Capillary refill time as part of an early warning score for rapid response team activation is an independent predictor of outcomes

BACKGROUND

Capillary refill time (CRT) is easy, quick to perform and when prolonged in critical illness, correlates with progression of organ failure and mortality. It is utilized in our hospital's early warning score (EWS) as one of 11 parameters. We sought to define CRT's value in predicting patient outcomes, compared to the remaining EWS elements.

METHODS

Five-year prospective observational study of 6480 consecutive Rapid Response Team (RRT) patients. CRT measured at the index finger was considered prolonged if time to previous-color return was >3 s. We analyzed the odds ratio of normal vs prolonged-CRT, compared to the other EWS variables, to individual and combined outcomes of mortality, cardiac arrest and higher-level of care transfer.

RESULTS

Twenty-percent (N = 1329) of RRT-patients had prolonged-CRT (vs normal-CRT), were twice as likely to die (36% vs 17.8%, p < .001), more likely to experience the combined outcome (72.1% vs 54.2%, p < .001) and had longer hospital length of stays, 15.3 (SD 0.3) vs 13.5 days (SD 0.5) (p < .001). Multivariable logistic regression for mortality ranked CRT second to hypoxia among all 11 variables evaluated (p < 001).

CONCLUSIONS

This is the first time CRT has been evaluated in RRT patients. Its measurement is easy to perform and proves useful as an assessment of adult patients at-risk for clinical decline. Its prolongation in our population was an independent predictor of mortality and the combined outcome. This study and others suggest that CRT should be considered further as a fundamental assessment of patients at-risk for clinical decline.

A Novel Bedside-Focused Ward Surveillance and Response System

BACKGROUND

Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated.

METHODS

A prospective five-year before-and-after comparison of adult ward patient outcomes was conducted at a community regional medical center. The key intervention was expanded administrative oversight of the system, which led to (1) restructuring the content and depth of ward nurse education regarding early recognition of at-risk patients; (2) system changes empowering prompt mobilization of the RRT; (3) development of RRT treatment protocols; and (4) a more frequent and comprehensive data collection and analysis for system compliance and performance improvement.

RESULTS

Some 28,914 patients were observed in the 24-month control period, and 39,802 patients were observed in the 33-month intervention period. RRT activations increased from 10.2 to 48.8/1,000 discharges (p <0.001), ward cardiac arrest decreased from 3.1 to. 2.4/1000 discharges (p = 0.04), hospital mortality decreased from 3.8% to 3.2% (p <0.001), and the observed-to-expected ratio decreased from 1.5 to 1.0 (p <0.001).

CONCLUSION

Expanded administrative involvement of an existing RRS that focused on early recognition of patient deterioration by the bedside nurse led to improved performance of the system, with a significant increase in number of RRTs and decreases in cardiac arrests and hospital mortality.