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The Impact of Health Information Technology for Early Detection of Patient Deterioration on Mortality and Length of Stay in the Hospital Acute Care Setting: Systematic Review and Meta-Analysis. Crit Care Med 2022; 50:1198-1209. [PMID: 35412476 DOI: 10.1097/ccm.0000000000005554] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the impact of health information technology (HIT) for early detection of patient deterioration on patient mortality and length of stay (LOS) in acute care hospital settings. DATA SOURCES We searched MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from 1990 to January 19, 2021. STUDY SELECTION We included studies that enrolled patients hospitalized on the floor, in the ICU, or admitted through the emergency department. Eligible studies compared HIT for early detection of patient deterioration with usual care and reported at least one end point of interest: hospital or ICU LOS or mortality at any time point. DATA EXTRACTION Study data were abstracted by two independent reviewers using a standardized data extraction form. DATA SYNTHESIS Random-effects meta-analysis was used to pool data. Among the 30 eligible studies, seven were randomized controlled trials (RCTs) and 23 were pre-post studies. Compared with usual care, HIT for early detection of patient deterioration was not associated with a reduction in hospital mortality or LOS in the meta-analyses of RCTs. In the meta-analyses of pre-post studies, HIT interventions demonstrated a significant association with improved hospital mortality for the entire study cohort (odds ratio, 0.78 [95% CI, 0.70-0.87]) and reduced hospital LOS overall. CONCLUSIONS HIT for early detection of patient deterioration in acute care settings was not significantly associated with improved mortality or LOS in the meta-analyses of RCTs. In the meta-analyses of pre-post studies, HIT was associated with improved hospital mortality and LOS; however, these results should be interpreted with caution. The differences in patient outcomes between the findings of the RCTs and pre-post studies may be secondary to confounding caused by unmeasured improvements in practice and workflow over time.
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Factora F, Maheshwari K, Khanna S, Chahar P, Ritchey M, O’Hara J, Mascha EJ, Mi J, Halvorson S, Turan A, Ruetzler K. Effect of a Rapid Response Team on the Incidence of In-Hospital Mortality. Anesth Analg 2022; 135:595-604. [DOI: 10.1213/ane.0000000000006005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Patient Deterioration on General Care Units: A Concept Analysis. ANS Adv Nurs Sci 2022; 45:E56-E68. [PMID: 34879020 DOI: 10.1097/ans.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient deterioration is a phenomenon that occurs from the inability to recognize it or respond to a change in condition. Despite the published reports on recognizing a deteriorating patient on general care floors, a gap remains in the ability of nurses to describe the concept, affecting patient outcomes. Walker and Avant's approach was applied to analyze patient deterioration. The aim of this article was to explore and clarify the meaning of patient deterioration and identify attributes, antecedents, and consequences. The defining attributes were compared to early warning scores. An operational definition was developed and its value to nurses established.
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Hoffman OL, Romano J, Kleinman ME. Emergency Medical Response for Non-Hospitalized Person Events in a Children's Hospital. Pediatrics 2022; 12:e2021006268. [PMID: 35288738 DOI: 10.1542/hpeds.2021-006268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Hospital-based code blue (CB) teams are designed for hospitalized patients (HP) with unanticipated medical emergencies outside of an ICU. At our freestanding pediatric institution, the same team responds to CB calls involving nonhospitalized persons (NHP) throughout the hospital campus. We hypothesized there are significant differences between the characteristics of NHP and HP requiring emergency medical response, and most responses for NHP do not require advanced critical care. METHODS We analyzed a retrospective cohort of CB responses at our large, urban, academic children's medical center from January to December 2017. We evaluated the demographic and clinical characteristics of these HP compared with NHP events. RESULTS There were 168 CB activations during the study, of which 135 (80.4%) were for NHP. Ninety-one (67.4%) of the NHP responses involved adults (age >18 years) compared with 6 (18.2%) of the HP. Triggers for CB team activation for NHP were most frequently syncope (42.2%), seizure (10.3%), or fall (9.6%) compared with seizure (30.3%), hypoxia (27.3%), or anaphylaxis (12.1%) for HP. Critical interventions such as bag-mask ventilation and cardiopulmonary resuscitation were infrequently performed for either cohort. CONCLUSIONS CB activations in our pediatric institution more often involve NHP than HP. NHP responses are more likely to involve adults and infrequently require advanced interventions. Use of a pediatric CB team for NHP events may be an unnecessary use of pediatric critical care resources. Future studies are warranted to evaluate the most effective team composition, training, and response system for NHP in a freestanding children's hospital.
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Affiliation(s)
- Olivia L Hoffman
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jane Romano
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Monica E Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts
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Hao J, Huang Y, Su J, Lu Z. Emergency and rapid response systems: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:311. [PMID: 35433985 PMCID: PMC9011274 DOI: 10.21037/atm-22-709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/04/2022] [Indexed: 11/06/2022]
Abstract
Background The emergency rapid response system (RRS) can reduce the mortality of hospitalized patients, and its core is the activation criteria and the rapid response team (RRT). This study adopted a bibliometric method to analyze the research status of RRSs for hospitalized patients. Methods The Science Citation Index Expanded (SCI-E) database was searched using the keywords "emergency" and "rapid response system", and the search results were analyzed using CiteSpace software. The retrieved data included the annual distribution of studies and literature citations; the source country of the literature; the distribution of institutions and authors of the literature; the cooperation between countries, institutions, and authors; the distribution of journals that published the literature, and the use of keywords in the literature. Results A total of 1,320 research papers were found, with a total of 29,920 citations. The number of papers and their citations increased yearly. The top 5 countries in terms of number of publications were the United States, Australia, China, the United Kingdom, and Canada. The top 5 countries in terms of centrality were the United States, the United Kingdom, Argentina, the Czech Republic, and Switzerland. The research institutions were mainly located in developed countries, such as the United States and Australia. There was relatively little collaboration between researchers. The journals that published the literature mainly specialized in critical care medicine and emergency medicine. The keyword analysis revealed that most studies focused on medical emergency teams (METs) and mortality. Conclusions There were few studies related to the emergency RRS for hospitalized patients. The majority of studies were from developed countries and mainly focused on the impact of team building and the effect of the RRS on mortality.
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Affiliation(s)
- Jing Hao
- Department of Emergency, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Yutao Huang
- Intensive Care Unit, Hejin Municipal People's Hospital, Hejin, China
| | - Jianguo Su
- Department of Emergency, Ningxia Chinese Medicine Research Center, Yinchuan, China
| | - Zhaofeng Lu
- Department of Emergency, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
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Song MJ, Lee DS, Choi YY, Lee DY, Jo HM, Lim SY, Park JS, Cho YJ, Yoon HI, Lee JH, Lee CT, Lee YJ. Incidence of preventable cardiopulmonary arrest in a mature part-time rapid response system: A prospective cohort study. PLoS One 2022; 17:e0264272. [PMID: 35213617 PMCID: PMC8880884 DOI: 10.1371/journal.pone.0264272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022] Open
Abstract
Background The purpose of a rapid response system (RRS) is to reduce the incidence of preventable cardiopulmonary arrests (CPAs) and patient deterioration in general wards. The objective of this study is to investigate the incidence and temporal trends of preventable CPAs and determine factors associated with preventable CPAs in a hospital with a mature RRS. Methods This was a single-center prospective cohort study of all CPAs occurring in the general ward between March 2017 and June 2020. The RRS operates from 07:00 to 23:00 on weekdays and from 07:00 to 12:00 on Saturdays. All CPAs were reviewed upon biweekly conference, and a panel of intensivists judged their preventability. Trends of preventable CPAs were analyzed using Poisson regression models and factors associated with preventable CPAs were analyzed using multivariable logistic regression. Results There were 253 CPAs over 40 months, and 64 (25.3%) of these were preventable. The incidence rate of CPAs was 1.07 per 1000 admissions and that of preventable CPAs was 0.27 per 1000 admissions. The number of preventable CPAs decreased by 24% each year (incidence rate ratio = 0.76; p = 0.039) without a change in the total CPA incidence. The most common contributor to the preventability was delayed response from physicians (n = 41, 64.1%). A predictable CPA with a pre-alarm sign had increased odds in the occurrence of preventable CPAs, while a cardiac cause of CPAs and RRS operating hours had decreased odds in terms of occurrence of preventable CPA. Conclusion Our study showed that one-fourth of all CPAs occurring in the general wards were preventable, and these arrests decreased each year. A mature RRS can evolve to reduce preventable CPAs with regular self-evaluation. Efforts should be directed at improving physicians’ response time since a delay in their response was the most common cause of preventable CPAs.
