The impact of introducing medical emergency team system on the documentations of vital signs

Pulse oximetry-derived respiratory rate in general care floor patients

Respiratory rate is recognized as a clinically important parameter for monitoring respiratory status on the general care floor (GCF). Currently, intermittent manual assessment of respiratory rate is the standard of care on the GCF. This technique has several clinically-relevant shortcomings, including the following: (1) it is not a continuous measurement, (2) it is prone to observer error, and (3) it is inefficient for the clinical staff. We report here on an algorithm designed to meet clinical needs by providing respiratory rate through a standard pulse oximeter. Finger photoplethysmograms were collected from a cohort of 63 GCF patients monitored during free breathing over a 25-min period. These were processed using a novel in-house algorithm based on continuous wavelet-transform technology within an infrastructure incorporating confidence-based averaging and logical decision-making processes. The computed oximeter respiratory rates (RRoxi) were compared to an end-tidal CO2 reference rate (RRETCO2). RRETCO2 ranged from a lowest recorded value of 4.7 breaths per minute (brpm) to a highest value of 32.0 brpm. The mean respiratory rate was 16.3 brpm with standard deviation of 4.7 brpm. Excellent agreement was found between RRoxi and RRETCO2, with a mean difference of -0.48 brpm and standard deviation of 1.77 brpm. These data demonstrate that our novel respiratory rate algorithm is a potentially viable method of monitoring respiratory rate in GCF patients. This technology provides the means to facilitate continuous monitoring of respiratory rate, coupled with arterial oxygen saturation and pulse rate, using a single non-invasive sensor in low acuity settings.

Temporal distribution of instability events in continuously monitored step-down unit patients: implications for Rapid Response Systems

AIM

Medical Emergency Teams (MET) activations are more frequent during daytime and weekdays, but whether due to greater patient instability, proximity from admission time, or caregiver concentration is unclear. We sought to determine if instability events, when they occurred, varied in their temporal distribution.

METHODS

Monitoring data were recorded (frequency 1/20Hz) in 634 SDU patients (41,635 monitoring hours). Vital sign excursion beyond our MET trigger thresholds defined alerts. The resultant 1399 alerts from 216 patients were tallied according to clock hour and time elapsed since admission. We fit patient ID (n=216), clock hour, time since SDU admission, and alert present into a null model and three mixed effect logistic regression models: clock hour, hours elapsed since admission, and both clock hour and time elapsed since admission as fixed effect covariates. We performed likelihood ratio tests on these models to assess if, among all alerts, there were proportionally more alerts for any given clock hour, or proximity to admission time.

RESULTS

Only time elapsed since admission (p<0.001), and not clock hour adjusting for time elapsed since admission (p=0.885), was significant for temporal disproportion. Results were unchanged if the first 24h following admission were excluded from the models.

CONCLUSION

Although instability alerts are distributed most frequently within 24h after SDU admission in unstable patients, they are otherwise not more likely to distribute proportionally more frequently during certain clock hours. If MET utilization peaks do not coincide with admission time peaks, other variables contributing to unrecognized instability should be explored.

Ensuring a proactive, evidence-based, patient safety approach to patient assessment

AIMS AND OBJECTIVES

To argue that if all nurses were to adopt the primary survey approach (assessment of airway, breathing, circulation and disability) as the first element of patient assessment, they would be more focused on active detection of clinical deterioration rather than passive collection of patient data.

BACKGROUND

Nurses are the professional group that carry the highest level of responsibility for patient assessment, accurate data collection and interpretation. The timely recognition of, and response to deteriorating patients, is dependent on the measurement and interpretation of pertinent physiological data by nurses.

DESIGN

Discursive paper.

METHODS

Traditionally taught and commonly used approaches to patient assessment such as 'vital signs' and 'body systems' are not evidence-based nor framed in patient safety. The primary survey approach as the first element in patient assessment has three major advantages: (1) data are collected according to clinical importance; (2) data are collected using the same framework as most organisation's rapid response system activation criteria; and (3) the primary survey acts as a patient safety checklist, thereby decreasing the risk of failure to recognise, and therefore respond to, deteriorating patients.

