1
|
Jeong H, Choi JW, Kim DK, Lee SH, Lee SY. Implementation and Outcomes of a Difficult Airway Code Team Composed of Anesthesiologists in a Korean Tertiary Hospital: A Retrospective Analysis of a Prospective Registry. J Korean Med Sci 2022; 37:e21. [PMID: 35040296 PMCID: PMC8763879 DOI: 10.3346/jkms.2022.37.e21] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In 2017, we established an airway call (AC) team composed of anesthesiologists to improve emergency airway management outside the operating room. In this retrospective analysis of prospectively collected data from the airway registry, we describe the characteristics of patients attended to and practices by the AC team during the first 4 years of implementation. METHODS All AC team activations in which an airway intervention was performed by the AC team between June 2017 and May 2021 were analyzed. RESULTS In all, 359 events were analyzed. Activation was more common outside of working hours (62.1%) and from the intensive care unit (85.0%); 36.2% of AC activations were due to known or anticipated difficult airway, most commonly because of acquired airway anomalies (n = 49), followed by airway edema or bleeding (n = 32) and very young age (≤ 1 years; n = 30). In 71.3% of the cases, successful intubation was performed by the AC team at the first attempt. However, three or more attempts were performed in 33 cases. The most common device used for successful intubation was the videolaryngoscope (59.7%). Tracheal intubation by the AC team failed in nine patients, who then required surgical airway insertion by otolaryngologists. However, there were no airway-related deaths. CONCLUSIONS When coupled with appropriate assistance from an otolaryngologist AC system, an AC team composed of anesthesiologists could be an efficient way to provide safe airway management outside the operating room. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0006643.
Collapse
Affiliation(s)
- Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Yeon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
2
|
Hynes AM, Lambe LD, Scantling DR, Bormann BC, Atkins JH, Rassekh CH, Seamon MJ, Martin ND. A surgical needs assessment for airway rapid responses: A retrospective observational study. J Trauma Acute Care Surg 2022; 92:126-134. [PMID: 34252060 DOI: 10.1097/ta.0000000000003348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.
Collapse
Affiliation(s)
- Allyson M Hynes
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (A.M.H., D.R.S., B.C.B., M.J.S., N.D.M.), Nursing Rapid Response Team (L.D.L.), Department of Anesthesiology and Critical Care (J.H.A.), and Department of Otorhinolaryngology: Head and Neck Surgery (C.H.R.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Higashino M, Hiraoka E, Kudo Y, Hoshina Y, Kitamura K, Sakai M, Ito S, Fujimoto Y, Hiasa Y, Hayashi K, Fujitani S, Suzuki T. Role of a rapid response system and code status discussion as determinants of prognosis for critical inpatients: An observational study in a Japanese urban hospital. Medicine (Baltimore) 2021; 100:e26856. [PMID: 34397894 PMCID: PMC8360430 DOI: 10.1097/md.0000000000026856] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022] Open
Abstract
Rapid response systems (RRS) have been introduced worldwide to reduce unpredicted in-hospital cardiac arrest (IHCA) and in-hospital mortality. The role of advance care planning (ACP) in the management of critical patients has not yet been fully determined in Japan.We retrospectively assessed the characteristics of all inpatients with unpredicted IHCA in our hospital between 2016 and 2018. Yearly changes in the number of RRS activations and the incidence of unpredicted IHCA with or without code status discussion were evaluated from 2014 to 2018. Hospital standardized mortality ratios were assessed from the data reported in the annual reports by the National Hospital Organization.A total of 81 patients (age: 70.9 ± 13.3 years) suffered an unpredicted IHCA and had multiple background diseases, including heart disease (75.3%), chronic kidney disease (25.9%), and postoperative status (cardiovascular surgery, 18.5%). Most of the patients manifested non-shockable rhythms (69.1%); survival to hospital discharge rate was markedly lower than that with shockable rhythms (26.8% vs 72.0%, P < .001). The hospital standardized mortality ratios was maintained nearly constant at approximately 50.0% for 3 consecutive years. The number of cases of RRS activation markedly increased from 75 in 2014 to 274 patients in 2018; conversely, the number of unpredicted IHCA cases was reduced from 40 in 2014 to 18 in 2018 (P < .001). Considering the data obtained in 2014 and 2015 as references, the RRS led to a reduction in the relative risk of unpredicted IHCA from 2016 to 2018 (ie, 0.618, 95% confidence interval 0.453-0.843). The reduction in unpredicted IHCA was attributed partly to the increased number of patients who had discussed the code status, and a significant correlation was observed between these parameters (R2 = 0.992, P < .001). The reduction in the number of patients with end-stage disease, including congestive heart failure and chronic renal failure, paralleled the incidence of unpredicted IHCA.Both RRS and ACP reduced the incidence of unpredicted IHCA; RRS prevents progression to unpredicted IHCA, whereas ACP decreases the number of patients with no code status discussion and thus potentially reducing the patient subgroup progressing to an unpredicted IHCA.
Collapse
Affiliation(s)
- Makoto Higashino
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Eiji Hiraoka
- Department of General Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yoshiko Kudo
- Intensive Care Unit, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yuiko Hoshina
- Strategic Planning and Analysis Division, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Koichi Kitamura
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Masahiro Sakai
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Shinsuke Ito
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yoshihisa Fujimoto
- Department of Emergency and Critical Care Medicine, Division of Critical Care, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Koichi Hayashi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Toshihiko Suzuki
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| |
Collapse
|
4
|
Hosokawa K, Kamada H, Ota K, Yamaga S, Ishii J, Shime N. Prevalence of rapid response systems in small hospitals: A questionnaire survey. Medicine (Baltimore) 2021; 100:e26261. [PMID: 34115019 PMCID: PMC8202584 DOI: 10.1097/md.0000000000026261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 05/24/2021] [Indexed: 01/04/2023] Open
Abstract
The rapid response system (RRS) was introduced for early stage intervention in patients with deteriorating clinical conditions. Responses to unexpected in-hospital patient emergencies varied among hospitals. This study was conducted to understand the prevalence of RRS in smaller hospitals and to identify the need for improvements in the responses to in-hospital emergencies.A questionnaire survey of 971 acute-care hospitals in western Japan was conducted from May to June 2019 on types of in-hospital emergency response for patients in cardiac arrest (e.g., medical emergency teams [METs]), before obvious deterioration (e.g., rapid response teams [RRTs]), and areas for improvement.We received 149 responses, including those from 56 smaller hospitals (≤200 beds), which provided fewer responses than other hospitals. Response systems for cardiac arrest were used for at least a limited number of hours in 129 hospitals (87%). The absence of RRS was significantly more frequent in smaller hospitals than in larger hospitals (13/56, 23% vs 1/60, 2%; P < .01). METs and RRTs operated in 17 (11%) and 15 (10%) hospitals, respectively, and the operation rate for RRTs was significantly lower in smaller hospitals than in larger hospitals (1/56, 2% vs 12/60, 20%; P < .01). Respondents identified the need for education and more medical staff and supervisors; data collection or involvement of the medical safety management sector was ranked low.The prevalence of RRS or predetermined responses before obvious patient deterioration was ≤10% in small hospitals. Specific education and appointment of supervisors could support RRS in small hospitals.