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Affiliation(s)
- Myung Jin Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong-Seon Lee
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun-Young Choi
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Da-Yun Lee
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hye-min Jo
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- * E-mail:
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Kawamura H, Komatsu Y, Tanaka K, Kanamoto M, Tobe M, Usami C, Hinohara H, Oshima K, Kitada Y, Tsuda K, Ogano T, Shimada H, Ohno T. Implementation of a rapid response system at an isolated radiotherapy facility through simulation training. BMJ Open Qual 2022; 11:bmjoq-2021-001578. [PMID: 35017175 PMCID: PMC8753419 DOI: 10.1136/bmjoq-2021-001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/21/2021] [Indexed: 11/15/2022] Open
Abstract
A rapid response system is required in a radiotherapy department for patients experiencing a critical event when access to an emergency department is poor due to geographic location and the patient is immobilised with a fixation device. We, therefore, rebuilt the response system and tested it through onsite simulations. A multidisciplinary core group was created and onsite simulations were conducted using a Plan-Do-Study-Act cycle. We identified the important characteristics of our facility, including its distance from the emergency department; the presence of many staff with little direct contact with patients; the treatment room environment and patient fixation with radiotherapy equipment. We also examined processes in each phase of the emergency response: detecting an emergency, calling the medical emergency team (MET), MET transportation to the site and on-site response and patient transportation to the emergency department. The protocol was modified, and equipment was updated. On-site simulations were held with and without explanation of the protocol and training scenario in advance. The time for the MET to arrive at the site during a 2017 simulation prior to the present project was 7 min, whereas the time to arrive after the first simulation session was shortened to 5 min and was then shortened further to 4 min in the second session, despite no prior explanation of the situation. A multidisciplinary project for emergency response with on-site simulations was conducted at an isolated radiation facility. A carefully planned emergency response is important not only in heavy ion therapy facilities but also in other departments and facilities that do not have easy access to hospital emergency departments.
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Affiliation(s)
| | - Yasuhiro Komatsu
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kazumi Tanaka
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Masaru Tobe
- Intensive Care Unit, Gunma University Hospital, Meabashi, Japan
| | - Chisato Usami
- Intensive Care Unit, Gunma University Hospital, Meabashi, Japan
| | | | - Kiyohiro Oshima
- Emergency Medical Center, Gunma University Hospital, Meabashi, Japan
| | - Yoko Kitada
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | - Kazuhisa Tsuda
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | - Tomoaki Ogano
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | | | - Tatsuya Ohno
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
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Jung H, Ko RE, Ko MG, Jeon K. Trends of in-hospital cardiac arrests in a single tertiary hospital with a mature rapid response system. PLoS One 2022; 17:e0262541. [PMID: 35025978 PMCID: PMC8757966 DOI: 10.1371/journal.pone.0262541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Most studies on rapid response system (RRS) have simply focused on its role and effectiveness in reducing in-hospital cardiac arrests (IHCAs) or hospital mortality, regardless of the predictability of IHCA. This study aimed to identify the characteristics of IHCAs including predictability of the IHCAs as our RRS matures for 10 years, to determine the best measure for RRS evaluation. Methods Data on all consecutive adult patients who experienced IHCA and received cardiopulmonary resuscitation in general wards between January 2010 and December 2019 were reviewed. IHCAs were classified into three groups: preventable IHCA (P-IHCA), non-preventable IHCA (NP-IHCA), and inevitable IHCA (I-IHCA). The annual changes of three groups of IHCAs were analyzed with Poisson regression models. Results Of a total of 800 IHCA patients, 149 (18.6%) had P-IHCA, 465 (58.1%) had NP-IHCA, and 186 (23.2%) had I-IHCA. The number of the RRS activations increased significantly from 1,164 in 2010 to 1,560 in 2019 (P = 0.009), and in-hospital mortality rate was significantly decreased from 9.20/1,000 patients in 2010 to 7.23/1000 patients in 2019 (P = 0.009). The trend for the overall IHCA rate was stable, from 0.77/1,000 patients in 2010 to 1.06/1,000 patients in 2019 (P = 0.929). However, while the incidence of NP-IHCA (P = 0.927) and I-IHCA (P = 0.421) was relatively unchanged over time, the incidence of P-IHCA decreased from 0.19/1,000 patients in 2010 to 0.12/1,000 patients in 2019 (P = 0.025). Conclusions The incidence of P-IHCA could be a quality metric to measure the clinical outcomes of RRS implementation and maturation than overall IHCAs.
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Affiliation(s)
- Hohyung Jung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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Nature and characteristics of orthopaedic medical emergency team (MET) events. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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] [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.
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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
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Acorda DE, Bracken JJ, Abela K, Ramsey-Coleman J, Stutts A, Kritz E, Bavare A. Longitudinal Evaluation of a Pediatric Rapid Response System with Realist Evaluation Framework. Jt Comm J Qual Patient Saf 2022; 48:196-204. [DOI: 10.1016/j.jcjq.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/17/2022]
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Sawicki JG, Tower D, Vukin E, Workman JK, Stoddard GJ, Burch M, Bracken DR, Hall B, Henricksen JW. Association Between Rapid Response Algorithms and Clinical Outcomes of Hospitalized Children. Hosp Pediatr 2021; 11:1385-1394. [PMID: 34849928 DOI: 10.1542/hpeds.2020-005603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To evaluate whether the implementation of clinical pathways, known as pediatric rapid response algorithms, within an existing rapid response system was associated with an improvement in clinical outcomes of hospitalized children. METHODS We retrospectively identified patients admitted to the PICU as unplanned transfers from the general medical and surgical floors at a single, freestanding children's hospital between July 1, 2017, and January 31, 2020. We examined the impact of the algorithms on the rate of critical deterioration events. We used multivariable Poisson regression and an interrupted time series analysis to measure 2 possible types of change: an immediate implementation effect and an outcome trajectory over time. RESULTS We identified 892 patients (median age: 4 [interquartile range: 1-12] years): 615 in the preimplementation group, and 277 in the postimplementation group. Algorithm implementation was not associated with an immediate change in the rate of critical deterioration events but was associated with a downward rate trajectory over time and a postimplementation trajectory that was significantly less than the preimplementation trajectory (trajectory difference of -0.28 events per 1000 non-ICU patient days per month; 95% confidence interval -0.40 to -0.16; P < .001). CONCLUSIONS Algorithm implementation was associated with a decrease in the rate of critical deterioration events. Because of the study's observational nature, this association may have been driven by unmeasured confounding factors and the chosen implementation point. Nevertheless, the results are a promising start for future research into how clinical pathways within a rapid response system can improve care of hospitalized patients.