CONCLUSION

The vital signs and body systems approaches to patient assessment have significant limitations in identifying clinical deterioration. The primary survey approach provides nurses with a consistent, evidence-based and sequenced approach to patient assessment in every clinical setting.

RELEVANCE TO CLINICAL PRACTICE

All nurses should use a primary survey approach as the first element of patient assessment in every patient encounter as a patient safety strategy.

Factors associated with post-intensive care unit adverse events: a clinical validation study

BACKGROUND

Many patients discharged from intensive care units (ICU) have complex care needs, placing them at risk of an adverse event in a ward environment. Currently, there is limited understanding of factors associated with these events in the post-intensive care population. A recent study explored intensive care liaison nurses' opinions on factors associated with these events; 25 factors were identified, highlighting the multifaceted nature of post-intensive care adverse events.

AIM

This study aimed to clinically validate 25 factors intensive care liaison nurses believe are associated with post-intensive care adverse events, to determine the factors' relevance and importance to clinical practice.

DESIGN

Prospective, clinical validation study.

METHOD

Data were prospectively collected on a convenience sample of 52 patients at 4 tertiary referral hospitals in an Australian capital city. All patients had experienced an adverse event after intensive care discharge.

RESULTS

Each of the 25 factors contributed to adverse events in at least 6 patients. The factors associated with the most adverse events were those that related to the patient such as illness severity and co-morbidities.

CONCLUSION

Clinical care and research should focus on modifiable factors in care processes to reduce the risk of future adverse events in post-intensive care patients.

RELEVANCE TO CLINICAL PRACTICE

Many patients are at risk of post-ICU adverse events due to the contribution of non-modifiable factors. However, by focusing on modifiable factors in care processes, the risk of post-ICU adverse events may be reduced.

Recognising clinical deterioration in emergency department patients

BACKGROUND

The use of rapid response systems such as Medical Emergency Team (MET) improves recognition and response to clinical deterioration in in-patient settings. However, few published studies have investigated use of rapid response systems in Australian emergency departments (ED).

AIM

To examine the frequency, nature and outcomes of clinical deterioration in ED patients and compare the utility of hospital MET calling criteria with ED specific Clinical Instability Criteria (CIC) for recognition of deteriorating patients. The outcomes of interest were the prevalence of deterioration in ED patients, the utility of MET versus ED CIC, and the outcomes (MET activation, in-hospital mortality at 30 days) of patients who experienced deterioration during ED care.

METHOD

An exploratory descriptive design was used. Vital sign data were prospectively collected from 200 patients receiving ED care in the general treatment areas of regional, publicly funded health service in Victoria, Australia, during May 2012. Outcome data were collected by follow up medical record audit.

RESULTS

Of the 200 ED patients recruited, 2% fulfilled the study site MET criteria and 7.5% fulfilled ED CIC. The median age of patients fulfilling MET criteria was 85 years compared with a median age of 74 years for patients fulfilling the ED CIC criteria. Of the 136 ED patients admitted to in-patient wards, 5.9% required MET activation during admission and 3.7% of these MET activations occurred within 24h of emergency admission. Five percent of patients died in-hospital within 30 days of ED attendance.

CONCLUSIONS

ED specific criteria for activation of a rapid response system identifies more ED patients at risk of clinical deterioration. The results of this study highlight a need for EDs to implement and evaluate systems to increase recognition of deteriorating patients designed specifically for the emergency care context.

ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome

OBJECTIVE

To evaluate characteristics and outcome of ICU patients admitted from general wards based on mode of admittance, via a rapid response team or conventional contact.

DESIGN

Observational prospective study.

SETTING

General ICU of a university hospital.

