardiac arrest and unexpected hospital mortality. Although hospitals are encouraged to increase emergency calling rates to improve in-hospital mortality, there are increasing concerns about the impact these calls have on the workload of the teams and the skill levels on the general wards. We set out to examine the relationship between emergency calling rates and adjusted in-hospital mortality.

DESIGN

Retrospective analysis of prospectively collected patient and emergency call data.

SETTING

Tertiary, metropolitan, and regional hospitals in the State of Victoria, Australia.

PATIENTS

Consecutive patients discharged from 1) St Vincent's Hospital Melbourne from January 2008 to June 2016 and 2) 15 Victorian hospitals from July 2010 to June 2015.

MEASUREMENTS AND MAIN RESULTS

We studied 441,029 patients from St Vincent's Hospital Melbourne. Median age was 61.0 years (interquartile range, 45-74 yr), 57.2% were men, and 0.70% died; monthly emergency calling rates varied between 9.21 and 30.69 (median 18.4) per 1,000 discharges. In-hospital mortality adjusted for age, gender, emergency status, same day admission, year of discharge, and Charlson Comorbidity Index was not reduced by higher calling rates in the month of discharge (odds ratio, 1.019; 95% CI, 1.008-1.031). We then examined 3,339,789 discharges from 15 Victorian hospitals with median age 61 years (interquartile range, 43-74 yr), 51.4% men, and hospital mortality 0.83% where yearly emergency calling rates varied from 18.46 to 33.40 (median, 25.75) per 1,000 discharges. Again, adjusted mortality was not reduced by higher calling rates in the year of discharge (odds ratio, 1.003; 95% CI, 1.001-1.006).

CONCLUSIONS

With adjustment for patient factors, illness, and comorbidities, increased emergency calling rates were not associated with reduced in-hospital mortality. Efforts to increase calling rates do not seem warranted.

Novel model for predicting inpatient mortality after emergency admission to hospital in Singapore: retrospective observational study

OBJECTIVES

To identify risk factors for inpatient mortality after patients' emergency admission and to create a novel model predicting inpatient mortality risk.

DESIGN

This was a retrospective observational study using data extracted from electronic health records (EHRs). The data were randomly split into a derivation set and a validation set. The stepwise model selection was employed. We compared our model with one of the current clinical scores, Cardiac Arrest Risk Triage (CART) score.

SETTING

A single tertiary hospital in Singapore.

PARTICIPANTS

All adult hospitalised patients, admitted via emergency department (ED) from 1 January 2008 to 31 October 2017 (n=433 187 by admission episodes).

MAIN OUTCOME MEASURE

The primary outcome of interest was inpatient mortality following this admission episode. The area under the curve (AUC) of the receiver operating characteristic curve of the predictive model with sensitivity and specificity for optimised cut-offs.

RESULTS

15 758 (3.64%) of the episodes were observed inpatient mortality. 19 variables were observed as significant predictors and were included in our final regression model. Our predictive model outperformed the CART score in terms of predictive power. The AUC of CART score and our final model was 0.705 (95% CI 0.697 to 0.714) and 0.817 (95% CI 0.810 to 0.824), respectively.

CONCLUSION

We developed and validated a model for inpatient mortality using EHR data collected in the ED. The performance of our model was more accurate than the CART score. Implementation of our model in the hospital can potentially predict imminent adverse events and institute appropriate clinical management.

Critical care outreach: A valuable resource?

BACKGROUND

Critical Care Outreach Services (CCOS) were recommended by the Department of Health in the United Kingdom in 2000. Despite being an established service, research studies have not explicitly demonstrated its efficacy.

AIM AND OBJECTIVES

To explore the impact of CCOS from the perspective of hospital ward staff to inform service improvement potential.

DESIGN

A pilot formative process evaluation was used to meet the study aims, including the development of a self-completion questionnaire.

