Hospital-wide physiological surveillance–A new approach to the early identification and management of the sick patient

Hospitalised patients, who suffer cardiac arrest and require unanticipated intensive care unit (ICU) admission or die, often exhibit premonitory abnormalities in vital signs. Sometimes, the deterioration is well documented, though there is little discernable evidence of intervention. In other cases, monitoring and recording of vital signs is infrequent or incomplete. Healthcare providers have introduced "track and trigger" systems to allow early identification of patients with physiological abnormalities, and rapid response teams to facilitate rapid and appropriate management. However, even when "track and trigger" systems are used, the recording of vital signs, patient chart completion and team activation remain sub-optimal. We have developed a system for collecting routine vital signs data at the bedside using standard personal digital assistants (PDA). The PDAs act as "thin clients" linked by a wireless local area network (W-LAN) to the hospital's intranet system, where raw and derived data are integrated with other patient information, e.g., name, hospital number, laboratory results. It is possible for raw physiology data, early warning scores (EWS), vital signs charts and oxygen therapy records to be made instantaneously available to any member of the hospital healthcare team via the W-LAN or hospital intranet. Early and direct contact with members of the patient's primary clinical team or rapid response team can be made through an automated alerting system, triggered by the EWS data. The ability to capture physiological data at the bedside, and to make these available to anyone with appropriate access rights at any time and in any place, should provide previously unattainable, clinical and administrative benefits. Analysis of the raw physiological data and patient outcomes will also make it possible to validate existing and future "track and trigger" systems.

Calculating early warning scores—A classroom comparison of pen and paper and hand-held computer methods

To assist in the early detection of critical illness, many hospitals now use a "track and trigger" system that allocates points to routine vital signs measurements on the basis of their derangement from an arbitrarily agreed "normal" range. These points are summed to provide an early warning score (EWS). Little is known about the accuracy with which EWS are calculated and charted. We compared the speed and accuracy of charting the weighted value attributed to each vital sign, and of calculating the EWS, using the traditional pen and paper method with that using a specially programmed, personal digital assistant (VitalPAC). Incorrect entries or omissions occurred in 24 (29%) of 84 EWS computed using pen/paper compared to 8 (10%) computed using the VitalPAC method. Fewer incorrect clinical actions were indicated using EWS derived via the VitalPAC method (4/84, 5%) than from those calculated using pen/paper (12/84, 14%). The mean time (+/-S.D.) taken for participants to calculate and chart a set of weighted values and EWS using the pen/paper method was 67.6+/-35.3 s (n=84). The corresponding time taken to enter a set of physiological data using the VitalPAC was 43.0+/-23.5 s (n=84). By comparison with the conventional pen/paper method, the use of VitalPAC was on average 1.6-times faster. The use of a device such as VitalPAC offers significant advantages both in speed and accuracy of recording of EWS.

The Acute Care Undergraduate TEaching (ACUTE) Initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom

BACKGROUND

The care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation.

DESIGN

Healthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale.

RESULTS

A total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation.

CONCLUSIONS

We propose these competencies form a core set for undergraduate training in resuscitation and acute care.

The use of routine laboratory data to predict in-hospital death in medical admissions

The ability to predict clinical outcomes in the early phase of a patient's hospital admission could facilitate the optimal use of resources, might allow focused surveillance of high-risk patients and might permit early therapy. We investigated the hypothesis that the risk of in-hospital death of general medical patients can be modelled using a small number of commonly used laboratory and administrative items available within the first few hours of hospital admission. Matched administrative and laboratory data from 9497 adult hospital discharges, with a hospital discharge specialty of general medicine, were divided into two subsets. The dataset was split into a single development set, Q(1) (n=2257), and three validation sets, Q(2), Q(3) and Q(4) (n(1)=2335, n(2)=2361, n(3)=2544). Hospital outcome (survival/non-survival) was obtained for all discharges. An outcome model was constructed from binary logistic regression of the development set data. The goodness-of-fit of the model for the validation sets was tested using receiver-operating characteristics curves (c-index) and Hosmer-Lemeshow statistics. Application of the model to the validation sets produced c-indices of 0.779 (Q(2)), 0.764 (Q(3)) and 0.757 (Q(4)), respectively, indicating good discrimination. Hosmer-Lemeshow analysis gave chi(2)=9.43 (Q(2)), chi(2)=7.39 (Q(3)) and chi(2)=8.00 (Q(4)) (p-values of 0.307, 0.495 and 0.433) for 8 degrees of freedom, indicating good calibration. The finding that the risk of hospital death can be predicted with routinely available data very early on after hospital admission has several potential uses. It raises the possibility that the surveillance and treatment of patients might be categorised by risk assessment means. Such a system might also be used to assess clinical performance, to evaluate the benefits of introducing acute care interventions or to investigate differences between acute care systems.