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Affiliation(s)
| | | | | | - Jennifer K Workman
- Departments of Pediatrics
- Critical Care, Primary Children's Hospital, Salt Lake City, Utah
| | - Gregory J Stoddard
- Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Mary Burch
- Intermountain Healthcare, Salt Lake City, Utah
| | | | - Brooke Hall
- Intermountain Healthcare, Salt Lake City, Utah
| | - Jared W Henricksen
- Departments of Pediatrics
- Critical Care, Primary Children's Hospital, Salt Lake City, Utah
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Bavare AC, Thomas JK, Yeppez D, Gazzaneo MC, Guffey D, Thammasitboon S. Evaluation of a Theory-Informed Pediatric Rapid Response Training Program Using the Logic Model. Hosp Pediatr 2021:hpeds.2021-005895. [PMID: 34807975 DOI: 10.1542/hpeds.2021-005895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The activators of rapid-response (RR) events tasked with recognition of clinical decompensation, initial management, and response activation seldom receive RR training. RR activators often experience negative emotions of "failure to rescue" that can compromise team performance during RRs. We used the logic model framework for development and evaluation of an educational program grounded in self-determination theory for pediatric RR activators. METHODS The program unfolded in a large quaternary pediatric hospital to impart knowledge and skills; foster autonomy, competence, and relatedness; and improve participants' satisfaction with performance in RRs. Logic model-guided inputs-activities-outputs-outcomes-context for program evaluation. Preintervention-postintervention follow-up surveys and interviews generated data to determine outcomes and impact of the program. The evaluation instruments were tested for validity and internal consistency. RESULTS Over 4 years, 207 multidisciplinary RR activators were trained. Iterative modifications yielded a workshop that incorporated multiple learning modalities, a standardized learner-centered case bank, formalized evaluation tools, and a database to track participation. Significant improvements in RR-related knowledge, self-efficacy, and self- determination were noted. Workshop evaluation yielded a mean score of 4.85 (0.27) on a 5-point scale. At 6-months follow-up survey and interviews, participants reported application of the knowledge and increased confidence with participation in real-life RR events. The workshop gained traction across the hospital, was associated with improved RR clinical outcomes, and contributed to professional advancement of the educators. CONCLUSIONS We successfully implemented a self-determination theory-informed RR training program for pediatric RR activators, and the logic model framework was used to facilitate comprehensive evaluation.
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Affiliation(s)
- Aarti C Bavare
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jenilea K Thomas
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Denae Yeppez
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Maria C Gazzaneo
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Satid Thammasitboon
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
- Center for Research, Innovation and Scholarship in Medical Education, Texas Children's Hospital, Houston, Texas
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Critical Care Resource Nurse Team: A Patient Safety and Quality Outcomes Model. Dimens Crit Care Nurs 2021; 41:46-53. [PMID: 34817961 DOI: 10.1097/dcc.0000000000000501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The Critical Care Resource Nurse Team (CCRNT) evolved from our traditional Rapid Response Team (RRT). The CCRNT is a unique paradigm created using the conceptual framework of the American Association of Critical Care Nursing Synergy Model for Patient Care. The goal of the CCRNT is to help align nurse competencies with patient needs. This team was seen as a much-needed strong clinical support by nursing leadership as large numbers of inexperienced new graduate registered nurses were hired and senior experienced nurses were leaving the workforce. The CCRNT supports 24/7 RRT, Code Blue, Code Stroke, Emergency Airway Response Team, Early Warning System, Medical Emergency Team, simulation team training, and bedside nurse support and mentoring. Coverage expanded from inpatient medical/surgical areas to all areas of the medical center and included hospital-wide initiatives. The focus for the CCRNT changed to a system-wide nursing and patient safety model to improve practice and intervene in near-miss events. This model improved communication between disciplines, provided critical surveillance of at-risk patients, supported patient safety with a significant decrease in patient mortality, and offered a 24/7 expert critical care nurse resource team for staff.
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Rosero EB, Romito BT, Joshi GP. Failure to rescue: A quality indicator for postoperative care. Best Pract Res Clin Anaesthesiol 2021; 35:575-589. [PMID: 34801219 DOI: 10.1016/j.bpa.2020.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/19/2020] [Indexed: 11/24/2022]
Abstract
Postoperative complications occur despite optimal perioperative care and are an important driver of mortality after surgery. Failure to rescue, defined as death in a patient who has experienced serious complications, has emerged as a quality metric that provides a mechanistic pathway to explain disparities in mortality rates among hospitals that have similar perioperative complication rates. The risk of failure to rescue is higher after invasive surgical procedures and varies according to the type of postoperative complication. Multiple patient factors have been associated with failure to rescue. However, failure to rescue is more strongly correlated with hospital factors. In addition, microsystem factors, such as institutional safety culture, teamwork, and other attitudes and behaviors may interact with the hospital resources to effectively prevent patient deterioration. Early recognition through bedside and remote monitoring is the first step toward prevention of failure to rescue followed by rapid response initiatives and timely escalation of care.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Okawa R, Yokono T, Koyama Y, Uchiyama M, Oono N. Clinical Sign-Based Rapid Response Team Call Criteria for Identifying Patients Requiring Intensive Care Management in Japan. Medicina (B Aires) 2021; 57:medicina57111194. [PMID: 34833412 PMCID: PMC8619995 DOI: 10.3390/medicina57111194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: For effective function of the rapid response system (RRS), prompt identification of patients at a high risk of cardiac arrest and RRS activation without hesitation are important. This study aimed to identify clinical factors that increase the risk of intensive care unit (ICU) transfer and cardiac arrest to identify patients who are likely to develop serious conditions requiring ICU management and appropriate RRS activation in Japan. Materials and Methods: We performed a single-center, case control study among patients requiring a rapid response team (RRT) call from 2017 to 2020. We extracted the demographic data, vital parameters, blood oxygen saturation (SpO2) and the fraction of inspired oxygen (FiO2) from the medical records at the time of RRT call. The patients were divided into two groups to identify clinical signs that correlated with the progression of clinical deterioration. Patient characteristics in the two groups were compared using statistical tests based on the distribution. Receiver operating characteristic (ROC) curve analysis was used to identify the appropriate cut-off values of vital parameters or FiO2 that showed a significant difference between-group. Multivariate logistic regression analysis was used to identify patient factors that were predictive of RRS necessity. Results: We analyzed the data of 65 patients who met our hospital’s RRT call criteria. Among the clinical signs in RRT call criteria, respiratory rate (RR) (p < 0.01) and the needed FiO2 were significantly increased (p < 0.01) in patients with severe disease course. ROC curve analysis revealed RR and needed FiO2 cut-off values of 25.5 breaths/min and 30%. The odds ratio for the progression of clinical deterioration was 40.5 times higher with the combination of RR ≥ 26 breaths/min and needed FiO2 ≥ 30%. Conclusions: The combined use of RR ≥ 26 breaths/min and needed FiO2 ≥ 30% might be valid for identifying patients requiring intensive care management.
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Affiliation(s)
- Reiko Okawa
- Emergency and Critical Care Center, Nagaoka Red Cross Hospital, Nagaoka 940-2085, Japan;
| | - Tomoe Yokono
- Department of Nursing, Niigata University Graduate School of Health Sciences, Niigata 951-8518, Japan; (Y.K.); (M.U.)
- Correspondence:
| | - Yu Koyama
- Department of Nursing, Niigata University Graduate School of Health Sciences, Niigata 951-8518, Japan; (Y.K.); (M.U.)
| | - Mieko Uchiyama
- Department of Nursing, Niigata University Graduate School of Health Sciences, Niigata 951-8518, Japan; (Y.K.); (M.U.)
| | - Naoko Oono
- Niigata College of Medical Technolgy, Niigata 950-2076, Japan;
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Goh KJ, Chai HZ, Ng LS, Phone Ko J, Tan DCX, Tan HL, Teo CWS, Phua GC, Tan QL. Outcomes of second-tier rapid response activations in a tertiary referral hospital: A prospective observational study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:838-847. [PMID: 34877587 DOI: 10.47102/annals-acadmedsg.2021238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION A second-tier rapid response team (RRT) is activated for patients who do not respond to first-tier measures. The premise of a tiered response is that first-tier responses by a ward team may identify and correct early states of deterioration or establish goals of care, thereby reducing unnecessary escalation of care to the RRT. Currently, utilisation and outcomes of tiered RRTs remain poorly described. METHODS A prospective observational study of adult patients (age ≥18 years) who required RRT activations was conducted from February 2018 to December 2019. RESULTS There were 951 consecutive RRT activations from 869 patients and 76.0% patients had a National Early Warning Score (NEWS) ≥5 at the time of RRT activation. The majority (79.8%) of patients required RRT interventions that included endotracheal intubation (12.7%), point-of-care ultrasound (17.0%), discussing goals of care (14.7%) and intensive care unit (ICU) admission (24.2%). Approximately 1 in 3 (36.6%) patients died during hospitalisation or within 30 days of RRT activation. In multivariate analysis, age ≥65 years, NEWS ≥7, ICU admission, longer hospitalisation days at RRT activation, Eastern Cooperative Oncology Group performance scores ≥3 (OR [odds ratio] 2.24, 95% CI [confidence interval] 1.45-3.46), metastatic cancer (OR 2.64, 95% CI 1.71-4.08) and haematological cancer (OR 2.78, 95% CI 1.84-4.19) were independently associated with mortality. CONCLUSION Critical care interventions and escalation of care are common with second-tier RRTs. This supports the need for dedicated teams with specialised critical care services. Poor functional status, metastatic and haematological cancer are significantly associated with mortality, independent of age, NEWS and ICU admission. These factors should be considered during triage and goals of care discussion.
