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

Outcomes and predictors of in-hospital mortality among patients admitted to the intensive care or step-down unit after a rapid response team activation: A retrospective cohort study

INTRODUCTION

It has been demonstrated that the implementation of rapid response teams (RRT) may improve clinical outcomes. Nevertheless, predictors of mortality among patients admitted to the intensive care unit (ICU) or to the step-down unit (SDU) after a RRT activation are not fully understood.

OBJECTIVE

To describe clinical characteristics, resource use, main outcomes, and to address predictors of in-hospital mortality among patients admitted to the ICU/SDU after RRT activation.

METHODS

Retrospective single-center cohort study conducted in a medical-surgical ICU/SDU located in a private quaternary care hospital. Adult patients admitted to the ICU or SDU between 2012 and 2020 were compared according to in-hospital mortality. A multivariate logistic regression analysis was performed to identify independent predictors of in-hospital mortality.

RESULTS

Among the 3841 patients included in this analysis [3165 (82.4%) survivors and 676 (17.6%) non-survivors], 1972 (51.3%) were admitted to the ICU and 1869 (48.7%) were admitted to the SDU. Compared to survivors, non-survivors were older [76 (64-87) yrs. vs. 67 (50-81) yrs.; p < 0.001], had a higher SAPS 3 score [64 (56-72) vs. 49 (40-57); p < 0.001], and had a longer length of stay (LOS) before unit admission [8 (3-19) days vs. 2 (1-7) days; p < 0.001). Non-survivors used more non-invasive ventilation (NIV) (42.2% vs. 20.9%; p < 0.001), mechanical ventilation (MV) (36.7% vs. 9.3%; p < 0.001), vasopressors (39.2% vs. 12.3%; p < 0.001), renal replacement therapy (15.5% vs. 4.3%; p < 0.001), and blood components transfusion (34.9% vs. 14.0%; p < 0.001). Independent predictors of in-hospital mortality were the SAPS 3 score, the Charlson Comorbidity Index, LOS before unit admission, immunosuppression, respiratory rate < 8 or > 28 ipm criteria for RRT activation, RRT activation during the night shift, and the need for high-flow nasal cannula, NIV, MV, vasopressors, and blood components transfusion.

CONCLUSION

Multiple factors may affect outcomes of ICU/SDU-admitted patients after RRT activation. Therefore, efforts should be made to boost RRT effectiveness to improve patient safety.

Characteristics and outcomes of patients screened by the rapid response team and transferred to intensive care unit in South Korea

The rapid response system (RRS) is associated with a reduction in in-hospital mortality. This study aimed to determine the characteristics and outcomes of patients transferred to the intensive care unit (ICU) by a rapid response team (RRT). This retrospective, multicenter cohort study included patients from nine hospitals in South Korea. Adult patients who were admitted to the general ward (GW) and required RRS activation were included. Patients with do-not-resuscitate orders and without lactate level or Sequential Organ Failure Assessment score were excluded. A total of 8228 patients were enrolled, 3379 were transferred to the ICU. The most common reasons for RRT activation were respiratory distress, sepsis and septic shock. The number of patients who underwent interventions, the length of hospital stays, 28-day mortality, and in-hospital mortality were higher in the ICU group than in the GW group. Factors that could affect both 28-day and in-hospital mortality included the severity score, low PaO2/FiO2 ratio, higher lactate and C-reactive protein levels, and hospitalization time prior to RRT activation. Patients admitted to the ICU after RRT activation generally face more challenging clinical situations, which may affect their survival outcomes.

Accelerometer-Measured Behavior Patterns in Incident Cerebrovascular Disease: Insights for Preventative Monitoring From the UK Biobank

BACKGROUND

The goal was to compare patterns of physical activity (PA) behaviors (sedentary behavior [SB], light PA, moderate-to-vigorous PA [MVPA], and sleep) measured via accelerometers for 7 days between patients with incident cerebrovascular disease (CeVD) (n=2141) and controls (n=73 938).

METHODS AND RESULTS

In multivariate models, cases spent 3.7% less time in MVPA (incidence rate ratio [IRR], 0.963 [95% CI, 0.929-0.998]) and 1.0% more time in SB (IRR, 1.010 [95% CI, 1.001-1.018]). Between 12 and 24 months before diagnosis, cases spent more time in SB (IRR, 1.028 [95% CI, 1.001-1.057]). Within the year before diagnosis, cases spent less time in MVPA (IRR, 0.861 [95% CI, 0.771-0.964]). Although SB time was not associated with CeVD risk, MVPA time, both total min/d (hazard ratio [HR], 0.998 [95% CI, 0.997-0.999]) and guideline threshold adherence (≥150 min/wk) (HR, 0.909 [95% CI, 0.827-0.998]), was associated with decreased CeVD risk. Comorbid burden had a significant partial mediation effect on the relationship between MVPA and CeVD. Cases slept more during 12:00 to 17:59 hours (IRR, 1.091 [95% CI, 1.002-1.191]) but less during 0:00 to 5:59 hours (IRR, 0.984 [95% CI, 0.977-0.992]). No between-group differences were significant at subgroup analysis.