METHODS

The exploratory questionnaire was distributed to a purposive sample of clinical staff (health care assistants, nurses, therapists, and doctors) on two medical and two surgical wards to establish the value of CCOS from the perspective of ward staff.

RESULTS

The questionnaire was distributed to 195 staff members, of who 58 replied (30%). A descriptive analysis of quantitative data and content analysis of free-text responses demonstrated that staff knew how and when to use the service, that it was highly valued by all members of the multidisciplinary team, and that CCOS were perceived to have diverse responsibilities. Service improvement suggestions included increased staffing and longer hours of operation.

CONCLUSIONS

Despite the lack of quality research supporting the efficacy of CCOS in previous research studies, the results of this project support the findings of previous evaluations that the value of the service lies in the support offered to ward staff and in the quality of care provided to patients.

RELEVANCE TO CLINICAL PRACTICE

Because of the size of this evaluation, it was impossible to draw any generalizable conclusions. However, results clearly indicate that value is given to the support that the Critical Care Outreach Service provides to ward staff.

Ward visits- one essential step in intensive care follow-up. An interview study with critical care nurses' and ward nurses'

OBJECTIVE

The aim of this study was to describe critical care nurses' and ward nurses' perceptions of the benefits and challenges with a nurse-led follow-up service for intensive care-survivors at general wards.

BACKGROUND

Patients recently transferred from intensive care to the general ward are still vulnerable and require complex care. There are different models of intensive care follow-up services and some include ward visits after transfer from intensive care. Research methodology/design: This study had a qualitative design. Data from 13 semi-structured interviews with Swedish critical care nurses and ward nurses were analysed using qualitative content analysis.

FINDINGS

The findings consisted of one theme, namely, "Being a part of an intra-organisational collaboration for improved quality of care", and four subthemes: "Provides additional care for the vulnerable patients, "Strengthens ward-based critical care", "Requires coordination and information", and "Creates an exchange of knowledge". The nurse-led follow-up service detected signs of deterioration and led to better quality of care. However, shortage of time, lack of interaction, feedback and information about the function of the follow-up service led to problems.

CONCLUSION

The findings indicate that ward visits should be included in the intensive care follow-up service. Furthermore, intra-organisational collaboration seems to be essential for intensive care survivors' quality of care.

What nurses involved in a Medical Emergency Teams consider the most vital areas of knowledge and skill when delivering care to the deteriorating ward patient. A nurse-oriented curriculum development project

INTRODUCTION

Critical care nurses have been involved in Rapid Response Teams since their inception, particularly in medically led RRTs, known as Medical Emergency Teams. It is assumed that critical care skills are required to escalate care for the deteriorating ward patient. However, evidence to support critical care nurses' involvement in METs is anecdotal. Currently, little is known about the educational requirements for nurses involved in RRT or METs.

OBJECTIVES

We aimed to identify and describe what nurses involved in a MET consider the most vital areas of knowledge and skill when delivering care to the deteriorating ward patient.

METHODS

An exploratory descriptive design was used and data was collected at a session of the Australian and New Zealand Intensive Care Society Rapid Response Team (ANZICS-RRT) Conference held at The Gold Coast, Australia in July 2015. All conference delegates were eligible to take part. Conference delegates totalled 293; 194 nurses, 89 doctors and 10 allied health professionals. Data collection took place in three phases, over a 90-minute period. First, demographic data were collected from all participants at the start of data collection. These data were collected using paper-based surveys. Second, extended response surveys; that is, paper-based surveys that asked open-ended questions to elicit free text responses, were used to collect participants' individual responses to the question: "What are the specific theoretical knowledge, skills and behavioural attributes required in a curricula to prepare nurses to be high functioning members of a MET?" Demographic, educational and work characteristics were descriptively analysed using SPSS (version 22). Participants perceptions of what knowledge, skills and attributes are required for nurses to recognise and respond to clinical deterioration were thematically analysed.