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Affiliation(s)
- Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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Winterbottom FA, Webre H. Rapid Response System Restructure: Focus on Prevention and Early Intervention. Crit Care Nurs Q 2021; 44:424-430. [PMID: 34437321 DOI: 10.1097/cnq.0000000000000379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article describes the staged restructure of the rapid response program into a dedicated 24/7 proactive rapid response system in a quaternary academic medical center in the southern United States. Rapid response nurses (RRNs) completed clinical leadership training on artificial intelligence, electronic risk stratification alerts, expert nurse rounding, emergency response, teamwork, closed-loop communication, and outcome measurement. The program goal was to reduce preventable deaths and resuscitation events outside the intensive care unit (ICU). Program outcomes between 2017 and 2019 included a 65% decrease in cardiac arrests outside the ICU, a 27% decrease of cardiac arrests inside the ICU, a 4.7% decrease in patients admitted to the ICU from inpatient beds, and a 27% reduction in the risk-adjusted mortality index for patients with expert proactive rounding encounters. Hospital peer group ranking on the Hospital Survey of Patient Safety improved in the areas of events reported, actions promoting patient safety, and continuous improvement suggesting a positive cultural shift. Implementation of a dedicated 24/7 RRN model of care integrating proactive rounding, technology, and ART can improve outcomes for patients and staff.
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Affiliation(s)
- Fiona A Winterbottom
- Critical Care Medicine (Dr Winterbottom) and Cardiac Medical Intensive Care Unit and Rapid Response (Ms Webre), Ochsner Medical Center, New Orleans, Louisiana
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Kim HJ, Jeon K, Kang BJ, Ahn JJ, Hong SB, Lee DH, Moon JY, Kim JS, Park J, Cho JH, Lee SM, Lee YJ. Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study. Respir Res 2021; 22:236. [PMID: 34446017 PMCID: PMC8394678 DOI: 10.1186/s12931-021-01824-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS. METHODS Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock. RESULTS After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75). CONCLUSIONS The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Ju Kang
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jong-Joon Ahn
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Jung Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jisoo Park
- Division of Pulmonology, Department of Internal Medicine, CHA University, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Jae Hwa Cho
- Division of Pulmonology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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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] [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.
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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
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Review of 20 Years of Continuous Quality Improvement of a Rapid Response System, at Four Institutions, to Identify Key Process Responsible for Its Success. Crit Care Explor 2021; 3:e0448. [PMID: 34396140 PMCID: PMC8357252 DOI: 10.1097/cce.0000000000000448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND: Rapid response systems are still in development, and their practices vary significantly from hospital to hospital. Although the literature supports their value and a four-arm structure, it is unclear within these arms (efferent, afferent, quality assurance, administrative arms) which processes and procedures are responsible for their efficacy. This article reports the evolution of a rapid response system over many years at four institutions and considers the key elements that likely contribute to its efficacy. METHODS: Retrospective evaluation of the processes, procedures, and outcomes of an adult general-ward rapid response system as it evolved, at four nonaffiliated community medical centers, spanning 2 decades of development and refinement. System and patient outcomes examined included the number of rapid response system activations/1,000 admissions, time to rapid response system activation and/or interventions, cardiac arrest rate, and/or hospital mortality over time. RESULTS: In the three hospitals that collected control and intervention data, there was significant increase in earlier and total number of rapid response system activations, more rapid administration of protocolized interventions, and associated decreases in cardiac arrest rate and hospital mortality of the respective population. In all four institutions three important common rapid response system processes were identified: early identification of at-risk patient using a novel focused bedside-assessment tool, leading to classification of the pathophysiologic process, linked to goal-directed intervention protocols. CONCLUSIONS: Our review of a rapid response system that evolved over 20 years across four unrelated institutions revealed a common care pathway that coupled a focused bedside at-risk patient assessment leading to pathophysiologic classification of the patients decline linked to goal-directed intervention protocols. We speculate that the improved outcomes observed are a consequence of effective implementation and coupling of these three processes, as they are important in identifying and treating early the signs of tissue hypoxia and hypoperfusion, which remain the basic pathophysiologic threats of acute deterioration.
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Byrne G, Ennis S, Barnes AM, Morrison P, Connors S, Quirke MB. Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews. Crit Care Nurse 2021; 41:e1-e10. [PMID: 34333613 DOI: 10.4037/ccn2021407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making. OBJECTIVES To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews. METHODS Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4). RESULTS Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review. CONCLUSIONS Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.
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Affiliation(s)
- Gobnait Byrne
- Gobnait Byrne is Director, Trinity Centre for Practice and Health-care Innovation, and an assistant professor, School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Shauna Ennis
- Shauna Ennis is Head of Learning and Development, Tallaght University Hospital, Dublin, Ireland
| | - Anne Marie Barnes
- Anne Marie Barnes is the Emergency Response System Coordinator, Tallaght University Hospital
| | - Patricia Morrison
- Patricia Morrison is the Assistant Director of Nursing and Lead Assistant Director of Nursing for the Perioperative Directorate, Tallaght University Hospital
| | - Siobhan Connors
- Siobhan Connors is a critical care outreach nurse, Tallaght University Hospital
| | - Mary B Quirke
- Mary B. Quirke is a research fellow, Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin
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Loisa E, Hoppu S, Hytönen S, Tirkkonen J. Rapid response team nurses' attitudes and barriers to the rapid response system: A multicentre survey. Acta Anaesthesiol Scand 2021; 65:695-701. [PMID: 33400259 DOI: 10.1111/aas.13779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 10/12/2020] [Accepted: 12/28/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite wide implementation of rapid response teams (RRTs), no published data exist on RRT nurses' attitudes and barriers to the rapid response system (RRS). METHODS We piloted a 5-point Likert-type scale questionnaire among all Finnish university hospitals' RRT nurses with optional open-ended comments. The impact of more frequent RRT participation was further investigated. RESULTS The response rate was 46% (n = 176/379, 34%-93% between hospitals). The respondents median experience on a RRT was three years (0.8-5) and median participation was two (1-5) RRT activations per month. Over 90% of the RRT nurses felt that RRS prevented cardiac arrests and improved patient safety. Nurses with five or more RRT activations/month believed their critical care skills had improved through these duties (94% vs 71%, P = .001), considered their RRT work meaningful (94% vs 76%, P = .005) and wanted to continue as RRT nurses (91% vs 74%, P = .015) more often than nurses with less than five RRT activations/month. In addition to the infrequent RRT participation, further negative experiences with RRS among the RRT nurses included feeling overworked (68%) or undercompensated (94%) for the RRT duties and conflicts between RRT and ward doctors (25%). CONCLUSION RRT nurses consider their work important and believe it fosters improved critical care skills; these beliefs are emphasized among those with more frequent RRT participation. Infrequent RRT participation, feeling overworked and/or undercompensated and conflicts between RRT and ward doctors may present barriers for successful RRS among RRT nurses.