CONCLUSIONS

Daily behavior patterns were significantly different in patients before CeVD. Although SB was not associated with CeVD risk, the association between MVPA and CeVD risk is partially mediated by comorbid burden. This study has implications for understanding observable behavior patterns in cerebrovascular dysfunction and may help in developing remote monitoring strategies to prevent or reduce cerebrovascular decline.

Safety and Effectiveness of Intensive Treatments Administered Outside the Intensive Care Unit to Hematological Critically Ill Patients: An Intensive Care without Walls Trial

Historically, the admission of hematological patients in the ICU shortly after the start of a critical illness is associated with better survival rates. Early intensive interventions administered by MET could play a role in the management of hematological critically ill patients, eventually reducing the ICU admission rate. In this retrospective and monocentric study, we evaluate the safety and effectiveness of intensive treatments administered by the MET in a medical ward frame. The administered interventions were mainly helmet CPAP and pharmacological cardiovascular support. Frequent reassessment by the MET at least every 8 to 12 h was guaranteed. We analyzed data from 133 hematological patients who required MET intervention. In-hospital mortality was 38%; mortality does not increase in patients not immediately transferred to the ICU. Only three patients died without a former admission to the ICU; in these cases, mortality was not related to the acute illness. Moreover, 37% of patients overcame the critical episode in the hematological ward. Higher SOFA and MEWS scores were associated with a worse survival rate, while neutropenia and pharmacological immunosuppression were not. The MET approach seems to be safe and effective. SOFA and MEWS were confirmed to be effective tools for prognostication.

Effect of a Wireless Vital Sign Monitoring System on the Rapid Response System in the General Ward

While wireless vital sign monitoring is expected to reduce the vital sign measurement time (thus reducing the nursing workload), its impact on the rapid response system is unclear. This study compared the time from vital sign measurement to recording and rapid response system activation between wireless and conventional vital sign monitoring in the general ward, to investigate the impact of wireless vital sign monitoring system on the rapid response system. The study divided 249 patients (age > 18 years; female: 47, male: 202) admitted to the general ward into non-wireless (n = 101) and wireless (n = 148) groups. Intervals from vital sign measurement to recording and from vital sign measurement to rapid response system activation were recorded. Effects of wireless system implementation for vital sign measurement on the nursing workload were surveyed in 30 nurses. The interval from vital sign measurement to recording was significantly shorter in the wireless group than in the non-wireless group (4.3 ± 2.9 vs. 44.7 ± 14.4 min, P < 0.001). The interval from vital sign measurement to rapid response system activation was also significantly lesser in the wireless group than in the non-wireless group (27.5 ± 12.9 vs. 41.8 ± 19.6 min, P = 0.029). The nursing workload related to vital sign measurement significantly decreased from 3 ± 0.87 to 2.4 ± 9.7 (P = 0.021) with wireless system implementation. Wireless vital sign monitoring significantly reduced the time to rapid response system activation by shortening the time required to measure the vital signs. It also significantly reduced the nursing workload.

Characteristics and outcomes of patients screened by rapid response team who transferred to the intensive care unit

BACKGROUND

The utilization of a rapid response team (RRT) has influenced the clinical outcomes of patients in the general ward. However, the characteristics of RRT-screened patients who are transferred to the intensive care unit (ICU) are unknown. Therefore, the present study aimed to evaluate these factors.

METHODS

We conducted a retrospective study using patient data from a tertiary medical center in Republic of Korea between January 2016 and December 2017. Multivariate logistic regression analyses were performed to assess the factors associated with the risk of in-hospital mortality.

RESULTS

A total of 1,096 patients were included: 389 patients were transferred to the ICU, and 707 patients stayed in the ward. Patients in the ICU group were more likely to be admitted for medical reasons, hepatobiliary disease, and high heart rate. More interventions were performed, hospital stays were longer, and the 28-day and in-hospital mortality rates were higher in the ICU group than in the ward group. Multivariate logistic regression analyses showed that risk factors affecting ICU admission were higher Sequential Organ Failure Assessment (SOFA) score, National Early Warning Score (NEWS), platelet count, and lactate level. ICU transfer was not associated with in-hospital mortality.

CONCLUSIONS

Among RRT-screened patients, those with higher SOFA score, NEWS, and lactate level were more likely to be transferred to the ICU. Therefore, these patients should be closely monitored and considered for ICU transfer.