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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Fildes C, Munt R, Chamberlain D. Impact of Dual Intensive Care Unit and Rapid Response Team Nursing Roles on Service Delivery in the Intensive Care Unit. Crit Care Nurse 2022; 42:23-31. [PMID: 36180060 DOI: 10.4037/ccn2022540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Rapid response teams generally consist of multidisciplinary specialist staff members with advanced knowledge and skills to manage deteriorating patients outside of the intensive care unit. These teams consist predominantly of intensive care unit nurses, who often undertake intensive care unit and rapid response team duties concurrently. Little has been published on the impact of these nurses' absence while attending a rapid response call on the nursing workforce, patient care, and resource allocation in the intensive care unit. OBJECTIVE To explore the impact of nurses' absence due to attending rapid response calls in other areas of the hospital on service delivery and resource allocation in the intensive care unit. METHODS A comprehensive search of 3 databases was performed to identify studies on relationships among the rapid response team, the intensive care unit, and nursing staff. RESULTS The search yielded 6 quantitative studies, 2 qualitative studies, and a mixed-methods study that were included for analysis. Four key themes were identified: (1) workforce, staffing processes, and resource allocation; (2) alterations to workload and resource allocation; (3) adverse events or incidents; and (4) funding variability of rapid response team models. Review of the studies indicated that dual intensive care unit and rapid response team nursing roles have negative effects on nurses' workload, increase the risk of adverse events, and may compromise patient safety. CONCLUSION The staffing of both the intensive care unit and the rapid response team should be examined carefully with an eye toward sustainability, cost-effectiveness, and clear outcome measures.
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Affiliation(s)
- Clinton Fildes
- Clinton Fildes is a nurse unit manager, Central Adelaide Local Health Network, Adelaide, South Australia, Australia. He is affiliated with the College of Nursing and Midwifery, Flinders University, Adelaide, South Australia, Australia
| | - Rebecca Munt
- Rebecca Munt is a research nurse, Central Adelaide Local Health Network and Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Diane Chamberlain
- Diane Chamberlain is a professor, Caring Futures Institute in the College of Nursing and Midwifery, Flinders University, Adelaide
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Feder J, Ramsay C, Tsampalieros A, Barrowman N, Richardson K, Rizakos S, Sweet J, McNally JD, Lobos AT. Relationship between Time of Day of Medical Emergency Team Activations and Outcomes of Hospitalized Pediatric Patients. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1744297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis study was conducted to investigate whether outcomes of medical emergency team (MET) activations differ by time of day of in-hospitalized pediatric patients. This is a retrospective cohort study. Data were extracted from the charts of 846 patients (with one or more MET activations) over a 5-year period. It was conducted at Children's Hospital of Eastern Ontario, a tertiary pediatric hospital in Ottawa, Canada, affiliated with University of Ottawa. Patients included children <18 years, admitted to a pediatric ward, who experienced a MET activation between January 1, 2016 and December 31, 2020. We excluded patients reviewed by the MET during a routine follow-up, planned pediatric intensive care unit (PICU) admissions from the ward, and MET activation in out-patient settings, post-anesthesia care unit, and neonatal intensive care unit. There was no intervention. A total of 1,230 MET encounters were included as part of the final analysis. Daytime (08:00–15:59) MET activation was associated with increased PICU admission (25.3%, p = 0.04). There was some evidence of a higher proportion of critical deterioration events (CDEs) during daytime MET activation; however, this did not reach statistical significance (24%, p = 0.09). The highest MET dosage occurred during the evening hours, 16:00 to 23:59 (15/1,000 admissions), and it was lowest overnight, 00:00 to 07:59 (8.8/1,000 admissions, p < 0.001). This period of lowest MET dosage immediately preceded the highest likelihood of PICU admission (08:00, 37.5%) and CDE (09:00, 30.2%). Following the period of lowest MET activity overnight, MET activations during early daytime hours were associated with the highest likelihood of unplanned PICU admission and CDEs. This work identifies potential high-risk periods for undetected critical deterioration and targets for future quality improvement.
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Affiliation(s)
- Joshua Feder
- Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Christa Ramsay
- Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Kara Richardson
- Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Sara Rizakos
- MD Candidate, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia Sweet
- MD Candidate, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Dayre McNally
- Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Critical Care, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anna-Theresa Lobos
- Division of Critical Care, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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McGrath SP, MacKenzie T, Perreard I, Blike G. Characterizing rescue performance in a tertiary care medical center: a systems approach to provide management decision support. BMC Health Serv Res 2021; 21:843. [PMID: 34416882 PMCID: PMC8379722 DOI: 10.1186/s12913-021-06855-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022] Open
Abstract
Background Allocation of limited resources to improve quality, patient safety, and outcomes is a decision-making challenge health care leaders face every day. While much valuable health care management research has concentrated on administrative data analysis, this approach often falls short of providing actionable information essential for effective management of specific system implementations and complex systems. This comprehensive performance analysis of a hospital-wide system illustrates application of various analysis approaches to support understanding specific system behaviors and identify leverage points for improvement. The study focuses on performance of a hospital rescue system supporting early recognition and response to patient deterioration, which is essential to reduce preventable inpatient deaths. Methods Retrospective analysis of tertiary care hospital inpatient and rescue data was conducted using a systems analysis approach to characterize: patient demographics; rescue activation types and locations; temporal patterns of activation; and associations of patient factors, including complications, with post-rescue care disposition and outcomes. Results Increases in bedside consultations (20% per year) were found with increased rescue activations during periods of resource limitations and changes (e.g., shift changes, weekends). Cardiac arrest, respiratory failure, and sepsis complications present the highest risk for rescue and death. Distributions of incidence of rescue and death by day of patient stay may suggest opportunities for earlier recognition. Conclusions Specific findings highlight the potential of using rescue-related risk and targeted resource deployment strategies to improve early detection of deterioration. The approach and methods applied can be used by other institutions to understand performance and allow rational incremental improvements to complex care delivery systems. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06855-w.