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Affiliation(s)
- Eetu Loisa
- Medical School Faculty of Medicine and Life Sciences University of Tampere Tampere Finland
- Department of Emergency, Anaesthesia and Pain Medicine and Emergency Medical Service Tampere University Hospital Tampere Finland
| | - Sanna Hoppu
- Department of Emergency, Anaesthesia and Pain Medicine and Emergency Medical Service Tampere University Hospital Tampere Finland
| | | | - Joonas Tirkkonen
- Department of Emergency, Anaesthesia and Pain Medicine and Emergency Medical Service Tampere University Hospital Tampere Finland
- Department of Intensive Care Medicine Tampere University Hospital Tampere Finland
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Viana MV, Nunes DSL, Teixeira C, Vieira SRR, Torres G, Brauner JS, Müller H, Butelli TCD, Boniatti MM. Changes in cardiac arrest profiles after the implementation of a Rapid Response Team. Rev Bras Ter Intensiva 2021; 33:96-101. [PMID: 33886858 PMCID: PMC8075345 DOI: 10.5935/0103-507x.20210010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/28/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate changes in the characteristics of in-hospital cardiac arrest after the implementation of a Rapid Response Team. METHODS This was a prospective observational study of in-hospital cardiac arrest that occurred from January 2013 to December 2017. The exclusion criterion was in-hospital cardiac arrest in the intensive care unit, emergency room or operating room. The Rapid Response Team was implemented in July 2014 in the study hospital. Patients were classified into two groups: a Pre-Rapid Response Team (in-hospital cardiac arrest before Rapid Response Team implementation) and a Post-Rapid Response Team (in-hospital cardiac arrest after Rapid Response Team implementation). Patients were followed until hospital discharge or death. RESULTS We had a total of 308 cardiac arrests (64.6 ± 15.2 years, 60.3% men, 13.9% with initial shockable rhythm). There was a decrease from 4.2 to 2.5 in-hospital cardiac arrest/1000 admissions after implementation of the Rapid Response Team, and we had approximately 124 calls/1000 admissions. Pre-Rapid Response Team cardiac arrest was associated with more hypoxia (29.4 versus 14.3%; p = 0.006) and an altered respiratory rate (14.7 versus 4.2%; p = 0.004) compared with post-Rapid Response Team cardiac arrest. Cardiac arrest due to hypoxia was more common before Rapid Response Team implementation (61.2 versus 38.1%, p < 0.001). In multivariate analysis, return of spontaneous circulation was associated with shockable rhythm (OR 2.97; IC95% 1.04 - 8.43) and witnessed cardiac arrest (OR 2.52; IC95% 1.39 - 4.59) but not with Rapid Response Team implementation (OR 1.40; IC95% 0.70 - 2.81) or premonitory signs (OR 0.71; IC95% 0.39 - 1.28). In multivariate analysis, in-hospital mortality was associated with non-shockable rhythm (OR 5.34; IC95% 2.28 - 12.53) and age (OR 1.03; IC95% 1.01 - 1.05) but not with Rapid Response Team implementation (OR 0.89; IC95% 0.40 - 2.02). CONCLUSION Even though Rapid Response Team implementation is associated with a reduction in in-hospital cardiac arrest, it was not associated with the mortality of in-hospital cardiac arrest victims. A significant decrease in cardiac arrests due to respiratory causes was noted after Rapid Response Team implementation.
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Affiliation(s)
- Marina Verçoza Viana
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Grupo de Trabalho em Ressuscitação Cardiopulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Diego Silva Leite Nunes
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cassiano Teixeira
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Silvia Regina Rios Vieira
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Grupo de Trabalho em Ressuscitação Cardiopulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Grazziela Torres
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Grupo de Trabalho em Ressuscitação Cardiopulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Janete Salles Brauner
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Grupo de Trabalho em Ressuscitação Cardiopulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Helena Müller
- Grupo de Trabalho em Ressuscitação Cardiopulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Thais Crivellaro Dutra Butelli
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Marcio Manozzo Boniatti
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Chung CC, Chiu WT, Huang YH, Chan L, Hong CT, Chiu HW. Identifying prognostic factors and developing accurate outcome predictions for in-hospital cardiac arrest by using artificial neural networks. J Neurol Sci 2021; 425:117445. [PMID: 33878655 DOI: 10.1016/j.jns.2021.117445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/25/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Accurate estimation of neurological outcomes after in-hospital cardiac arrest (IHCA) provides crucial information for clinical management. This study used artificial neural networks (ANNs) to determine the prognostic factors and develop prediction models for IHCA based on immediate preresuscitation parameters. METHODS The derived cohort comprised 796 patients with IHCA between 2006 and 2014. We applied ANNs to develop prediction models and evaluated the significance of each parameter associated with favorable neurological outcomes. An independent dataset of 108 IHCA patients receiving targeted temperature management was used to validate the identified parameters. The generalizability of the models was assessed through fivefold cross-validation. The performance of the models was assessed using the area under the curve (AUC). RESULTS ANN model 1, based on 19 baseline parameters, and model 2, based on 11 prearrest parameters, achieved validation AUCs of 0.978 and 0.947, respectively. ANN model 3 based on 30 baseline and prearrest parameters achieved an AUC of 0.997. The key factors associated with favorable outcomes were the duration of cardiopulmonary resuscitation; initial cardiac arrest rhythm; arrest location; and whether the patient had a malignant disease, pneumonia, and respiratory insufficiency. On the basis of these parameters, the validation performance of the ANN models achieved an AUC of 0.906 for IHCA patients who received targeted temperature management. CONCLUSION The ANN models achieved highly accurate and reliable performance for predicting the neurological outcomes of successfully resuscitated patients with IHCA. These models can be of significant clinical value in assisting with decision-making, especially regarding optimal postresuscitation strategies.
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Affiliation(s)
- Chen-Chih Chung
- Department of Neurology, Taipei Medical University - Shuang Ho Hospital, New Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Wei-Ting Chiu
- Department of Neurology, Taipei Medical University - Shuang Ho Hospital, New Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yao-Hsien Huang
- Department of Neurology, Taipei Medical University - Shuang Ho Hospital, New Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; College of Public Health, Taipei Medical University, Taiwan
| | - Lung Chan
- Department of Neurology, Taipei Medical University - Shuang Ho Hospital, New Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Taipei Medical University - Shuang Ho Hospital, New Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan.
| | - Hung-Wen Chiu
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan; Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
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Duffy CC, Atkins JH. Characteristics of intraoperative emergencies and perspectives on operating room emergency responses in a large Academic Medical Center: A case series. J Clin Anesth 2021; 72:110264. [PMID: 33819829 DOI: 10.1016/j.jclinane.2021.110264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Caoimhe C Duffy
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Division of Perioperative & Procedural Services, Hospital of the University of Pennsylvania, Philadelphia, USA.
| | - Joshua H Atkins
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Hirakawa E, Ibara S, Yoshihara H, Kamitomo M, Kodaira Y, Kibe M, Ishihara C, Naito Y, Yamamoto M, Yamamoto T, Takayama T, Kurimoto T, Mikami Y, Ohashi H. Safety, speed, and effectiveness of air transportation for neonates. Pediatr Int 2021; 63:415-422. [PMID: 32688450 DOI: 10.1111/ped.14401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Japan, 44.3% of neonates are delivered in private clinics without an attending pediatrician. Obstetricians in the clinics must resuscitate asphyxiated neonates in unstable condition, such as respiratory failure, and they are frequently transferred to tertiary perinatal medical centers. There has been no study comparing the physiological status and prognosis of neonates transported by ambulance with those transported by helicopter. METHODS Medical and transport records were used to compare the physiological status of neonates transported to Kagoshima City Hospital by land and those transported by air between January 1, 2013, and December 31, 2017. RESULTS Data from 425 neonates transferred by land and 143 by air were analyzed. There were no significant differences between the two groups in mean gestational age, mean birthweight, fetal blood pH, Apgar score, or the Score for Neonatal Acute Physiology with Perinatal Extension-II (SNAPPE-II) on arrival to the tertiary center (16.3 ± 15.4 [95% confidence interval (CI): 13.2-17.7] vs 16.4 ± 15.4 [95% CI: 13.9-19.0], respectively; P = 0.999); both groups had SNAPPE-II score 10-19, indicating no difference in mortality risk. The times to starting first aid and to admission to the intensive care unit were significantly reduced in neonates transported by air than by land. In subgroup analysis of patients of a gestational age ≤28 weeks, all cases of severe intraventricular hemorrhage (IVH) were observed in the land transportation group. CONCLUSIONS Neonatal transportation by air is as safe as land transportation, and time to first aid and intensive care are significantly reduced by transportation by air than by land. Air transport could also contribute to the prevention of IVH in neonatal transportation.