Impact of a one-day inter-professional course (ALERT™) on attitudes and confidence in managing critically ill adult patients

Anecdotal evidence suggests that anxiety and lack of confidence in managing acutely ill patients adversely affects performance. We evaluated the impact of attending an ALERT course on the confidence levels and attitudes of healthcare staff in relation to the recognition and management of acutely ill patients. A questionnaire, which examined knowledge, experience, confidence and teamwork, was distributed to participants prior to commencing an ALERT course. One hundred and thirty-one respondents agreed to participate in a follow-up questionnaire 6 weeks after completing the course. Respondents reported significantly more knowledge (pre 5.47+/-1.69, post 7.37+/-1.22; p < 0.01) in recognising a critically ill patient after attending an ALERT course. Mean scores for respondents' confidence in their ability to recognise a critically ill patient (pre 6.04; post 7.71; t = 11.74; p < 0.01), keep such a patient alive (pre 5.70; post 7.30; t = 10.01; p < 0.01) and remember all the life-saving measures (pre 5.60; post 7.32; t = 11.71; p < 0.01) were increased. Fewer respondents were very worried about being responsible for a critically ill patient (pre 13; post 2; chi2 = 8.55; p < 0.003). There was a significant increase in the number of respondents indicating that they would use a system of assessment for acute illness (pre 23; post 37; chi2 = 4.25; p = 0.035). More staff said that they would approach a registrar or a consultant for help (chi2 = 3.29, n = 131, p < 0.05; chi2 = 7.51, n = 131, p < 0.01). There was a significant improvement in attendees' confidence in working in an interdisciplinary team when caring for critically ill patients (pre 40.66; post 42.91; t = 2.32; p = 0.05). We conclude that attending an ALERT course has beneficial effects on the confidence levels and attitudes of healthcare staff in relation to the recognition and management of acutely ill patients.

Staff awareness of a ‘Do Not Attempt Resuscitation’ policy in a District General Hospital

UK hospitals have been instructed to ensure that all staff understand the institution's resuscitation policy. Using a questionnaire, we determined the level of knowledge about the hospital's 'do not attempt resuscitation' (DNAR) policy amongst a range of staff. Six hundred and seventy-seven questionnaires were returned. 91.4% of responders did not know the correct overall percentage survival to hospital discharge following an in-hospital cardiac arrest. 19.3% of doctors, 10.6% of nurses, and 8.9% of health care support workers (HCSW) gave answers in the correct range (i.e., 15-25%). Most doctors (93.5%), nurses (93.5%), and HCSW (78.9%) correctly identified that cardiopulmonary resuscitation (CPR) should be the default position, when a DNAR decision does not exist. The majority of doctors (78.5%), nurses (73.2%) and HCSW (65.8%) appreciated that the hospital policy allowed a senior trainee doctor (specialist registrar; SpR) to make the initial decision without consultation with more senior medical staff. Knowledge of who was ultimately responsible for the DNAR decision was also good, with 100% of doctors, 100% of midwives, 98.3% of nurses and 78.9% of HCSW responding correctly. Ten percent of doctors, 15% of nurses and 10.5% of HCSW believed that the next of kin could demand resuscitation or a DNAR status. There was inconsistency about what information staff felt should be included in DNAR documentation and what, if any, continuing care should be given to patients who are not for resuscitation. Our study demonstrates that there is room for improvement in the awareness of staff about the DNAR process. The local DNAR policy is being reviewed to ensure that its messages are clear and a specific DNAR educational programme has been commenced.