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Affiliation(s)
- Susan P McGrath
- Analytics Institute, Dartmouth-Hitchcock Health, Lebanon, NH, 03756, USA.
| | - Todd MacKenzie
- Department of Biomedical Data Science, Dartmouth College, Hanover, NH, 03755, USA
| | - Irina Perreard
- Analytics Institute, Dartmouth-Hitchcock Health, Lebanon, NH, 03756, USA
| | - George Blike
- Department of Anesthesiology, Dartmouth-Hitchcock Health, Lebanon, NH, 03756, USA
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5
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Baig MM, GholamHosseini H, Afifi S, Lindén M. A systematic review of rapid response applications based on early warning score for early detection of inpatient deterioration. Inform Health Soc Care 2021; 46:148-157. [PMID: 33472485 DOI: 10.1080/17538157.2021.1873349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM The aim of this study was to investigate the effectiveness of current rapid response applications available in acute care settings for escalation of patient deterioration. Current challenges and barriers, as well as key recommendations, were also discussed. METHODS We adopted PRISMA review methodology and screened a total of 559 articles. After considering the eligibility and selection criteria, we selected 13 articles published between 2015 and 2019. The selection criteria were based on the inclusion of studies that report on the advancement made to the current practice for providing rapid response to the patient deterioration in acute care settings. RESULTS We found that current rapid response applications are complicated and time-consuming for detecting inpatient deterioration. Existing applications are either siloed or challenging to use, where clinicians are required to move between two or three different applications to complete an end-to-end patient escalation workflow - from vital signs collection to escalation of deteriorating patients. We found significant differences in escalation and responses when using an electronic tool compared to the manual approach. Moreover, encouraging results were reported in extensive documentation of vital signs and timely alerts for patient deterioration. CONCLUSION The electronic vital signs monitoring applications are proved to be efficient and clinically suitable if they are user-friendly and interoperable. As an outcome, several key recommendations and features were identified that would be crucial to the successful implementation of any rapid response system in all clinical settings.
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Affiliation(s)
| | - Hamid GholamHosseini
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Shereen Afifi
- School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Maria Lindén
- School of Innovation, Design and Engineering, Mälardalen University, Västerås, Sweden
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Walker RM, Boorman RJ, Vaux A, Cooke M, Aitken LM, Marshall AP. Identifying barriers and facilitators to recognition and response to patient clinical deterioration by clinicians using a behaviour change approach: A qualitative study. J Clin Nurs 2021; 30:803-818. [PMID: 33351998 DOI: 10.1111/jocn.15620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/03/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Failure of clinicians to recognise and respond to patient clinical deterioration is associated with increased hospital mortality. Emergency response teams are implemented throughout hospitals to support direct-care clinicians in managing patient deterioration, but patient clinical deterioration is often not identified or acted upon by clinicians in ward settings. To date, no studies have used an integrative theoretical framework in multiple sites to examine why clinicians' delay identification and action on patients' clinical deterioration. AIM To identify barriers and facilitators that influence clinicians' absent or delayed response to patient clinical deterioration using the Theoretical Domains Framework. METHODS The Theoretical Domains Framework guided: (a) semi-structured interviews with clinicians, health consumers and family members undertaken at two sites; (b) deductive analyses of inductive themes to identify barriers and facilitators to optimal care. This study complied with the COREQ research guidelines. FINDINGS Seven themes identified: (a) information transfer; (b) ownership of patient care; (c) confidence to respond; (d) knowledge and skills; (e) culture; (f) emotion; and (g) environmental context and resources. DISCUSSION The Theoretical Domains Framework identified traditional social and professional hierarchies and limitations due to environmental contexts and resources as contributors to diminished interprofessional recognition and impediments to the development of effective relationships between professional groups. Communication processes were impacted by these restraints and further confounded by inadequate policy development and limited access to regular effective team-based training. As a result, patient safety was compromised, and clinicians frustrated. CONCLUSIONS These results inform the development, implementation and evaluation of a behaviour change intervention and increase knowledge about barriers and facilitators to timely response to patient clinical deterioration. RELEVANCE TO CLINICAL PRACTICE Results contribute to understanding of why clinicians delay responding to patient clinical deterioration and suggest key recommendations to identify and challenge traditional hierarchies and practices that prevent interdisciplinary collaboration and decision-making.