PATIENTS

: A total of 694 admissions to ICU from general wards.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between 2007 and 2009, two cohorts admitted to ICU from general wards were identified: those admitted by the rapid response team and those admitted in a conventional way. Patients admitted directly from the trauma room, the emergency department, operating room, other hospitals, or other ICUs were excluded. Of 694 admissions, 355 came through a rapid response team call. Rapid response team patients were older (p < 0.01), and they had more severe comorbidities, higher severity score (p < 0.01), and almost three times more often the diagnosis of severe sepsis (p < 0.01) than conventionally admitted patients. Rapid response team patients had higher ICU mortality and 30-day mortality with a crude odds ratio for mortality within 30 days of 1.57 (95% confidence interval 1.08-2.28). Adjusted for age and comorbidities however, the difference was no longer significant with an odds ratio of 1.11 (95% confidence interval 0.70-1.76).

CONCLUSIONS

This study suggests that the rapid response team is an important system for identifying complex patients in need of intensive care. More than half of ICU admissions from the wards came through a rapid response team call. Compared with conventional admissions, rapid response team patients had a high proportion of characteristics that could be related to a worse prognosis. Severe sepsis at the wards was mainly detected by the rapid response team and was the most common admitting diagnosis among the rapid response team patients. When adjusted for confounding factors, outcome between the groups did not differ, supporting the use of rapid response systems to identify deteriorating ward patients.

Impact of professionalism in nursing on in-hospital bedside monitoring practice

AIM

This article reports a study exploring nursing practice of monitoring in-hospital patients including intra- and interprofessional communication and collaboration.

BACKGROUND

Sub-optimal care in general in-hospital wards may lead to admission for intensive care, cardiac arrest, or sudden death. Reasons may include infrequent measurements of vital parameters, insufficient knowledge of their predictive values, and/or sub-optimal use of Medical Emergency Teams. This study was designed to improve understanding of nursing practice and to identify changes required to support nursing staff in improving standards of clinical monitoring practice and patient safety in general in-hospital wards.

DESIGN

The study was designed as a qualitative descriptive clinical study, based on method triangulation including structured individual observations and semi-structured individual interviews.

METHODS

In the spring of 2009, structured observations and semi-structured interviews of 13 nurses were carried out at a university hospital in Copenhagen, Denmark. The observational notes and interview transcriptions were analysed using content analysis.

RESULTS

One theme (Professionalism influences nursing monitoring practice) and two sub-themes (Knowledge and skills and Involvement in clinical practice through reflections) were identified. Three categories (Decision-making, Sharing of knowledge, and Intra- and interprofessional interaction) were found to be associated with the theme, the sub-themes, and with each other.

CONCLUSION

Clinical monitoring practice varies considerably between nurses with different individual levels of professionalism. Future initiatives to improve patient safety by further developing professionalism among nurses need to embrace individual and organizational attributes to strengthen their practice of in-hospital patient monitoring and management.

Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study

BACKGROUND

Late transfer of children with critical illness from community hospitals undermines the advantages of community-based care. It was hypothesized that implementation of the Bedside Paediatric Early Warning System (Bedside PEWS) would reduce late transfers.

METHODS

A prospective before-and-after study was performed in a community hospital 22-bed inpatient paediatric ward. The primary outcome, significant clinical deterioration, was a composite measure of circulatory and respiratory support before transfer. Secondary outcomes were stat calls and resuscitation team calls, paediatrician workload and perceptions of frontline staff.

RESULTS

Care was evaluated for 842 patient-days before and 2350 patient-days after implementation. The median inpatient census was 13. Implementation of the Bedside PEWS was associated with fewer stat calls to paediatricians (22.6 versus 5.1 per 1000 patient-days; P<0.0001), fewer significant clinical deterioration events (2.4 versus 0.43 per 1000 patient-days; P=0.013), reduced apprehension when calling the physician and no change in paediatrician workload.

DISCUSSION

Implementation of the Bedside PEWS is feasible and safe, and may improve clinical outcomes.

Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children

Introduction

The timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals.

Methods

We performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients.

Results

A total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001).

Conclusions

The Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.