Collapse
Affiliation(s)
- Koji Hosokawa
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
- Department of Anesthesiology and Reanimatology, Faculty of Medical Sciences, University of Fukui, 23-3 Eiheijicho, Yoshidagun, Fukui
| | - Hiroki Kamada
- Department of Medicine, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| | - Satoshi Yamaga
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| | - Junki Ishii
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| |
Collapse
|
5
|
García-Del-Valle S, Arnal-Velasco D, Molina-Mendoza R, Gómez-Arnau JI. Update on early warning scores. Best Pract Res Clin Anaesthesiol 2021; 35:105-113. [PMID: 33742570 DOI: 10.1016/j.bpa.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 12/23/2022]
Abstract
Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.
Collapse
|
6
|
Kim Y, Dym AA, Yang K, Fein DG, Bangar M, Ferenchick HRB, Keene A, Orsi D, Washington MA, Eisen LA. The Effect of Numbered Jerseys on Directed Commands, Teamwork, and Clinical Performance During Simulated Emergencies. J Healthc Qual 2021; 43:24-31. [PMID: 32502088 DOI: 10.1097/jhq.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Communication and teamwork are essential during inpatient emergencies such as cardiac arrest and rapid response (RR) codes. We investigated whether wearing numbered jerseys affect directed commands, teamwork, and performance during simulated codes. Eight teams of 6 residents participated in 64 simulations. Four teams were randomized to the experimental group wearing numbered jerseys, and four to the control group wearing work attire. The experimental group used more directed commands (49% vs. 31%, p < .001) and had higher teamwork score (25 vs. 18, p < .001) compared with control group. There was no difference in time to initiation of chest compression, bag-valve-mask ventilation, and correct medications. Time to defibrillation was longer in the experimental group (190 vs. 140 seconds, p = .035). Using numbered jerseys during simulations was associated with increased use of directed commands and better teamwork. Time to performance of clinical actions was similar except for longer time to defibrillation in the jersey group.
Collapse
|
7
|
Levy N, Zucco L, Ehrlichman RJ, Hirschberg RE, Hutton Johnson S, Yaffe MB, Ramachandran SK, Bose S, Leibowitz A. Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis with In Situ Simulation. Anesthesiology 2020; 133:985-996. [PMID: 32773686 PMCID: PMC7434018 DOI: 10.1097/aln.0000000000003521] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.
Collapse
|
8
|
Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S222-S283. [PMID: 33084395 DOI: 10.1161/cir.0000000000000896] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
Collapse
|
9
|
Abstract
Management of pulmonary embolism (PE) has become more complex due to the expanded role of catheter-based therapies, surgical thrombectomies, and cardiac assist technologies, such as right ventricular assist devices and extracorporeal support. Due to the heterogeneity of PE, a multidisciplinary team approach is necessary. The manifestation of PE response teams are in response to this complex need and similar to the proliferation of stroke, trauma, and rapid response teams. Intensive care units are an ideal location for formulating a comprehensive treatment plan that necessitates an interaction between multiple specialties. This article addresses the unique needs of critically ill patients with PE.
Collapse
Affiliation(s)
- Michael Baram
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA.
| | - Bharat Awsare
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA
| | - Geno Merli
- Department of Medicine and Surgery, Division of Vascular Medicine, Jefferson University Hospital, 111 South 11th Street Suite 6210, Philadelphia, PA 19107, USA
| |
Collapse
|
10
|
Ko BS, Lim TH, Oh J, Lee Y, Yun I, Yang MS, Ahn C, Kang H. The effectiveness of a focused rapid response team on reducing the incidence of cardiac arrest in the general ward. Medicine (Baltimore) 2020; 99:e19032. [PMID: 32150050 PMCID: PMC7478490 DOI: 10.1097/md.0000000000019032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Rapid response teams have been adopted to prevent unexpected in-ward cardiac arrest. However, there is no convincing evidence of optimal operation with rapid response team. Our aim was to address the impact of focused rapid response team on the safety of patients in wards. Comparison of focused with extended rapid response teams was performed in single center. The extended team operated on adult patients in whole ward (both medical and nonmedical ward) 24 hours per day, 7 days per week during 2012. In 2015, the operational time of the focused team was office hours from Monday to Friday and study population were limited to adult patients in the nonmedical ward. Unexpected in-ward cardiac arrests were compared between the extended team and focused team periods. During the focused team period, there was significant reduction in cardiac arrest per 1000 admissions in whole ward compared to the before the rapid response team period (1.09 vs 1.67, P < .001). Compared to that of the extended team period (1.42), there was also a significant reduction in cardiac arrest rate (P = .04). The cardiac arrest rate of nonmedical ward patients was also significantly decreased in the focused team period compared to that before the rapid response team period (0.43 vs 0.95, P < .001). Compared to the extended team period (0.64), there was a marginally significant reduction in cardiac arrest of nonmedical ward patients (P = .05). The focused rapid response team was associated with a reduced incidence of unexpected in-ward cardiac arrest. Further research on the optimal composition and operational time is needed.
Collapse
Affiliation(s)
- Byuk Sung Ko
- Hanyang Rapid Response Team
- Department of Emergency Medicine, College of Medicine, Hanyang University
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University
| | - Jaehoon Oh
- Department of Emergency Medicine, College of Medicine, Hanyang University
| | - Yoonje Lee
- Department of Emergency Medicine, Korea University Medical Center, Korea University, Seoul
| | | | | | - Chiwon Ahn
- Department of Emergency Medicine, Armed Forces Yangju Hospital, Yangju, Korea
| | - Hyunggoo Kang
- Hanyang Rapid Response Team
- Department of Emergency Medicine, College of Medicine, Hanyang University
| |
Collapse
|
11
|
Chen QT, Hawker F. Modifications to predefined rapid response team calling criteria: prevalence, characteristics and associated outcomes. CRIT CARE RESUSC 2020; 22:86. [PMID: 32102648 PMCID: PMC10692445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|
12
|
Ohmer M, Durning SJ, Kucera W, Nealeigh M, Ordway S, Mellor T, Mikita J, Howle A, Krajnik S, Konopasky A, Ramani D, Battista A. Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings. MedEdPORTAL 2019; 15:10834. [PMID: 31773062 PMCID: PMC6869982 DOI: 10.15766/mep_2374-8265.10834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/30/2018] [Accepted: 05/21/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels. METHODS Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning. Descriptive statistics were used to analyze the initial implementation evaluation results. RESULTS Twenty physicians from multiple training stages and specialties (interns, residents, attendings, family physicians, internists, surgeons) underwent the simulated scenario. Participants engaged in clinical reasoning processes consistent with the design, considering a total of 19 differential diagnoses. Ten participants provided the correct leading diagnosis, tension pneumothorax, with an additional eight providing pneumothorax and all participants offering relevant supporting evidence. There was also good evidence of management reasoning, with all participants either performing an intervention or calling for assistance and reflecting on management plans in the think-aloud. The scenario was a reasonable approximation of clinical practice, with a mean authenticity rating of 4.15 out of 5. Finally, the scenario presented adequate challenge, with interns and residents rating it as only slightly more challenging (means of 7.83 and 7.17, respectively) than attendings (mean of 6.63 out of 10). DISCUSSION Despite the challenges of scenario complexity, evaluation results indicate that this resource supports the observation and analysis of diagnostic and management reasoning of diverse specialties from interns through attendings.