Long-term effect of introducing an early warning score on respiratory rate charting on general wards

The respiratory rate is an early indicator of disease, yet many clinicians underestimate its importance and hospitals report a poor level of respiratory rate recording. We studied the short- and long-term effects of introducing a new patient vital signs chart and the modified early warning score (MEWS), which incorporates respiratory rate on the prevalence of respiratory rate recording in six general wards of our hospital. Prior to the commencement of the study, the average percentage of occupied beds where at least one respiratory rate recording had been made in a single 24-h period was 29.5+/-13.5%. After the introduction of the new vital signs chart to all six wards, and the introduction of MEWS to three wards, this rose to 68.9+/-20.9%. When all six wards had been using both the new chart and the MEWS system for almost 1 year, the figure had reached 91.2+/-5.6%. During the pre-introduction period, there was no difference in the prevalence of respiratory rate recording between the specialties (orthopaedic, 26.9%; surgery, 32.9%; medicine, 29.8%; p=0.118). During the second two audit periods, the prevalence of respiratory rate monitoring was consistently higher on medical wards than on surgical and orthopaedic wards (p<0.001). The study confirms the long-term beneficial effect of introducing the MEWS system on respiratory rate recording into the general wards of our hospital. As respiratory rate abnormalities are early markers of disease, it is hoped that improved monitoring will have an impact on the nature and timeliness of the response to critical illness. This may have an impact on the future incidence of potentially avoidable cardiac arrest, deaths and unanticipated intensive care unit admission.

Intensive care requirements for an ageing population--a microcosm of problems facing the NHS?

The changing patterns of admissions to an intensive care unit (ICU) were investigated in relation to age. The local population and the patients admitted to ICU in each year from 1996 to 2002 were stratified by age. The trend in the ratio of admissions to population showed the most extreme changes in those aged > or = 60 years. For this group, there was an increase of 2.62 admissions per 10,000 population per year (95% Confidence interval (CI) 1.41 to 3.85, p = 0.004). APACHE II (Acute Physiology and Chronic Health Evaluation II) scores increased by 0.45 points per year (95% CI 0.16 to 0.74, p = 0.013) and length of ICU stay increased by 0.21 days per year (95% CI 0.03 to 0.38, p = 0.032). This rapid increase in the use of ICU resources by patients aged > or = 60 years over a period of six years, combined with an ageing population, suggests that current projections of future ICU provision may be inadequate.

Impact of attending a 1-day multi-professional course (ALERT™) on the knowledge of acute care in trainee doctors

We have described previously deficiencies in the knowledge in trainee doctors of aspects of acute illness, its recognition and management. This led to the development of a 1-day multi-professional course in acute care for newly qualified doctors and nurses, ALERT. Using a questionnaire, we assessed the knowledge of basic aspects of acute care amongst 118 senior house officers, 36 of whom had previously attended an ALERT course. The average (+/-S.D.) knowledge score was higher for those who had completed an ALERT course (9.44 +/- 1.63 points versus 7.45 +/- 2.32 points; P < 0.05). In addition, those in the post-ALERT group also showed significantly better knowledge of the signs of complete airway obstruction, normal capillary refill time, percentage survival after in-hospital cardiac arrest, consent arrangements for operation in unconscious patients, minimum hourly urine output, the need to inflate the reservoir bag on a high concentration oxygen mask and the role of the reservoir. Similar differences existed between trainees who had completed an ALERT course and a group of SHOs assessed in 1991, who had not done so. We believe that we have demonstrated evidence that doctors' knowledge of acute care can be improved by attending courses such as ALERT.

Do textbooks of clinical examination contain information regarding the assessment of critically ill patients?

We postulated that some of the reported deficiencies in trainee doctors' knowledge of acute care might be due to the quantity and quality of available information about the examination and clinical assessment of critically ill patients in commonly used medical textbooks. Using an agreed assessment system, 30 routinely available texts of clinical examination were reviewed. None of these contained a section devoted specifically to "assessing the critically ill patient" and few could be regarded as giving a comprehensive, systematic description of an assessment system suitable for use with the acutely ill. In general, descriptions of how to assess airway patency were rare, with only one describing how to differentiate partial from complete airway obstruction. Only four of the texts mentioned that measuring the respiratory rate would be useful in critically ill patients and the assessment of capillary refill time was poorly covered. Use of the AVPU scale to describe neurological status was found in only 3% of texts, and there was poor description of the clinical significance of hypotension, tachycardia, oliguria, hypothermia and pyrexia. We conclude that the current texts available to medical students and junior doctors do not provide sufficient information regarding the assessment of critically ill patients.

External validation of the SAPS II, APACHE II and APACHE III prognostic models in South England: a multicentre study

OBJECTIVE

External validation of three prognostic models in adult intensive care patients in South England. DESIGN. Prospective cohort study.

SETTING

Seventeen intensive care units (ICU) in the South West Thames Region in South England.