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Affiliation(s)
- Eiji Hirakawa
- Department of Neonatology, Nagasaki Harbor Medical Center, Nagasaki, Japan.,Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Satoshi Ibara
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Hideaki Yoshihara
- Department of, Emergency Medicine, Kagoshima City Hospital, Kagoshima, Japan
| | - Masato Kamitomo
- Department of, Obstetrics, Kagoshima City Hospital, Kagoshima, Japan
| | - Yuichi Kodaira
- Department of Obstetrics, Funabashi Central Hospital, Chiba, Japan
| | - Masaya Kibe
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Chie Ishihara
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Yoshiki Naito
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Masakatsu Yamamoto
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Tsuyoshi Yamamoto
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Tatsu Takayama
- Department of Neonatology, Nagasaki Harbor Medical Center, Nagasaki, Japan.,Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Tomonori Kurimoto
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Yuta Mikami
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Hiroshi Ohashi
- Departments of, Department of, Neonatology, Kagoshima City Hospital, Kagoshima, Japan
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Barriers and enablers of recognition and response to deteriorating patients in the acute hospital setting: A theory-driven interview study using the Theoretical Domains Framework. J Adv Nurs 2021; 77:2831-2844. [PMID: 33739478 DOI: 10.1111/jan.14830] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/02/2021] [Accepted: 03/05/2021] [Indexed: 12/01/2022]
Abstract
AIM To explore barriers and enablers of recognition and response to signs of patient deterioration by nursing staff in an acute hospital. DESIGN A theory-driven interview study underpinned by the Theoretical Domains Framework of behaviour change. METHODS Between 07/01/2019 and 18/12/2019 a purposive sample of registered nurses and healthcare assistants was recruited to participate in a semi-structured (audio-recorded) interview, to explore the determinants of seven specified behaviours of the afferent limb. Anonymised transcripts were deductively coded (using the 14 Theoretical Domains Framework domains as coding categories) and then extracts within each domain were inductively analysed to synthesise belief statements and themes. Prioritisation criteria from published literature were applied. RESULTS Thirty-two semi-structured interviews were conducted. From 1,888 quotes, 184 belief statements and 66 themes were synthesised. One hundred and forty-six belief statements, represented by 58 themes, met prioritisation criteria. Nine domains of the Theoretical Domains Framework were of high importance: Knowledge; Social, Professional Role and Identity; Beliefs about Consequences; Reinforcement; Intentions; Goals; Memory, Attention and Decision Processes; Environment, Context and Resources and Social Influences. CONCLUSIONS Barriers and enablers most likely to impact on nursing staff afferent limb behaviour were identified in nine domains of the Theoretical Domains Framework.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London, London, UK.,Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Judith Dyson
- School of Health Sciences, Birmingham City University, Birmingham, UK
| | - Jillian Hartin
- Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City University of London, London, UK.,School of Nursing and Midwifery, Griffith University, Nathan, Qld., Australia
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Modifications to medical emergency team activation criteria and implications for patient safety: A point prevalence study. Aust Crit Care 2021; 34:580-586. [PMID: 33712324 DOI: 10.1016/j.aucc.2021.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 12/16/2020] [Accepted: 01/28/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood. OBJECTIVES The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria. METHODS This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death. RESULTS Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications. CONCLUSIONS In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes.
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Abstract
Objective The aim of this systematic review was to synthesize the evidence on the impact of rapid response teams (RRTs) on failure to rescue events. Methods Systematic searches were conducted using CINAHL, MEDLINE, PsychINFO, and Cochrane, for articles published from 2008 to 2018. English-language, peer-reviewed articles reporting the impact of RRTs on failure to rescue events, including hospital mortality and in-hospital cardiac arrest events, were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Results Ten articles were identified for inclusion: 3 meta-analyses, 3 systematic reviews, and 4 single studies. The systematic reviews and meta-analyses were of moderate-to-high quality, limited by the methodological quality of the included individual studies. The single studies were both observational and investigational in design. Patient outcomes included hospital mortality (8 studies), in-hospital cardiac arrests (9 studies), and intensive care unit (ICU) transfer rates (5 studies). There was variation in the composition of RRTs, and 4 studies conducted subanalyses to examine the effect of physician inclusion on patient outcomes. Conclusions There is moderate evidence linking the implementation of RRTs with decreased mortality and non-ICU cardiac arrest rates. Results linking RRT to ICU transfer rates are inconclusive and challenging to interpret. There is some evidence to support the use of physician-led teams, although evaluation of team composition was variable. Lastly, the benefits of RRTs may take a significant period after implementation to be realized, owing to the need for change in safety culture.
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81
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Covino M, De Matteis G, Burzo ML, Santoro M, Fuorlo M, Sabia L, Sandroni C, Gasbarrini A, Franceschi F, Gambassi G. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and prognosis of hypertensive patients hospitalised with COVID-19. Intern Med J 2021; 50:1483-1491. [PMID: 33022124 PMCID: PMC7675354 DOI: 10.1111/imj.15078] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Among hypertensive patients, the association between treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) and the clinical severity of COVID-19, remains uncertain. AIMS To determine whether hypertensive patients hospitalised with COVID-19 are at risk of worse outcomes if on treatment with ACEI or ARB compared to other anti-hypertensive medications. METHODS This is a retrospective study conducted at a single academic medical centre (Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy) from 1 to 31 March 2020. We compared patients on treatment with an ACEI/ARB (ACEI/ARB group) to patients receiving other anti-hypertensive medications (No-ACEI/ARB group). The end-points of the study were the all-cause in-hospital death and the combination of in-hospital death or need for intensive care unit (ICU) admission. RESULTS The sample included 166 COVID-19 patients; median age was 74 years and 109 (66%) were men. Overall, 111 (67%) patients were taking an ACEI or ARB. Twenty-nine (17%) patients died during the hospital stay, and 51 (31%) met the combined end-point. After adjustment for comorbidities, age and degree of severity at the presentation, ACEI or ARB treatment was an independent predictor neither of in-hospital death nor of the combination of in-hospital death/need for ICU. No differences were documented between treatment with ACEI compared to ARB. CONCLUSIONS Among hypertensive patients hospitalised for COVID-19, treatment with ACEI or ARB is not associated with an increased risk of in-hospital death.
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Affiliation(s)
- Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe De Matteis
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Livia Burzo
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Santoro
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mariella Fuorlo
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Sabia
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Sandroni
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Giovanni Gambassi
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
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Kang BJ, Hong SB, Jeon K, Lee SM, Lee DH, Moon JY, Lee YJ, Kim JS, Park J, Ahn JJ. Rapid Response System Should Be Enhanced at Non-general Ward Locations: a Retrospective Multicenter Cohort Study in Korea. J Korean Med Sci 2021; 36:e7. [PMID: 33429471 PMCID: PMC7801145 DOI: 10.3346/jkms.2021.36.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND A rapid response system (RRS) contributes to the safety of hospitalized patients. Clinical deterioration may occur in the general ward (GW) or in non-GW locations such as radiology or dialysis units. However, there are few studies regarding RRS activation in non-GW locations. This study aimed to compare the clinical characteristics and outcomes of patients with RRS activation in non-GW locations and in the GW. METHODS From January 2016 to December 2017, all patients requiring RRS activation in nine South Korean hospitals were retrospectively enrolled and classified according to RRS activation location: GW vs non-GW RRS activations. RESULTS In total, 12,793 patients were enrolled; 222 (1.7%) were non-GW RRS activations. There were more instances of shock (11.6% vs. 18.5%) and cardiac arrest (2.7% vs. 22.5%) in non-GW RRS activation patients. These patients also had a lower oxygen saturation (92.6% ± 8.6% vs. 88.7% ± 14.3%, P < 0.001) and a higher National Early Warning Score 2 (7.5 ± 3.4 vs. 8.9 ± 3.8, P < 0.001) than GW RRS activation patients. Although non-GW RRS activation patients received more intubation (odds ratio [OR], 3.135; P < 0.001), advanced cardiovascular life support (OR, 3.912; P < 0.001), and intensive care unit transfer (OR, 2.502; P < 0.001), their hospital mortality (hazard ratio, 0.630; P = 0.013) was lower than GW RRS activation patients upon multivariate analysis. CONCLUSION Considering that there were more critically ill but recoverable cases in non-GW locations, active RRS involvement should be required in such locations.