Collapse
Affiliation(s)
- Megan Ohmer
- Research Assistant, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Steven J. Durning
- Professor, Department of Medicine and Pathology, Uniformed Services University of the Health Sciences
- Director, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Walter Kucera
- Resident, Department of Surgery, Walter Reed National Military Medical Center
| | - Matthew Nealeigh
- Resident, Department of Surgery, Walter Reed National Military Medical Center
| | - Sarah Ordway
- Fellow, Department of Internal Medicine, Division of Gastroenterology, Walter Reed National Military Medical Center
| | - Thomas Mellor
- Fellow, Department of Internal Medicine, Division of Gastroenterology, Naval Medical Center San Diego
| | - Jeffery Mikita
- Chief, Department of Simulation, Walter Reed National Military Medical Center
- Program Director, Department of Internal Medicine, Division of Pulmonology and Critical Care Medicine, Walter Reed National Military Medical Center
- Associate Professor, Department of Medicine, Uniformed Services University of the Health Sciences
| | - Anna Howle
- Simulation Educator, Department of Simulation, Walter Reed National Military Medical Center
| | - Sarah Krajnik
- Simulation Educator, Department of Simulation, Walter Reed National Military Medical Center
| | - Abigail Konopasky
- Assistant Professor, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Divya Ramani
- Research Assistant, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| | - Alexis Battista
- Assistant Professor, Department of Medicine, Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences
| |
Collapse
|
13
|
Breen D, O’Brien S, McCarthy N, Gallagher A, Walshe N. Effect of a proficiency-based progression simulation programme on clinical communication for the deteriorating patient: a randomised controlled trial. BMJ Open 2019; 9:e025992. [PMID: 31289064 PMCID: PMC6629454 DOI: 10.1136/bmjopen-2018-025992] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 05/13/2019] [Accepted: 06/11/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE This study aimed to determine the effectiveness of a proficiency-based progression (PBP) training approach to clinical communication in the context of a clinically deteriorating patient. DESIGN This is a randomised controlled trial with three parallel arms. SETTING This study was conducted in a university in Ireland. PARTICIPANTS This study included 45 third year nursing and 45 final year medical undergraduates scheduled to undertake interdisciplinary National Early Warning Score (NEWS) training over a 3-day period in September 2016. INTERVENTIONS Participants were prospectively randomised to one of three groups before undertaking a performance assessment of the ISBAR (Identification, Situation, Background, Assessment, Recommendation) communication tool relevant to a deteriorating patient in a high-fidelity simulation facility. The groups were as follows: (i) E, the Irish Health Service national NEWS e-learning programme only; (ii) E+S, the national e-learning programme plus standard simulation; and (iii) E+PBP, the national e-learning programme plus PBP simulation. MAIN OUTCOME MEASURES The primary outcome was the proportion in each group reaching a predefined proficiency benchmark comprising a series of predefined steps, errors and critical errors during the performance of a standardised, high-fidelity simulation assessment case which was recorded and scored by two independent blinded assessors. RESULTS 6.9% (2/29) of the E group and 13% (3/23) of the E+S group demonstrated proficiency in comparison to 60% (15/25) of the E+PBP group. The difference between the E and the E+S groups was not statistically significant (χ2=0.55, 99% CI 0.63 to 0.66, p=0.63) but was significant for the difference between the E and the E+PBP groups (χ2=22.25, CI 0.00 to 0.00, p<0.000) and between the E+S and the E+PBP groups (χ2=11.04, CI 0.00 to 0.00, p=0.001). CONCLUSIONS PBP is a more effective way to teach clinical communication in the context of the deteriorating patient than e-learning either alone or in combination with standard simulation. TRIAL REGISTRATION NUMBER NCT02886754; Results.
Collapse
Affiliation(s)
- Dorothy Breen
- Department of Anaesthesia and Intensive Care, Cork University Hospital Group, Cork, Ireland
| | - Sinead O’Brien
- School of Nursing and Midwifery, University College Cork National University of Ireland, Cork, Ireland
| | - Nora McCarthy
- Medical Education Unit, School of Medicine, University College Cork National University of Ireland, Cork, Ireland
| | - Anthony Gallagher
- Faculty of Life and Health Sciences, Ulster University, Londonderry, UK
| | - Nuala Walshe
- School of Nursing and Midwifery, University College Cork National University of Ireland, Cork, Ireland
| |
Collapse
|
14
|
Ganju A, Kapitola K, Chalwin R. Modifications to predefined rapid response team calling criteria: prevalence, characteristics and associated outcomes. CRIT CARE RESUSC 2019; 21:32-38. [PMID: 30857510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Standardised rapid response team (RRT) calling criteria may not be applicable to all patients, and thus, modifications of these criteria may be reasonable to prevent unnecessary calls. Little data are available regarding the efficacy or safety of modifying RRT calling criteria; therefore, this study aimed to detail the prevalence and characteristics of modifications to RRT call triggers and explore their relationship with patient outcomes. DESIGN AND OUTCOME MEASURES A pilot retrospective cohort study within a convenience sample of patients attended by a hospital RRT between July and December 2014; rates of repeat RRT calling and in-hospital mortality were compared between patients with and without modifications to standard calling criteria. Secondary analyses examined four different types of modifications, narrowing or widening of existing physiological calling criteria, to observations without defined calling criteria, and others. All analyses were performed using multivariable regression. RESULTS During the study period, 673 patients had RRT calls, of whom 620 (91.2%) had data available for analysis. The majority of study patients (393; 63.4%) had modifications documented. Patients with modifications were more likely to have repeat RRT calls (odds ratio [OR], 2.86; 95% CI, 1.69-4.85) and experience in-hospital mortality (OR, 2.16; 95% CI, 1.31-3.57) versus patients without modifications. In the secondary analyses, although all classes of modification had higher rates of repeat calling, none reached statistical significance. Mortality was associated with having modifications that were more conservative than the standard calling criteria (adjusted OR, 2.81; 95% CI, 1.31-6.08). CONCLUSION Modifications to standard calling criteria were frequently made, but did not seem to prevent further RRT calls and were associated with increased mortality. These findings suggest that modifications should be made with caution.