RESULTS

Participants were predominantly female (88.3%, n = 91) with 54.4% (n = 56) holding a Bachelor of Nursing. Participants had a median of 20 years (IQR 16) experience as RNs, and a median of 14 years (IQR 13) experience in critical care. Participants formed part of METs frequently, with nearly half the cohort seeing clinically deteriorating patients more than once per day (37.9%, n = 33) or daily (10%, n = 9). Thematic analysis of survey responses revealed four main themes desired in Rapid Response Team Curricula: Clinical Deterioration Theory, Clinical Deterioration Skills, Rapid Response System Governance, and Professionalism and Teamwork.

CONCLUSIONS

We suggest that a curriculum that educates nurses on the specific requirements of assessing, managing and evaluating all aspects of clinical deterioration is now required.

Relationship between diurnal patterns in Rapid Response Call activation and patient outcome

BACKGROUND

The Rapid Response Call (RRC) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. To date, there have been few studies which have explored the relationship between time of day of RRC and patient outcome.

OBJECTIVE

To examine the relationship between the time of RRC activations and patient outcome.

METHOD

All adult inpatients with a RRC in non-critical care wards of a metropolitan Australian hospital in 2012 were retrospectively reviewed. RRCs occurring between 18:00-07:59 were defined as 'out of hours'.

RESULTS

There were 892 RRC during the study period. RRCs out of hours were associated with a higher rate of ICU admissions immediately after the RRC (19.4% vs. 12.3%, p<0.001). Patients experiencing an out-of-hours RRC were more likely to have an in-hospital cardiopulmonary arrest (OR=1.7, p<0.04). In-hospital mortality rate was significantly higher for patients with out-of-hours RRCs (35.5% vs. 25.0%, p=0.014). After adjusting for confounders out-of-hours RRC were independently associated with increased need for ICU admissions and in-hospital mortality.

CONCLUSION

The diurnal timing of RRCs appears to have significant implications for patient mortality and morbidity, patient outcomes are worse if RRC occurs out of hours. This finding has implications for staffing and resource allocation.

Failure to activate the in-hospital emergency team: causes and outcomes

Objective

To determine the incidence of afferent limb failure of the in-hospital Medical Emergency Team, characterizing it and comparing the mortality between the population experiencing afferent limb failure and the population not experiencing afferent limb failure.

Methods

A total of 478 activations of the Medical Emergency Team of Hospital Pedro Hispano occurred from January 2013 to July 2015. A sample of 285 activations was obtained after excluding incomplete records and activations for patients with less than 6 hours of hospitalization. The sample was divided into two groups: the group experiencing afferent limb failure and the group not experiencing afferent limb failure of the Medical Emergency Team. Both populations were characterized and compared. Statistical significance was set at p ≤ 0.05.

Result

Afferent limb failure was observed in 22.1% of activations. The causal analysis revealed significant differences in Medical Emergency Team activation criteria (p = 0.003) in the group experiencing afferent limb failure, with higher rates of Medical Emergency Team activation for cardiac arrest and cardiovascular dysfunction. Regarding patient outcomes, the group experiencing afferent limb failure had higher immediate mortality rates and higher mortality rates at hospital discharge, with no significant differences. No significant differences were found for the other parameters.

Conclusion

The incidence of cardiac arrest and the mortality rate were higher in patients experiencing failure of the afferent limb of the Medical Emergency Team. This study highlights the need for health units to invest in the training of all healthcare professionals regarding the Medical Emergency Team activation criteria and emergency medical response system operations.