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Affiliation(s)
- Byung Ju Kang
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sang Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jisoo Park
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, CHA University, CHA Bundang Medical Center, Seongnam, Korea
| | - Jong Joon Ahn
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
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End-of-life care and intensive care unit clinician involvement in a private acute care hospital: A retrospective descriptive medical record audit. Aust Crit Care 2020; 34:452-459. [PMID: 33358274 DOI: 10.1016/j.aucc.2020.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION More Australians die in the hospital than in any other setting. This study aimed to (i) evaluate the quality of end-of-life (EOL) care in the hospital against an Australian National Standard, (ii) describe the characteristics of intensive care unit (ICU) clinician involvement in EOL care, and (iii) explore the demographic and clinical factors associated with quality of EOL care. METHOD A retrospective descriptive medical record audit was conducted on 297 adult inpatients who died in 2017 in a private acute care hospital in Melbourne, Australia. Data collected related to 20 'Processes of Care', considered to contribute to the quality of EOL care. The decedent sample was separated into three cohorts as per ICU clinician involvement. RESULTS The median age of the sample was 81 (25th-75th percentile = 72-88) years. The median tally for EOL care quality was 16 (25th-75th percentile = 13-17) of 20 care processes. ICU clinicians were involved in 65.7% (n = 195) of cases; however, contact with the ICU outreach team or an ICU admission during the final inpatient stay was negatively associated with quality of EOL care (coefficient = -1.51 and -2.07, respectively). Longer length of stay was positively associated with EOL care (coefficient = .05). Specialist palliative care was involved in 53% of cases, but this was less likely for those admitted to the ICU (p < .001). Evidence of social support, bereavement follow-up, and religious support were low across all cohorts. CONCLUSION Statistically significant differences in the quality of EOL care and a negative association between ICU involvement and EOL care quality suggest opportunities for ICU outreach clinicians to facilitate discussion of care goals and the appropriateness of ICU admission. Advocating for inclusion of specialist palliative care and nonclinical support personnel in EOL care has merit. Future research is necessary to investigate the relationship between ICU intervention and EOL care quality.
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Mankidy B, Howard C, Morgan CK, Valluri KA, Giacomino B, Marfil E, Voore P, Ababio Y, Razjouyan J, Naik AD, Herlihy JP. Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards. PLoS One 2020; 15:e0241816. [PMID: 33259488 PMCID: PMC7707602 DOI: 10.1371/journal.pone.0241816] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose This study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates. Methods In this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team. Results Hospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED. Conclusion Implementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.
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Affiliation(s)
- Babith Mankidy
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
| | - Christopher Howard
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Christopher K. Morgan
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Kartik A. Valluri
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Bria Giacomino
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Eddie Marfil
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
| | - Prakruthi Voore
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
| | - Yao Ababio
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
| | - Javad Razjouyan
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Veterans Affairs Health Services Research & Development, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
| | - Aanand D. Naik
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Veterans Affairs Health Services Research & Development, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
| | - James P. Herlihy
- Department of Medicine, Baylor College of Medicine, Baylor St Luke’s Medical Center, Houston, Texas, United States of America
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
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Covino M, Sandroni C, Santoro M, Sabia L, Simeoni B, Bocci MG, Ojetti V, Candelli M, Antonelli M, Gasbarrini A, Franceschi F. Predicting intensive care unit admission and death for COVID-19 patients in the emergency department using early warning scores. Resuscitation 2020; 156:84-91. [PMID: 32918985 PMCID: PMC7480278 DOI: 10.1016/j.resuscitation.2020.08.124] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
AIMS To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED). METHODS In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated. RESULTS We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes. CONCLUSION In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration.
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Affiliation(s)
- Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Michele Santoro
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Luca Sabia
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Maria Grazia Bocci
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Veronica Ojetti
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Marcello Candelli
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Institute of Internal Medicine and Gastroenterology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Institute of Emergency Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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86
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The effect of system performance improvement on patients with cardiac arrest: A systematic review. Resuscitation 2020; 157:156-165. [PMID: 33129915 DOI: 10.1016/j.resuscitation.2020.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/20/2020] [Accepted: 10/19/2020] [Indexed: 12/19/2022]
Abstract
AIM The aim of our review was to understand the effect of interventions to improve system-level performance on the clinical outcomes of patients with cardiac arrest. METHODS We searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomised controlled trials and non-randomised studies published before July 21, 2020 reporting systems interventions to improve outcomes. Characteristics, study design, evaluation methods and outcomes of included studies were extracted. (PROSPERO registration CRD42020161882). RESULTS One cluster randomised trial and 26 non-randomised studies were included. There were 18 studies focusing on interventions for patients with out-of-hospital cardiac arrest and 9 studies for patients with in-hospital cardiac arrest. Interventions included implementation of a bundle of care strategy, evaluation of cardiopulmonary resuscitation (CPR) quality with feedback/debriefing, data surveillance, and CPR training programs. Although improved survival with favorable neurologic outcome at discharge after the implementation of specific interventions was found in 13 studies, improved survival to hospital discharge in 14 studies and improved survival to admission in 3 studies, there were still 7 studies showing no significant improvement of clinical outcomes after interventions. CONCLUSION Although only moderate to very low certainty of evidence exists to support the effect of system-level performance improvement on the clinical outcomes of patients, we recommend that organisations or communities evaluate their performance and target key areas with the goal to improve performance because of no known risks and the potential for a large beneficial effect.
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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: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [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.
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88
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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, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djärv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A188-A239. [PMID: 33098918 DOI: 10.1016/j.resuscitation.2020.09.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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.
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89
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Artificial intelligence algorithm for predicting cardiac arrest using electrocardiography. Scand J Trauma Resusc Emerg Med 2020; 28:98. [PMID: 33023615 PMCID: PMC7541213 DOI: 10.1186/s13049-020-00791-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In-hospital cardiac arrest is a major burden in health care. Although several track-and-trigger systems are used to predict cardiac arrest, they often have unsatisfactory performances. We hypothesized that a deep-learning-based artificial intelligence algorithm (DLA) could effectively predict cardiac arrest using electrocardiography (ECG). We developed and validated a DLA for predicting cardiac arrest using ECG. METHODS We conducted a retrospective study that included 47,505 ECGs of 25,672 adult patients admitted to two hospitals, who underwent at least one ECG from October 2016 to September 2019. The endpoint was occurrence of cardiac arrest within 24 h from ECG. Using subgroup analyses in patients who were initially classified as non-event, we confirmed the delayed occurrence of cardiac arrest and unexpected intensive care unit transfer over 14 days. RESULTS We used 32,294 ECGs of 10,461 patients and 4483 ECGs of 4483 patients from a hospital were used as development and internal validation data, respectively. Additionally, 10,728 ECGs of 10,728 patients from another hospital were used as external validation data, which confirmed the robustness of the developed DLA. During internal and external validation, the areas under the receiver operating characteristic curves of the DLA in predicting cardiac arrest within 24 h were 0.913 and 0.948, respectively. The high risk group of the DLA showed a significantly higher hazard for delayed cardiac arrest (5.74% vs. 0.33%, P < 0.001) and unexpected intensive care unit transfer (4.23% vs. 0.82%, P < 0.001). A sensitivity map of the DLA displayed the ECG regions used to predict cardiac arrest, with the DLA focused most on the QRS complex. CONCLUSIONS Our DLA successfully predicted cardiac arrest using diverse formats of ECG. The results indicate that cardiac arrest could be screened and predicted not only with a conventional 12-lead ECG, but also with a single-lead ECG using a wearable device that employs our DLA.