Collapse
Affiliation(s)
- Anamika Ganju
- Intensive Care Unit, Prince Charles Hospital, Brisbane, QLD, Australia.
| | - Karoline Kapitola
- Rapid Response System, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - Richard Chalwin
- Rapid Response System, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| |
Collapse
|
15
|
Currey J, Massey D, Allen J, Jones D. 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. Nurse Educ Today 2018; 67:77-82. [PMID: 29803014 DOI: 10.1016/j.nedt.2018.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 04/09/2018] [Accepted: 05/12/2018] [Indexed: 06/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Judy Currey
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, c/- Deakin University, Geelong, Victoria 3125, Australia.
| | - Debbie Massey
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Queensland, 4558, Australia.
| | - Josh Allen
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, c/- Deakin University, Geelong, Victoria 3125, Australia.
| | - Daryl Jones
- Austin Health, A/Prof School of Public Health and Preventive Medicine, Monash University, Honorary A/Prof Department of Surgery, University of Melbourne, Austin Hospital, 145 Studley Rd, Heidelberg, VIC 3084, Melbourne, Australia.
| |
Collapse
|
16
|
Moreira AAS, Ramos RO, Ligório ABS, Junqueira KD, Corrêa KS. Rapid response team: what factors interfere with your performance? Invest Educ Enferm 2018; 36:e05. [PMID: 30148939 DOI: 10.17533/udea.iee.v36n2e05] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 05/31/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Describe the knowledge in the literature related to factors that influence the performance of response teams. METHODS Integrative review of the literature of articles published in Portuguese, English or Spanish between 2006 and 2016. The descriptors hospital rapid response equipment, cardiac arrest and hospital mortality were used for the search in the PubMed/Medline, Lilacs - Bireme and CINAHL bibliographic databases. RESULTS 19 studies were included for the analysis. The results were categorized in: sociocultural barriers and institutional policies, late activation of the rapid response team, composition and/or strengthening of the team's capacity, and use of facilitating tools. The sociocultural barriers found were: the presence of interprofessional hierarchies and beliefs, the limitations of institutional policies were related to the lack of training and human resources deficit. Late activations increased mortality, duration of hospitalization, and admission to the intensive care unit. The teams composed of intensive care professionals showed a reduction in mortality and in the occurrence of cardiac arrest. The use of new tools did not promote changes in the response of the team. CONCLUSIONS The factors found in this review influence the performance of the rapid response team. The foregoing should be taken into account to improve the survival of patients who require this type of care.
Collapse
|
17
|
Mark L, Lester L, Cover R, Herzer K. A Decade of Difficult Airway Response Team: Lessons Learned from a Hospital-Wide Difficult Airway Response Team Program. Crit Care Clin 2018; 34:239-251. [PMID: 29482903 DOI: 10.1016/j.ccc.2017.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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] [Indexed: 11/17/2022]
Abstract
A decade ago the Difficult Airway Response Team (DART) program was created at The Johns Hopkins Hospital as a multidisciplinary effort to address airway-related adverse events in the nonoperative setting. Root cause analysis of prior events indicated that a major factor in adverse patient outcomes was lack of a systematic approach for responding to difficult airway patients in an emergency. The DART program encompasses operational, safety, and educational initiatives and has responded to approximately 1000 events since its initiation, with no resultant adult airway-related adverse events or morbidity. This article provides lessons learned and recommendations for initiating a DART program.
Collapse
Affiliation(s)
- Lynette Mark
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine Multidisciplinary Airway Programs, Difficult Airway Response Team (DART) Program, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine Multidisciplinary Airway Programs, Difficult Airway Response Team (DART) Program, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
| | - Laeben Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine Multidisciplinary Airway Programs, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Emergency Medicine, Johns Hopkins Medicine Multidisciplinary Airway Programs, Johns Hopkins Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Renee Cover
- Johns Hopkins Health System Legal Department, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Kurt Herzer
- Oscar Health, 219 Withers Street, Brooklyn, NY 11211, USA
| |
Collapse
|
18
|
Abstract
Sepsis rapid response teams are being incorporated into hospitals around the world. Based on the concept of the medical emergency team, the sepsis rapid response team consists of a specifically trained team of health care providers educated in the early recognition, diagnosis, and treatment of patients at risk of having or who have sepsis. Using hospital-wide initiatives consisting of multidisciplinary education, training, and specific resource utilization, such teams have been found to improve patient outcomes.
Collapse
Affiliation(s)
- Tammy Ju
- Department of Surgery, George Washington University, 2150 Pennsylvania Avenue, NW 6B, Washington, DC 20037, USA
| | - Mustafa Al-Mashat
- Department of Internal Medicine, George Washington University, 2150 Pennsylvania Avenue, NW 6B, Washington, DC 20037, USA
| | - Lisbi Rivas
- Department of Surgery, George Washington University, 2150 Pennsylvania Avenue, NW 6B, Washington, DC 20037, USA
| | - Babak Sarani
- Department of Surgery, George Washington University, 2150 Pennsylvania Avenue, NW 6B, Washington, DC 20037, USA.
| |
Collapse
|
19
|
Risaliti C, Evans K, Buehler J, Besecker B, Ali N. Decoding Code Blue: A process to assess and improve code team function. Resuscitation 2017; 122:e15-e16. [PMID: 29155295 DOI: 10.1016/j.resuscitation.2017.11.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Carleen Risaliti
- Division of Pulmonary, Critical Care, and Sleep Medicine, 201 Davis Heart & Lung Research Institute, 473 W. 12th Avenue, Columbus, OH 43210, United States.
| | - Kimberly Evans
- Quality & Patient Safety, 630 Ackerman Rd, 2nd Floor, Rm F2050, Columbus, OH 43202, United States.
| | - Jeri Buehler
- Education, Development and Resources, 660 Ackerman Rd, Columbus, OH 43218, United States.
| | - Beth Besecker
- Pulmonary, Critical Care, and Sleep Medicine, 201 Davis Heart & Lung Research Institute, 473 W. 12th Avenue, Columbus, OH 43210, United States.
| | - Naeem Ali
- Division of Pulmonary, Critical Care, and Sleep Medicine, 168 Doan Hall, 410 W 10th Avenue, Columbus, OH 43210, United States.