PATIENTS AND PARTICIPANTS

Data of 16646 patients were analysed.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We compared directly the predictive accuracy of three prognostic models (SAPS II, APACHE II and III), using formal tests of calibration and discrimination. The external validation showed a similar pattern for all three models tested: good discrimination, but imperfect calibration. The areas under the receiver operating characteristics (ROC) curves, used to test discrimination, were 0.835 and 0.867 for APACHE II and III, and 0.852 for the SAPS II model. Model calibration was assessed by Lemeshow-Hosmer C-statistics and was Chi(2 )=232.1 for APACHE II, Chi(2 )=443.3 for APACHE III and Chi(2 )=287.5 for SAPS II.

CONCLUSIONS

Disparity in case mix, a higher prevalence of outcome events and important unmeasured patient mix factors are possible sources for the decay of the models' predictive accuracy in our population. The lack of generalisability of standard prognostic models requires their validation and re-calibration before they can be applied with confidence to new populations. Customisation of existing models may become an important strategy to obtain authentic information on disease severity, which is a prerequisite for reliably measuring and comparing the quality and cost of intensive care.

Common faults in resuscitation equipment--guidelines for checking equipment and drugs used in adult cardiopulmonary resuscitation

Successful advanced life support relies, in part, upon the availability and correct functioning of resuscitation equipment. However, numerous publications report deficiencies and defects in key items of resuscitation equipment, particularly those relating to airway management and defibrillation. Some of these are generic and relate to basic device failure (e.g. intrinsic design faults, manufacturing errors, random component failure), external factors (e.g. power failure, gas supply failure, electromagnetic interference) and human error (notably, inadequate knowledge, lack of experience and training, inadequate checking, insufficient maintenance). However, others are device specific. This paper identifies the common, generic faults that lead to equipment malfunction and recommends the resuscitation equipment essential for successful cardiopulmonary resuscitation. It also describes examples of specific equipment malfunction and makes suggestions for the nature and frequency of resuscitation equipment and drug checks, using a structured, and easy-to-recall list.

Waiting for the break of dawn? The effects of discharge time, discharge TISS scores and discharge facility on hospital mortality after intensive care

OBJECTIVE

To assess the effects of discharge Therapeutic Intervention Scoring System (TISS) scores, discharge time and type of discharge facility on ultimate hospital mortality after intensive care.

DESIGN

Retrospective cohort study.

SETTING

General intensive care unit (ICU) in a district general hospital.

PATIENTS AND PARTICIPANTS

One thousand six hundred fifty-four ICU patients discharged to hospital wards or high dependency units (HDUs).

MAIN MEASUREMENTS AND RESULTS

Vital status at ultimate hospital discharge was the main outcome measurement. The crude hospital mortality after ICU discharge (12.6%) was significantly associated with increasing discharge TISS scores (chi(2) for trend =9.0, p=0.028). This trend was similarly observed after adjusting for severity of disease. Patients with high TISS scores (>30) who were discharged to hospital wards had a higher risk (1.31; CI: 1.02-1.83) of in-hospital death compared with patients discharged to HDUs. Crude mortality was significantly higher for late 20.00 h to 7.59 h) than for early (8.00 h to 19.59 h) discharges (18.8% versus 11.2%, chi(2) =12.1, p=0.0004). Adjusted for disease severity, the mortality risk was 1.70-fold (CI: 1.28-2.25) increased for late ICU discharges. Patients discharged late to hospital wards had significantly higher severity-adjusted risks (1.87; CI:1.36-2.56) than had patients discharged to HDUs (1.35; CI: 0.77-2.36).

CONCLUSIONS

Both late discharge and high discharge TISS scores are indicators of "premature" ICU discharge and were associated with increased mortality. Intermediate care reduced the mortality of patients discharged "prematurely" from ICU. This adds to the growing evidence of the benefits of intermediate care after ICU discharge.

The effects of two methods for customising the original SAPS II model for intensive care patients from South England

Model customisation is used to adjust prognostic models by re-calibrating them to obtain more reliable mortality estimates. We used two methods for customising the Simplified Acute Physiology Score II model for 15,511 intensive care patients by altering the logit and the coefficients of the original equation. Both methods significantly improved model calibration, but customising the coefficients was slightly more effective. The Hosmer-Lemeshow chi(2)-value improved from 306.0 (p< 0.001) before, to 14.5 (p < 0.07) and 23.3 (p < 0.06) after customisation of the coefficients and the logit, respectively. Discrimination was not affected. The standardised mortality ratio for the entire population declined from 1.16 (95% confidence interval: 1.13-1.20, p < 0.001) to 0.99 (95% confidence interval: 0.96-1.02, p < 0.22) after customisation of the coefficients. The uniformity-of-fit for patients grouped by operative status and comorbidities also improved, but remained imperfect for patients stratified by location before intensive care unit admission. Amalgamation of large, regional databases could provide the basis for the re-calibration of standard prognostic models, which could then be used as a national reference system to allow more reliable comparisons of the efficacy and quality of care based on severity adjusted outcome measures.