Vital signs in older patients: age-related changes

Vital signs are objective measures of physiological function that are used to monitor acute and chronic disease and thus serve as a basic communication tool about patient status. The purpose of this analysis was to review age-related changes of traditional vital signs (blood pressure, pulse, respiratory rate, and temperature) with a focus on age-related molecular changes, organ system changes, systemic changes, and altered compensation to stressors. The review found that numerous physiological and pathological changes may occur with age and alter vital signs. These changes tend to reduce the ability of organ systems to adapt to physiological stressors, particularly in frail older patients. Because of the diversity of age-related physiological changes and comorbidities in an individual, single-point measurements of vital signs have less sensitivity in detecting disease processes. However, serial vital sign assessments may have increased sensitivity, especially when viewed in the context of individualized reference ranges. Vital sign change with age may be subtle because of reduced physiological ranges. However, change from an individual reference range may indicate important warning signs and thus may require additional evaluation to understand potential underlying pathological processes. As a result, individualized reference ranges may provide improved sensitivity in frail, older patients.

Continuum of hospital care: the role of intensive care

PURPOSE OF REVIEW

This review outlines the way the specialty of intensive care has expanded over the last decade in response to the changing population of hospital patients, being older with more comorbidities and having more complex interventions. The previous disjointed professional and geographical silos, providing patient care, are being challenged and a more patient focussed continuum of care is replacing it.

RECENT FINDINGS

There have been many reports over the last few years, describing patient centred systems, constructed around the needs of the seriously ill, at-risk patient, including trauma systems and Medical Emergency Team-type systems. There is now general agreement that in most settings these systems are responsible for a significant reduction in mortality and serious adverse events such as cardiac arrest rates.

SUMMARY

The implications for the move towards systems to improve patient outcome and decrease mortality in hospitals are having a significant impact on the way we practise medicine, resulting in an emphasis, among other things, of constructing our care around the needs of patients, rather than rigidly practice medicine from within our own tribal boundaries, for example professional boundaries, medical specialty boundaries and geographical boundaries.

Development and initial validation of the Bedside Paediatric Early Warning System score

INTRODUCTION

Adverse outcomes following clinical deterioration in children admitted to hospital wards is frequently preventable. Identification of children for referral to critical care experts remains problematic. Our objective was to develop and validate a simple bedside score to quantify severity of illness in hospitalized children.

METHODS

A case-control design was used to evaluate 11 candidate items and identify a pragmatic score for routine bedside use. Case-patients were urgently admitted to the intensive care unit (ICU). Control-patients had no 'code blue', ICU admission or care restrictions. Validation was performed using two prospectively collected datasets.

RESULTS

Data from 60 case and 120 control-patients was obtained. Four out of eleven candidate-items were removed. The seven-item Bedside Paediatric Early Warning System (PEWS) score ranges from 0-26. The mean maximum scores were 10.1 in case-patients and 3.4 in control-patients. The area under the receiver operating characteristics curve was 0.91, compared with 0.84 for the retrospective nurse-rating of patient risk for near or actual cardiopulmonary arrest. At a score of 8 the sensitivity and specificity were 82% and 93%, respectively. The score increased over 24 hours preceding urgent paediatric intensive care unit (PICU) admission (P < 0.0001). In 436 urgent consultations, the Bedside PEWS score was higher in patients admitted to the ICU than patients who were not admitted (P < 0.0001).

CONCLUSIONS

We developed and performed the initial validation of the Bedside PEWS score. This 7-item score can quantify severity of illness in hospitalized children and identify critically ill children with at least one hours notice. Prospective validation in other populations is required before clinical application.

Implementing a pediatric rapid response system to improve quality and patient safety

Life-threatening events are common in today's hospitals, where an increasing proportion of patients with urgent admission are cared for by understaffed, often inexperienced personnel. Medical errors play a key role in causing adverse events and failure to rescue deteriorating patients. In-hospital cardiac arrest outcomes are generally poor, but these events are often preceded by a pattern of deterioration with abnormal vital signs and mental status. When hospital staff or family members observe warning signs and trigger timely intervention by a rapid response team, rates of cardiac arrest and mortality can be reduced. Rapid response team involvement can be used to trigger careful review of preceding events to help uncover important systems issues and allow for further improvements in patient safety.