| |
Collapse
|
20
|
Peek KN, Gillham M. Is the New Zealand Early Warning Score useful following cardiac surgery? N Z Med J 2017; 130:9-14. [PMID: 28859061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIMS The rate of medical emergency team (MET) calling among post-cardiac surgery patients is unknown. We set out to determine what the call frequency would be if MET activation occurred in every instance that the early warning score (EWS) breached our local threshold, what the outcome was for these patients and what the calling rate might be if the proposed New Zealand EWS (NZEWS) system was implemented with 100% adherence. METHODS The clinical records of 400 consecutive post-cardiac surgery patients were examined. The number of times a patient's EWS reached the threshold which mandated a call to the MET was determined, as was the actual rate of calling, the occurrence of inpatient death and re-admission to the intensive care unit (ICU). The rate of calling was then determined using the NZEWS, and with a routine modification to the heart rate score. RESULTS There were 73 occasions (MET events) where the EWS reached the MET calling threshold. The MET was only called twice. There were no inpatient deaths and 12 ICU re-admissions in the study cohort. Nine ICU re-admissions were preceded by a MET event, two by cardiac arrest and one had neither. Re-scoring with NZEWS yielded 53 events. Eight of the 12 ICU admissions were preceded by a NZEWS event. CONCLUSIONS The rate of MET triggering EWS in patients post-cardiac surgery is high at 182/1,000 admissions. Using NZEWS could reduce the MET calling rate without significant risk to patient safety.
Collapse
Affiliation(s)
| | - Michael Gillham
- Cardiothoracic and Vascular Intensive Care and High Dependency Unit. Auckland District Health Board, Auckland
| |
Collapse
|
21
|
Kim R, Passev J. Nursing Education Improves RRT Team Efficiency. Hosp Peer Rev 2017; 42:67-69. [PMID: 29996022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
|
22
|
Abstract
Rapid response team (RRT) adoption and implementation are associated with improved quality of care of patients who experience an unanticipated medical emergency. The sustainability of RRTs is vital to achieve long-term benefits of these teams for patients, staff, and hospitals. Factors required to achieve RRT sustainability remain unclear. This study examined the relationship between sustainability elements and RRT sustainability in hospitals that have previously implemented RRTs.
Collapse
|
23
|
Abstract
BACKGROUND The use of rapid response systems (RRS), which were designed to bring clinicians with critical care expertise to the bedside to prevent unnecessary deaths, has increased. RRS rely on accurate detection of acute deterioration events. Early warning scores (EWS) have been used for this purpose but were developed using heterogeneous populations. Predictive performance may differ in medical vs surgical patients. OBJECTIVE To evaluate the performance of published EWS in medical vs surgical patient populations. DESIGN Retrospective cohort study. SETTING Two tertiary care academic medical center hospitals in the Midwest totaling more than 1500 beds. PATIENTS All patients discharged from January to December 2011. INTERVENTION None. MEASUREMENTS Time-stamped longitudinal database of patient variables and outcomes, categorized as surgical or medical. Outcomes included unscheduled transfers to the intensive care unit, activation of the RRS, and calls for cardiorespiratory resuscitation ("resuscitation call"). The EWS were calculated and updated with every new patient variable entry over time. Scores were considered accurate if they predicted an outcome in the following 24 hours. RESULTS All EWS demonstrated higher performance within the medical population as compared to surgical: higher positive predictive value (P < .0001 for all scores) and sensitivity (P < .0001 for all scores). All EWS had positive predictive values below 25%. CONCLUSIONS The overall poor performance of the evaluated EWS was marginally better in medical patients when compared to surgical patients. Journal of Hospital Medicine 2017;12:217-223.
Collapse
Affiliation(s)
- Anil N. Makam
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, University of Texas Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Anil N. Makam, MD, MAS, 5323 Harry Hines Blvd., Dallas, TX 75390-9169; Telephone: 214-648-3272; Fax: 214-648-3232;
| | - Oanh K. Nguyen
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Clark
- Office of Research Administration, Parkland Health and Hospital System, Dallas, Texas
| | - Ethan A. Halm
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
24
|
Sprogis SK, Currey J, Considine J, Baldwin I, Jones D. Physiological antecedents and ward clinician responses before medical emergency team activation. CRIT CARE RESUSC 2017; 19:50-56. [PMID: 28215132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To investigate the frequency, characteristics and timing of objectively measured clinical instability in adult ward patients in the 24 hours preceding activation of the medical emergency team (MET). We also examined ward clinician responses to documented clinical instability. DESIGN, SETTING AND PARTICIPANTS A descriptive, exploratory design with a retrospective medical record audit. We descriptively analysed data from 200 ward patients reviewed by the MET at a tertiary teaching hospital in Melbourne, Australia, during 2014. MAIN OUTCOME MEASURES Frequency and characteristics of urgent clinical review (UCR) criteria breaches in the 24 hours preceding MET activation, and in-hospital mortality. RESULTS Overall, 78.5% of patients breached UCR criteria at least once in the 24 hours preceding MET activation, with 80.9% having multiple breaches. The most common causes of UCR criteria breaches were hypoxaemia without supplemental oxygen (27.4%, n = 43) and hypoxaemia with supplemental oxygen (21.7%, n = 34) for first UCR criteria breaches, and tachycardia (33.1%, n = 42) for last UCR criteria breaches during the 24 hours we examined. The median time before MET activation for first and last breaches was 17.1 hours and 1.2 hours, respectively. Examination of the clinician documentation suggested a high incidence of pre-MET activation afferent limb failure. In-hospital mortality was 12%. CONCLUSIONS Patients commonly and repeatedly breached objectively measured UCR criteria in the 24 hours preceding MET activation, providing numerous opportunities for clinicians to recognise and respond to early clinical deterioration. The high incidence of pre- MET afferent limb failure requires further exploration.
Collapse
Affiliation(s)
- Stephanie K Sprogis
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.
| | - Judy Currey
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Julie Considine
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Ian Baldwin
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| |
Collapse
|
25
|
Abstract
BACKGROUND Rapid response teams (RRTs) help in delivering safe, timely care. Typically they are activated by clinicians using specific parameters. Allowing patients and families to activate RRTs is a novel intervention. The University of Pittsburgh Medical Center developed and implemented a patient- and family-initiated rapid response system called Condition Help (CH). METHODS When the CH system is activated, a patient care liaison or an on-duty administrator meets bedside with the unit charge nurse to address the patient's concerns. In this study, we collected demographic data, call reasons, call designations (safety or nonsafety), and outcome information for all CH calls made during the period January 2012 through June 2015. RESULTS Two hundred forty patients/family members made 367 CH calls during the study period. Most calls were made by patients (76.8%) rather than family members (21.8%). Of the 240 patients, 43 (18%) made multiple calls; their calls accounted for 46.3% of all calls (170/367). Inadequate pain control was the reason for the call in most cases (48.2%), followed by dissatisfaction with staff (12.5%). The majority of calls involved nonsafety issues (83.4%) rather than safety issues (11.4%). In 41.4% of cases, a change in care was made. CONCLUSIONS Patient- and family-initiated RRTs are designed to engage patients and families in providing safer care. In the CH system, safety issues are identified, but the majority of calls involve nonsafety issues. Journal of Hospital Medicine 2017;12:157-161.