The Effect of Rapid Response System Revision on Standard and Specific Intensive Care Unit Outcomes in a Regional Hospital

Hospital systems for the recognition (afferent limb) and management (efferent limb) of deteriorating patients, or Rapid Response Systems (RRSs), are being mandated worldwide, in spite of conflicting evidence regarding their efficacy. We have evaluated the impact of an Adult Deterioration Detection System (Q–ADDS)–based RRS specifically on illness severity at intensive care unit (ICU) admission and ICU length of stay (LOS), as well as previously studied endpoints. We undertook a retrospective, single-centre observational study comparing equivalent 18-month periods before the Q–ADDS–based RRS, and after implementation. The primary endpoints of the study were illness severity of unplanned ICU admissions from the ward, ICU length of stay, and ICU mortality. Secondary endpoints were RRS call numbers, rate of unplanned ICU admissions, and ward-based cardiorespiratory arrests. Following the introduction of the new RRS, Acute Pain and Chronic Health Evaluation (APACHE) II (17 versus 21, P <0.001), APACHE III (64 versus 68, P=0.011) and Simplified Acute Physiology Score (35 versus 38, P=0.044) scores at ICU admission from the ward were reduced. Fewer patients were in the >50% predicted mortality range of APACHE II (16% versus 32%, P <0.001), APACHE III (18% versus 28%, P=0.012) and Simplified Acute Physiology Score (14% versus 24%, P=0.006). ICU mortality was unchanged (13.7% versus 13.8%, P=0.93). ICU LOS was reduced (3 versus 4 days, P=0.02); prolonged stay (>7 days) was not significantly changed (19% versus 27%, P=0.055). Unplanned ICU admissions, cardiorespiratory arrests and hospital mortality were unchanged. The frequency of RRS activation (48 versus 11 per 1,000 admissions, P <0.001) was markedly increased. This Q–ADDS form–based RRS has resulted in lower illness severity at ICU admission from the ward, and fewer patients with scores associated with a >50% predicted mortality. Overall, ICU length of stay was reduced. These specific outcomes may reliably reflect RRS efficacy, even in smaller centres.

Early Experience of Medical Alert System in a Rural Training Hospital: a Pilot Study

Background

Medical emergency teams (METs) have shown their merit in preventing unexpected cardiac arrest. However, it might be impractical for small- or medium-sized hospitals to operate an MET due to limited manpower and resources. In this study, we sought to evaluate the feasibility of a medical alert system (MAS) that alerts all doctors involved in patient care of patient deterioration via text message using smart-phones.

Methods

The MAS was test-operated from July 2015 to September 2015, in five general wards with a high incidence of cardiac arrest. The number of cardiac arrests was compared to that of 2014. The indication for activation of MAS was decided by the intensive care unit committee of the institution, which examined previous reports on MET.

Results

During the three-month study period, 2,322 patients were admitted to the participating wards. In all, MAS activation occurred in 9 patients (0.39%). After activation, 7 patients were admitted to the intensive care unit. Two patients (0.09%) experienced cardiac arrest. Of 13,129 patients admitted to the ward in 2014, there were 50 cases (0.38%) of cardiac arrest (p = 0.009).

Conclusions

It is feasible to use MAS to prevent unexpected cardiac arrest in a general ward.

Timing and Location of Medical Emergency Team Activation Is Associated with Seriousness of Outcome: An Observational Study in a Tertiary Care Hospital

Purpose

The medical emergency team (MET) can be activated anytime and anywhere in a hospital. We hypothesized the timing and location of MET activation are associated with seriousness of outcome.

Materials and Methods

We tested for an association of clinical outcomes with timing and location using a university hospital cohort in Japan (n = 328). The primary outcome was short-term serious outcome (unplanned ICU admission after MET activation or death at scene).

Results

Patients for whom the MET was activated in the evening or night-time had significantly higher rates of short-term serious outcome than those for whom it was activated during the daytime (vs. evening: adjusted OR = 2. 53, 95% CI = 1.24–5.13, P = 0.010; night-time: adjusted OR = 2.45, 95% CI = 1.09–5.50, P = 0.030). Patients for whom the MET was activated in public space had decreased short-term serious outcome compared to medical spaces (public space: adjusted OR = 0.19, 95% CI = 0.07–0.54, P = 0.0017). Night-time (vs. daytime) and medical space (vs. public space) were significantly associated with higher risks of unexpected cardiac arrest and 28-day mortality.