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Affiliation(s)
- Rachel M Walker
- School of Nursing and Midwifery, Griffith University, Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Qld, Australia.,Division of Surgery, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Rhonda J Boorman
- School of Nursing and Midwifery, Griffith University, Brisbane, Qld, Australia
| | - Amanda Vaux
- Metro South Patient Flow Program, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Marie Cooke
- School of Nursing and Midwifery, Griffith University, Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Qld, Australia
| | - Leanne M Aitken
- School of Nursing and Midwifery, Griffith University, Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Qld, Australia.,School of Health Sciences, City University of London, London, UK
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Qld, Australia.,Gold Coast Health, Gold Coast, Qld, Australia
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7
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Sok S, Sim H, Han B, Park SJ. Burnout and Related Factors of Nurses Caring for DNR Patients in Intensive Care Units, South Korea. Int J Environ Res Public Health 2020; 17:E8899. [PMID: 33266053 PMCID: PMC7729810 DOI: 10.3390/ijerph17238899] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 12/21/2022]
Abstract
This study examined the factors related to burnout, depression, job stress, and job satisfaction in intensive care unit (ICU) nurses caring for do not resuscitate (DNR) patients, as well as analyzed any differences. A cross-sectional descriptive design was employed. Study participants involved a total of 115 nurses caring for DNR patients in ICUs in South Korean hospitals. Measures involved a demographic form, Copenhagen Burnout Inventory (CBI), Center for Epidemiologic Studies Depression Scale, Nursing Job Stress Scale (Korean version), and Nursing Job Satisfaction Scale (Korean version). Data were collected from February to March 2017. The analyses illustrated a higher level of burnout, a slightly lower level of depression, a slightly lower level of nursing job stress, and a very slightly higher level of nursing job satisfaction compared with the median value of the score range for each scale. Burnout had a significant, positive relationship with depression and nursing job stress, and depression had a significant, positive relationship with nursing job stress. This study illuminates preliminary evidence that ICU nurses who are caring for DNR patients have a higher level of burnout compared with the median value of the score range in the CBI (Korean version). Burnout, depression, job stress, and job satisfaction were interrelated in ICU nurses.
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Affiliation(s)
- Sohyune Sok
- College of Nursing Science, Kyung Hee University, Seoul 02447, Korea
| | - Hyebeen Sim
- Department of Nursing, Graduate School, Kyung Hee University, Seoul 02447, Korea; (H.S.); (B.H.); (S.J.P.)
| | - Bokhee Han
- Department of Nursing, Graduate School, Kyung Hee University, Seoul 02447, Korea; (H.S.); (B.H.); (S.J.P.)
| | - Se Joung Park
- Department of Nursing, Graduate School, Kyung Hee University, Seoul 02447, Korea; (H.S.); (B.H.); (S.J.P.)
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8
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McGrath SP, Wells E, McGovern KM, Perreard I, Stewart K, McGrath D, Blike G. Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems. Adv Health Care Manag 2020; 18. [PMID: 32077653 DOI: 10.1108/s1474-823120190000018006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.
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9
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Fernando SM, Reardon PM, Bagshaw SM, Scales DC, Murphy K, Shen J, Tanuseputro P, Heyland DK, Kyeremanteng K. Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deterioration. Crit Care 2018. [PMID: 29534744 PMCID: PMC5851273 DOI: 10.1186/s13054-018-2005-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Rapid Response Teams (RRTs) are groups of healthcare providers that are used by many hospitals to respond to acutely deteriorating patients admitted to the wards. We sought to identify outcomes of patients assessed by RRTs outside standard working hours. Methods We used a prospectively collected registry from two hospitals within a single tertiary care-level hospital system between May 1, 2012, and May 31, 2016. Patient information, outcomes, and RRT activation information were stored in the hospital data warehouse. Comparisons were made between RRT activation during daytime hours (0800–1659) and nighttime hours (1700–0759). The primary outcome was in-hospital mortality, analyzed using a multivariable logistic regression model. Results A total of 6023 RRT activations on discrete patients were analyzed, 3367 (55.9%) of which occurred during nighttime hours. Nighttime RRT activation was associated with increased odds of mortality, as compared with daytime RRT activation (adjusted OR 1.34, 95% CI 1.26–1.40, P = 0.02). The time periods associated with the highest odds of mortality were 0600–0700 (adjusted OR 1.30, 95% CI 1.09–1.61) and 2300–2400 (adjusted OR 1.34, 95% CI 1.01–1.56). Daytime RRT activation was associated with increased odds of intensive care unit admission (adjusted OR 1.40, 95% CI 1.31–1.50, P = 0.02). Time from onset of concerning symptoms to RRT activation was shorter among patients assessed during daytime hours (P < 0.001). Conclusions Acutely deteriorating ward patients assessed by an RRT at nighttime had a higher risk of in-hospital mortality. This work identifies important shortcomings in health service provision and quality of care outside daytime hours, highlighting an opportunity for quality improvement. Electronic supplementary material The online version of this article (10.1186/s13054-018-2005-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Peter M Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Kyle Murphy
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Shen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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