Collapse
Affiliation(s)
- Elizabeth L Eden
- Internal Medicine Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laurie L Rack
- Medicine Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ling-Wan Chen
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gregory M Bump
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
26
|
Subramaniam A, Botha J, Tiruvoipati R. The limitations in implementing and operating a rapid response system. Intern Med J 2016; 46:1139-1145. [PMID: 26913367 DOI: 10.1111/imj.13042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 09/16/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 02/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- A Subramaniam
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia.
| | - J Botha
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
| | - R Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
27
|
Stewart NH, Tanksley A, Arora VM. In reference to "The effect of a rapid response team on resident perceptions of education and autonomy". J Hosp Med 2015; 10:418. [PMID: 25832827 DOI: 10.1002/jhm.2358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/04/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Nancy H Stewart
- Department of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Audrey Tanksley
- Department of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Vineet M Arora
- Department of General Internal Medicine, University of Chicago, Chicago, Illinois
| |
Collapse
|
28
|
|
29
|
Kapu AN, Wheeler AP, Lee B. Addition of acute care nurse practitioners to medical and surgical rapid response teams: a pilot project. Crit Care Nurse 2015; 34:51-9. [PMID: 24488890 DOI: 10.4037/ccn2014847] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background Vanderbilt University Hospital's original rapid response team included a critical care charge nurse and a respiratory therapist. A frequently identified barrier to care was the time delay between arrival of the rapid response team and arrival of the primary health care team. Objective To assess the impact of adding an acute care nurse practitioner to the rapid response team. Methods Acute care nurse practitioners were added to surgical and medical rapid response teams in January 2011 to diagnose and order treatments on rapid response calls. Results In 2011, the new teams responded to 898 calls, averaging 31.8 minutes per call. The most frequent diagnoses were respiratory distress (18%), postoperative pain (13%), hypotension (12%), and tachyarrhythmia (10%). The teams facilitated 360 transfers to intensive care and provided 3056 diagnostic and therapeutic interventions. Communication with the primary team was documented on 97% of the calls. Opportunities for process improvement were identified on 18% of the calls. After implementation, charge nurses were surveyed, with 96% expressing high satisfaction associated with enhanced service and quality. Conclusions Teams led by nurse practitioners provide diagnostic expertise and treatment, facilitation of transfers, team communication, and education.
Collapse
|
30
|
Abstract
Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. A response system to rapidly evaluate inpatients with acute neurologic symptoms facilitates evaluation and treatment of stroke developing during hospitalization. The National Stroke Association implemented an in-hospital stroke quality-improvement initiative from July 2010 to June 2011 in 6 certified stroke centers from Michigan, South Carolina, Pennsylvania, Colorado, Washington, and North Carolina. Three hundred ninety-three in-hospital stroke alerts were examined over a 1-year period. Of the alerts, 42.5% were for ischemic stroke, 8.7% probable or possible TIA, 2.8% intracranial hemorrhage, and 46.1% were stroke mimics. The most common stroke mimics were seizure, hypotension, and delirium. Participating hospitals had an alarm rate for diagnoses other than acute cerebrovascular events ranging from 28.0% to 66.7%. Of 194 in-hospital stroke/transient ischemic attack cases, 8.2% received intravenous thrombolysis alone, 10.3% received intra-arterial/mechanical thrombolysis alone, and 1% received both. No patient with a stroke mimic received thrombolysis. Our findings suggest that in-hospital response teams need to be prepared to respond to a range of acute medical conditions other than ischemic stroke.
Collapse
Affiliation(s)
- Ethan Cumbler
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; National Stroke Association, Centennial, Colorado
| | | |
Collapse
|
31
|
Nicholls C. Deteriorating patients and time pressures. Australas Emerg Nurs J 2015; 18:56-57. [PMID: 25435176 DOI: 10.1016/j.aenj.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 09/15/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Christian Nicholls
- College of Emergency Nurses Australasia, Australia; Monash University, Australia.
| |
Collapse
|
32
|
Hancock C. A national quality improvement initiative for reducing harm and death from sepsis in Wales. Intensive Crit Care Nurs 2015; 31:100-5. [PMID: 25604031 DOI: 10.1016/j.iccn.2014.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 03/24/2014] [Revised: 11/14/2014] [Accepted: 11/19/2014] [Indexed: 11/19/2022]
Abstract
AIMS The Rapid Response to Acute Illness (RRAILS) Programme is a quality and service improvement initiative which is participated in by all Welsh healthcare organisations including the Welsh Ambulance Service Trust (WAST) and Velindre Cancer Centre. The aims of the programme were and are: Implementing the National Early Warning Score (NEWS) as standard in all clinical areas in all 18 acute hospitals. Quantifying the incidence of sepsis and acute deterioration in the non Critical Care setting. Improving reliability of systems for identification, escalation and treatment of sepsis. Demonstrably improving outcomes from sepsis and other causes of acute deterioration. METHODS Clinical teams participated in learning sets at which they were trained in service improvement and human factors principles and then supported to implement 'bundles' of best evidence whilst measuring both processes and outcomes. FINDINGS All organisations have implemented standardised tools and operating procedures including NEWS, sepsis screening tools, Patient Status at A Glance (PSAG) boards, sepsis response bags and an antibiotic formulary. All organisations have demonstrated improvements in the reliability of detection and escalation of acute deterioration whilst many have started to demonstrate local improvements in outcomes. CONCLUSION The collaborative learning set is an effective method for improving quality of sepsis care throughout a single healthcare economy.