Conclusions

Patients for whom the MET was activated in the evening/night-time, or in medical space, had a higher rate of short-term serious outcomes. Taking measures against these risk factors may improve MET performance.

The limitations in implementing and operating a rapid response system

Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.

Integration of a difficult airway response team into a hospital emergency response system

Hospital-wide emergency response teams have been an area of development for several decades. Highly specialized to address emergent needs, they mimic the cardiac-pulmonary arrest teams established at hospitals nationwide, such as heart attack, brain attack, medical emergency, rapid response, and difficult airway response teams (DART). The DART at Johns Hopkins Hospital is a collaboration of the Anesthesiology and Critical Care Medicine, Otolaryngology-Head and Neck Surgery, General Surgery, and Emergency Medicine departments. This successful model may be used by other hospitals to establish improved and comprehensive care of the difficult airway patient.

The timing of discharge from the intensive care unit and subsequent mortality. A prospective, multicenter study

RATIONALE

Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic.

OBJECTIVES

To determine factors independently associated with mortality after ICU discharge.

METHODS

This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010.

MEASUREMENTS AND MAIN RESULTS

We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49-74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3-25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00-18:00) and 1,672 (16.4%) after-hours (18:00-06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P < 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5-45.6).

CONCLUSIONS

In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.

Rapid response systems: are they really effective?

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

The Clinical Trials Group Turns 20: A Clinician's Perspective

A clinician's perspective on the first 20 years of the Australian and New Zealand Intensive Care Society Clinical Trials Group and its influence on intensive care clinical practice over this same time period. This point of view discusses the importance of the Clinical Trials Group and the significance of several major published research trials.

The effect of rapid response teams on end-of-life care: a retrospective chart review

BACKGROUND

A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care.

OBJECTIVES

To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes.

METHODS

A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers.

RESULTS

In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05).

CONCLUSIONS

A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.

Year in review 2012: Critical Care--management

Outcomes research plays a key role in defining the effects of medical care in critical care. Last year Critical Care published a number of papers that evaluated patient-centered and policy-relevant outcomes. We present this review article focusing on key reported outcomes associated with severe community-acquired pneumonia, mortality associated with decisions regarding triage to the ICU, and both short-term and long-term mortality associated with ICU admissions. We further analyze the literature, assessing outcomes such as quality of life and the psychological burden associated with critical care. We also reviewed processes of care, and studies looking at cost analysis of treatment associated with critical care.

Use of a modified pediatric early warning score in a department of pediatric and adolescent medicine

Background

Several versions of the Pediatric Early Warning Score (PEWS) exist, but there is limited information available on the use of such systems in different contexts. In the present study, we aimed to examine the relationship between a modified version of The Brighton Paediatric Early Warning Score (PEWS) and patient characteristics in a Norwegian department of pediatric and adolescent medicine. In addition, we sought to establish guidelines for escalation in patient care based on the PEWS in our patient population.

Methods

The medical records of patients referred for acute care from March to May 2011 were retrospectively reviewed. Children with a PEWS ≥3 were compared to children with a PEWS 0–2 with regard to age, diagnostic group and indicators of severe disease.

Results

A total of 761 patients (0−18 years of age) were included in the analysis. A younger age and diagnostic groups such as lower airway and cardiovascular disease were associated with PEWS ≥3. Upper airway disease and minor injury were more frequent in patients with PEWS 0−2. Children with PEWS ≥3 received fluid resuscitation, intravenous antibiotics, and oxygen supplementation, and were transferred to a higher level of care more often than children with PEWS 0−2.

Conclusions

A PEWS ≥3 was associated with severe illnesses and surrogate markers of cardio-respiratory compromise. Patients with PEWS ≥3 should be carefully monitored to prevent further deterioration.

Rapid-response systems as a patient safety strategy: a systematic review

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.