Knowledge of aspects of acute care in trainee doctors

Deficiencies in trainees' knowledge, skills, and attitudes have the potential to influence the initial assessment, treatment, and outcome of acutely ill ward patients. Knowledge of basic aspects of acute care were assessed among a group of 185 trainee doctors at six hospitals. Many were unaware of the signs of total airway obstruction, confusing them with those of partial obstruction (pre-registration house officers (PRHOs) 11%, senior house officers (SHOs) 14%) or apnoea (PRHOs 47%, SHOs 26%). Knowledge about the use of non-rebreathing oxygen masks was poor; 23% of trainees could not describe the purpose of the reservoir bag or gave answers that were unclear or incorrect. Seven trainees thought that it was involved in humidification, or carbon dioxide collection or removal. Seventeen per cent of trainees could not quote the maximum deliverable inspired oxygen concentration provided by these masks or gave values below the normal range. Thirty one per cent of trainees thought that the lower end of the normal range for pulse oximetry (S(p)O(2)) was below 95%; nine (5%) believed it to be below 90%. There was also poor knowledge of the factors influencing the function of a pulse oximeter. Similar deficits in knowledge and understanding existed in relation to the normal capillary refill time, minimum hourly urine output, the use of the AVPU scale and the role of blood glucose testing in unconscious adults. Only 22% of PRHOs and 21% of SHOs identified the correct percentage hospital survival for patients who suffer an in-hospital cardiac arrest. Knowledge of aspects of consent was unsatisfactory. It is recommended that all medical schools urgently incorporate training about common aspects of "generic" acute care in their curricula.

ALERT--a multiprofessional training course in the care of the acutely ill adult patient

The Acute Life-threatening Events--Recognition and Treatment (ALERT) course is a one-day multidisciplinary course originally designed to give newly qualified doctors and nurses greater confidence and ability in the recognition and management of adult patients who have impending or established critical illness. It may also be suitable for many other groups of health service workers. ALERT was developed using principles common to many advanced life support courses and incorporates aspects of clinical governance, multidisciplinary education and interprofessional working. It incorporates pre-course reading, informal and interactive seminars, practical demonstrations and role-play during clinically based scenarios. A novel aspect of ALERT is that participants undertake role interchange during scenarios, thereby facilitating mutual understanding. At all times during the course, participants are encouraged to reflect on their actions and to pay particular attention to detail. The course focuses on those problems that lead ward nurses to call doctors for assistance, e.g. 'the blue patient', 'the hypotensive patient'. Communication skills are covered frequently in the course, during seminars and scenarios, but also as a specific session that covers three aspects--breaking bad news, writing patient notes and interpersonal/interprofessional communication.

The impact of low-risk intensive care unit admissions on mortality probabilities by SAPS II, APACHE II and APACHE III

A large proportion of intensive care unit patients are low-risk admissions. Mortality probabilities generated by predictive systems may not accurately reflect the mortality experienced by subpopulations of critically ill patients. We prospectively assessed the impact of low-risk admissions (mortality risk < 10%) on the mortality estimates generated by three prognostic models. We studied 1497 consecutive admissions to a general intensive care unit. The performance of the three models for subgroups and the whole population was analysed. The proportions of patients designated as low risk varied with the model and differences in model performance were most pronounced for these patients. The APACHE II mortality ratios (1.32 vs. 1.19) did not differ for low- and higher risk patients, but mortality ratios generated by APACHE III (2.38 vs. 1.23) and SAPS II (2.19 vs. 1.16) were nearly two-fold greater. Calibration for higher risk patients was similar for all three models but the APACHE III system calibrated worse than the other models for low-risk patients. This may have contributed to the poorer overall calibration of the APACHE III system (Hosmer-Lemeshow C-test: APACHE III chi(2) = 329; APACHE II chi(2) = 42; SAPS II chi(2) = 62). Imperfect characterisation of the large proportion of low-risk intensive care unit admissions may contribute to the deterioration of the models' predictive accuracies for the intensive care population as a whole.