Collapse
Affiliation(s)
- Chris Hancock
- NHS Wales, Innovation House, Bridgend Road, Llanharan CF72 9RP, United Kingdom.
| |
Collapse
|
33
|
O'Leary KJ, Didwania AK. Rapid response teams in teaching hospitals: aligning efforts to improve medical education and quality. J Hosp Med 2015; 10:62-3. [PMID: 25603792 DOI: 10.1002/jhm.2294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | |
Collapse
|
34
|
Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med 2015; 10:8-12. [PMID: 25603788 DOI: 10.1002/jhm.2270] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/06/2014] [Accepted: 08/10/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND The impact of rapid response teams (RRTs) on resident physicians' education and clinical autonomy is not well described. OBJECTIVE To determine whether resident physicians perceive educational benefit from collaboration with an RRT and whether they believe that the RRT adversely affects their clinical autonomy. DESIGN Survey study. METHODS Study subjects were asked to participate in a brief online survey. The survey contained 7 demographic items and 20 RRT-related items graded on a 5-point Likert scale ranging from strongly disagree to strongly agree. SETTING/SUBJECTS The study was conducted at a tertiary care academic medical center. Subjects included all residents in specialties involving direct patient care and the potential to use the adult RRT. RESULTS The response rate was 72%; 35% of respondents were interns, and 69% were in medical fields. Residents agreed that working with the RRT is a valuable educational experience (78%) and disagreed that the RRT decreased their clinical autonomy (76%). Surgical residents were less likely than medical residents to perceive educational value from RRT interactions (P = 0.01) or to report collaborative decision making with the RRT (P = 0.04). CONCLUSIONS The majority of resident physicians perceive educational benefit from interaction with the RRT, though this benefit is greater for less experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. Few residents, irrespective of years of training or specialty, felt that the RRT reduced their clinical autonomy.
Collapse
Affiliation(s)
- Brad W Butcher
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | |
Collapse
|
35
|
Winters BD, Pronovost PJ. Rapid response systems: should we still question their implementation? J Hosp Med 2013; 8:278-81. [PMID: 23606379 DOI: 10.1002/jhm.2050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 03/27/2013] [Accepted: 04/01/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Bradford D Winters
- Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD 21287, USA.
| | | |
Collapse
|
36
|
Bonafide CP, Roberts KE, Weirich CM, Paciotti B, Tibbetts KM, Keren R, Barg FK, Holmes JH. Beyond statistical prediction: qualitative evaluation of the mechanisms by which pediatric early warning scores impact patient safety. J Hosp Med 2013; 8:248-53. [PMID: 23495086 DOI: 10.1002/jhm.2026] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 01/08/2013] [Accepted: 01/16/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND Early warning scores (EWSs) assign points to clinical observations and generate scores to help clinicians identify deteriorating patients. Despite marginal predictive accuracy in retrospective datasets and a paucity of studies prospectively evaluating their clinical effectiveness, pediatric EWSs are commonly used. OBJECTIVE To identify mechanisms beyond their statistical ability to predict deterioration by which physicians and nurses use EWSs to support their decision making. DESIGN Qualitative study. SETTING A children's hospital with a rapid response system. PARTICIPANTS Physicians and nurses who recently cared for patients with false-positive and false-negative EWSs (score failures). INTERVENTION Semistructured interviews. MEASUREMENTS Themes identified through grounded theory analysis. RESULTS Four themes emerged among the 57 subjects interviewed: (1) The EWS facilitates safety by alerting physicians and nurses to concerning changes and prompting them to think critically about deterioration. (2) The EWS provides less-experienced nurses with vital sign reference ranges. (3) The EWS serves as evidence that empowers nurses to overcome barriers to escalating care. (4) In stable patients, those with baseline abnormal physiology, and those experiencing neurologic deterioration, the EWS may not be helpful. CONCLUSIONS Although pediatric EWSs have marginal performance when applied to datasets, clinicians who recently experienced score failures still considered them valuable to identify deterioration and transcend hierarchical barriers. Combining an EWS with a clinician's judgment may result in a system better equipped to respond to deterioration than retrospective data analyses alone would suggest. Future research should seek to evaluate the clinical effectiveness of EWSs in real-world settings.
Collapse
Affiliation(s)
- Christopher P Bonafide
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Saver C. 'Second victim' rapid-response team helps fellow clinicians recover from trauma. OR Manager 2013; 29:10-27. [PMID: 23755465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
|
38
|
Morris A, Owen HM, Jones K, Hartin J, Welch J, Subbe CP. Objective patient-related outcomes of rapid-response systems - a pilot study to demonstrate feasibility in two hospitals. CRIT CARE RESUSC 2013; 15:33-39. [PMID: 23432499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To establish and test the feasibility of measurement of a comprehensive set of mutually exclusive outcomes in the 7 days after referral of patients to a rapid-response team (RRT), to facilitate audit and aid analysis of failure-to-rescue events. DESIGN, SETTING AND PARTICIPANTS Observational cohort study of RRTs in a district general hospital and a university hospital in the United Kingdom. PARTICIPANTS Patients seen by two RRTs after local track-and-trigger systems were triggered. MAIN OUTCOME MEASURES An agreed set of patient-centred outcomes tested at Days 1, 3 and 7 after RRT call-out. Positive outcomes were defined as transfer to a critical care unit (CCU) within 4 hours of the trigger event, improved track-and-trigger scores, death without attempted cardiopulmonary resuscitation, decision about treatment limitation, new pathology, chronic pathology or hospital discharge. Negative outcomes were delayed transfer to a CCU, lack of improvement in track-and-trigger scores, death after cardiopulmonary arrest, or loss to follow-up. RESULTS In the initial pilot study, 75% of patients achieved positive outcomes on Day 1 after RRT call-out, and there were no significant changes to outcomes on Days 3 and 7. A higher rate of negative outcomes was seen in patients who triggered an RRT call-out at night. There was significant variation in outcomes between clinical specialties. In neither of the centres were events reported that could not be classified using our matrix of outcomes. CONCLUSION It is possible to classify RRT episodes using readily available data, and areas with suboptimal performance can be targeted. Our matrix may additionally facilitate comparison of rapid-response systems.
Collapse
Affiliation(s)
- Andrew Morris
- Department of Critical Care Medicine, Wrexham Maelor Hospital, London, UK
| | | | | | | | | | | |
Collapse
|
39
|
Benin AL, Borgstrom CP, Jenq GY, Roumanis SA, Horwitz LI. Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators. BMJ Qual Saf 2012; 21:391-8. [PMID: 22389019 PMCID: PMC3423909 DOI: 10.1136/bmjqs-2011-000390] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. METHODS We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. RESULTS Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. CONCLUSIONS The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.
Collapse
Affiliation(s)
- Andrea L Benin
- Department of Performance Management, Yale New Haven Health System, New Haven, Connecticut 06519, USA.
| | | | | | | | | |
Collapse
|
40
|
Kansal A, Havill K. The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients. CRIT CARE RESUSC 2012; 14:38-43. [PMID: 22404060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To determine the impact on call characteristics and patient outcomes since the implementation of a two-tiered rapid-response system along with new observation charts and calling criteria. DESIGN AND SETTING A retrospective before-and-after study in an Australian tertiary referral hospital. PARTICIPANTS Consecutive adult patients (_18 years), who had a rapid-response call between June and October 2009 ("before") and between June and October 2010 ("after"). MAIN OUTCOME MEASURES Incidence of "serious adverse events" (cardiac arrests, unexpected deaths, and unplanned intensive care unit/high-dependency unit [HDU] admissions); subsequent illness severity and ICU/HDU and hospital mortality and length of stay; episodes of repeat calls for the same patient, time since admission and treatment limitation/ not-for-resuscitation order profiles. RESULTS Statistically significant increase in number of rapid response calls from 14.3 to 21.2 per 1000 hospital admissions before and after, respectively (P < 0.001); this was associated with a 16% decrease in composite serious adverse events (not significant). There were no significant differences in the number of unplanned ICU/HDU admissions, admission severity scores and subsequent ICU/HDU and hospital mortality and length of stay. There was a significant increase in number of calls for patients who were admitted to hospital within 24 hours (2.5 v 4.7 per 1000 hospital admissions before and after, respectively; P < 0.05) and for patients who were transferred from acute care areas within 24 hours (3.7 v 6.2 per 1000 hospital admissions before and after, respectively; P < 0.05). There was a significant increase in number of repeat calls for the same patient (1.6 v 4.2 per 1000 hospital admissions before and after, respectively; P < 0.001); this was associated with higher mortality compared with single review in the after period (35.8% v 18.5%, respectively; P = 0.005). CONCLUSIONS Implementation of a two-tiered rapid-response system and new observation charts and calling criteria increased the number of rapid-response calls with a nonsignificant trend towards a decreased incidence of serious adverse events. Further improvements in care of hospitalised patients may be possible by preventing repeat calls or calls within 24 hours of hospital admission and discharge from acute care areas.
Collapse
Affiliation(s)
- Amit Kansal
- John Hunter Hospital, Newcastle, NSW, Australia.
| | | |
Collapse
|
41
|
Affiliation(s)
- Kathy D Duncan
- Institute for Healthcare Improvement, Cambridge, MA, USA
| | | | | |
Collapse
|
42
|
Abstract
Sixty-three (approximately 80%) of the 81 hospitals that responded to a survey sent to all hospitals in The Netherlands with nonpediatric intensive care units had a rapid response system (RRS) in place or were in the final process of starting one. Among many other findings regarding RRS infrastructure and implementation, only 38% of the hospitals allowed nurses to activate the rapid response team without physician consent.
Collapse
Affiliation(s)
- Jeroen Ludikhuize
- Department of Internal Medicine and Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
43
|
Wang GS, Erwin N, Zuk J, Henry DB, Dobyns EL. Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital. J Hosp Med 2011; 6:131-5. [PMID: 21387548 DOI: 10.1002/jhm.832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 03/03/2010] [Accepted: 07/02/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Pediatric in-hospital arrests are uncommon but are associated with poor outcomes. In preparation for implenting a Rapid Response Team (RRT) at The Children's Hospital, we reviewed our data collection of 13 years of emergency response team (ERT) activations. We describe demographic and clinical variables, including outcomes of ERT activations at a free-standing tertiary care children's hospital. METHODS Analysis was performed on data collected from January 1993 through July 2007. Variables collected included age, sex, admission diagnosis, core event, admission diagnosis and secondary diagnosis, medical division or winter/nonwinter months, day/night shifts, survival of core event, survival to discharge, and primary attending service. RESULTS There were 1537 ERT activations in the database, 203 were eliminated due to missing data or were adult visitors/employees. The remaining 1334 were included for analysis. Our results showed 39%(511) of all ERT activations occurred in patients under 1 year of age. The most common admission diagnosis category was cardiac disease. There was no statistical significance between summer and winter months although more activations occurred during daytime hours (P < .001). Survival rate of an ERT was 90%, with a 78% survival rate to discharge. CONCLUSION Our data support the general belief that younger children with chronic disease are at highest risk for ERT activations. These risk factors should be taken into consideration when planning patient placement, medical staffing, and the threshold for ICU consultations or admissions. More extensive multisite studies using clinical data are necessary to further identify hospitalized children at risk for sudden decompensation.
Collapse
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine, The Children's Hospital, Aurora, Colorado, USA.
| | | | | | | | | |
Collapse
|
44
|
Boermeester MA. [Effect of emergency intervention team still unclear. More evidence is necessary]. Ned Tijdschr Geneeskd 2011; 155:A3500. [PMID: 21557829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Changes in health care culture are accompanied by a flood of initiatives with respect to patient safety and quality of care. These initiatives are incentives from government, laymen press, health insurance companies and health care providers. This makes evidence-based patient safety an absolute necessity to guide the priorities of policy makers. A medical emergency team (MET), also referred to as a rapid response team (RRT), is an example of a good initiative to improve health care quality that is being embraced rapidly worldwide, but solid evidence of its effectiveness is lacking. The number of cardiopulmonary arrests seems to have decreased, but adequate correction for case mix confounders has not been done and the effect on patient outcome, i.e. in-hospital mortality, has not been convincingly demonstrated.
Collapse
|
45
|
Meynaar IA, van Dijk H, Visser SS, Verheijen M, Dawson L, Tangkau PL. [Rapid response system in derangement of vital signs: five years experience in a large general hospital]. Ned Tijdschr Geneeskd 2011; 155:A3257. [PMID: 21586185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Hospitalized patients are at risk for adverse events such as unexpected cardiac arrest or admission to an Intensive Care Unit (ICU). Prior to these adverse events these patients often have derangements in vital signs that are not recognized and treated adequately. To identify and treat those patients at risk, our hospital implemented a rapid response system in 2004. The purpose of this paper is to describe implementation and results of our rapid response system. DESIGN Prospective cohort study. METHOD The implementation of the rapid response system started by training all doctors and nurses to score vital signs using a dedicated score card. If a patient scores 3 or more points, the patients' treating physician has to see the patient and - if necessary - call the medical emergency team (MET), consisting of an ICU physician and an ICU nurse. We analyzed all consecutive MET calls in the period January 2005-December 2009. RESULTS A total of 1058 MET calls for 981 patients were analyzed. In 606 patients (57.3%) it was decided to transfer the patient to a higher dependency unit, in most cases the ICU. In 353 patients (33.4%) treatment could be continued on the ward. In 88 patients (8.4%) it was decided that ICU treatment would not be beneficial and limits on treatment were put in place. Of the 981 patients, 255 (26.0%) died in hospital. CONCLUSION In our hospital the rapid response system has developed into an important tool for the early identification and treatment of patients at risk. However, our data cannot prove the efficacy of the rapid response system in terms of reducing hospital mortality.
Collapse
Affiliation(s)
- Iwan A Meynaar
- Reinier de Graaf Groep, afd. Intensive Care, Delft, the Netherlands.
| | | | | | | | | | | |
Collapse
|
46
|
Chakraborti C. A quality conundrum: well done but not enough. J Hosp Med 2010; 5:E32; author reply E33. [PMID: 20063288 DOI: 10.1002/jhm.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|