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90
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography. J Adv Nurs 2020; 76:3548-3562. [PMID: 32996620 DOI: 10.1111/jan.14551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/09/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022]
Abstract
AIM To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. DESIGN Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. METHODS An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. RESULTS Observation was conducted for 300 hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. CONCLUSION Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. IMPACT Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Judith Dyson
- School of Health Sciences, City University of London, London, UK
| | - Jillian Hartin
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City University of London, London, UK.,School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia
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Hessulf F, Herlitz J, Rawshani A, Aune S, Israelsson J, Södersved-Källestedt ML, Nordberg P, Lundgren P, Engdahl J. Adherence to guidelines is associated with improved survival following in-hospital cardiac arrest. Resuscitation 2020; 155:13-21. [PMID: 32707144 DOI: 10.1016/j.resuscitation.2020.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most resuscitation guidelines have recommendations regarding maximum delay times from collapse to calling for the rescue team and initiation of treatment following cardiac arrest. The aim of the study was to investigate the association between adherence to guidelines for cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest (IHCA) and survival with a focus on delay to treatment. METHODS We used the Swedish Registry for CPR to study 3212 patients with a shockable rhythm and 9113 patients with non-shockable rhythm from January 1, 2008 to December 31, 2017. Adult patients older than or equal to 18 years with a witnessed IHCA where resuscitation was initiated were included. We assessed trends in adherence to guidelines and their associations with 30-day survival and neurological function. Adherence to guidelines was defined as follows: time from collapse to calling for the rescue team and CPR within 1 min for non-shockable rhythms. For shockable rhythms, adherence was defined as the time from collapse to calling for the rescue team and CPR within 1 min and defibrillation within 3 min. RESULTS In patients with a shockable rhythm, the 30-day survival for those treated according to guidelines was 66.1%, as compared to 46.5% among those not treated according to guidelines on one or more parameters, adjusted odds ratio 1.84 (95% CI 1.52-2.22). Among patients with a non-shockable rhythm the 30-day survival for those treated according to guidelines was 22.8%, as compared to 16.0% among those not treated according to guidelines on one or more parameters, adjusted odds ratio 1.43 (95% CI 1.24-1.65). Neurological function (cerebral performance category 1-2) among survivors was better among patients treated in accordance with guidelines for both shockable (95.7% vs 91.1%, <0.001) and non-shockable rhythms (91.0% vs 85.5%, p < 0.008). Adherence to the Swedish guidelines for CPR increased slightly 2008-2017. CONCLUSIONS Adherence to guidelines was associated with increased probability of survival and improved neurological function in patients with a shockable and non-shockable rhythm, respectively. Increased adherence to guidelines could increase cardiac arrest survival.
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Affiliation(s)
- Fredrik Hessulf
- Department of Anaesthesiology and Intensive Care Medicine, Halland Hospital, SE-301 85 Halmstad, Sweden; Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; PreHospen - Centre of Prehospital Research; Academy of Caring Science, Welfare and Work Life, University of Borås, SE-501 90 Borås, Sweden
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Solveig Aune
- Unit for EMS-coordination, Provider Governance and Coordination, Head Office, Region Västra Götaland, Sweden
| | - Johan Israelsson
- Department of Internal Medicine, Division of Cardiology, Kalmar County Hospital, Kalmar, Sweden; Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden; Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden
| | | | - Per Nordberg
- Karolinska Institute, Institution for Clinical Research and Education, South Hospital, Stockholm, Sweden
| | - Peter Lundgren
- Department of Anaesthesiology and Intensive Care Medicine, Halland Hospital, SE-301 85 Halmstad, Sweden; Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Engdahl
- Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
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Kurita T, Nakada TA, Kawaguchi R, Fujitani S, Atagi K, Naito T, Arai M, Arimoto H, Masuyama T, Oda S. Impact of increased calls to rapid response systems on unplanned ICU admission. Am J Emerg Med 2020; 38:1327-1331. [DOI: 10.1016/j.ajem.2019.10.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/18/2019] [Accepted: 10/20/2019] [Indexed: 11/26/2022] Open
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Galazzi A, Bonasera Vincenti NM, Giusti GD, Brioni M, Adamini I, Laquintana D, Ristagno G, Grasselli G. The Medical Emergency Team in Italy: an overview of in-hospital emergencies response. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:9-18. [PMID: 32573502 PMCID: PMC7975838 DOI: 10.23750/abm.v91i6-s.9878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/01/2020] [Indexed: 11/23/2022]
Abstract
Background and aim: Medical Emergency Team (MET), implemented in many hospitals worldwide, aims to improve the safety of in-hospital patients whose condition is deteriorating. This study describes MET presence and organization in the Italian National Healthcare System Hospitals. Methods: A national survey with an online questionnaire was performed. The questionnaire, created ad hoc, was sent by e-mail to the nursing coordinators and MET referents of the Hospitals affiliated to the Italian National Healthcare System with an Anesthesia and Intensive Care service. Results: One hundred-ninety-seven hospitals were interviewed (36.2% of the whole national network). A dedicated MET, composed at least by an intensivist and a nurse, was present only in 118 cases (59.9%). The team was composed by a non-dedicated staff (67.8% of doctors, 69.5% of nurses) and a minimum shared standard of education for the nurse component was absent. One third of the estimated hospitals did not use a warning score for emergency call activation. Discussion and conclusion: This survey showed a heterogenous and often lacking organization of in-hospital emergency management in Italy. MET system needs to be implemented in terms of presence in the Italian hospitals, and standardized for personnel structure and training, and equipment availability. A broader study is necessary to compare our data with those of other European Countries to better identify the specific areas which need to be improved more promptly. (www.actabiomedica.it)
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Vital sign abnormalities as predictors of clinical deterioration in subacute care patients: A prospective case-time-control study. Int J Nurs Stud 2020; 108:103612. [PMID: 32473397 DOI: 10.1016/j.ijnurstu.2020.103612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/03/2020] [Accepted: 04/14/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Emergency interhospital transfers from inpatient subacute care to acute care occur in 8% to 17.4% of admitted patients and are associated with high rates of acute care readmission and in-hospital mortality. Serious adverse events in subacute care (rapid response team or cardiac arrest team calls) and increased nursing surveillance are the strongest known predictors of emergency interhospital transfer from subacute to acute care hospitals. However, the epidemiology of clinical deterioration across sectors of care, and specifically in subacute care is not well understood. OBJECTIVES To explore the trajectory of clinical deterioration in patients who did and did not have an emergency interhospital transfer from subacute to acute care; and develop an internally validated predictive model to identify the role of vital sign abnormalities in predicting these emergency interhospital transfers. DESIGN This prospective, exploratory cohort study is a subanalysis of data derived from a larger case-time-control study. SETTING Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services' acute care hospitals. PARTICIPANTS All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management unit to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded. METHODS Study data were collected between 22 August 2015 and 30 October 2016 by medical record audit. The Cochran-Mantel-Haenszel test and bivariate logistic regression analysis were used to compare cases with controls and to account for health service clustering effect. RESULTS Data were collected on 603 transfers (557 patients) and 1160 controls. Adjusted for health service, ≥2 vital sign abnormalities in subacute care (adjusted odds ratio=8.81, 95% confidence intervals:6.36-12.19, p<0.001) and serious adverse events during the first acute care admission (adjusted odds ratio=1.28, 95% confidence intervals:1.08-1.99, p=0.015) were the clinical factors associated with increased risk of emergency interhospital transfer. An internally validated predictive model showed that vital sign abnormalities can fairly predict emergency interhospital transfers from subacute to acute care hospitals. CONCLUSION Serious adverse events in acute care should be a key consideration in decisions about the location of subacute care delivery. During subacute care, 15.7% of cases had vital signs fulfilling organisational rapid response team activation criteria, yet missed rapid response team activations were common suggesting that further consideration of the criteria and strategies to optimise recognition and response to clinical deterioration in subacute care are needed.
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Fu LH, Schwartz J, Moy A, Knaplund C, Kang MJ, Schnock KO, Garcia JP, Jia H, Dykes PC, Cato K, Albers D, Rossetti SC. Development and validation of early warning score system: A systematic literature review. J Biomed Inform 2020; 105:103410. [PMID: 32278089 PMCID: PMC7295317 DOI: 10.1016/j.jbi.2020.103410] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/19/2020] [Accepted: 03/21/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This review aims to: 1) evaluate the quality of model reporting, 2) provide an overview of methodology for developing and validating Early Warning Score Systems (EWSs) for adult patients in acute care settings, and 3) highlight the strengths and limitations of the methodologies, as well as identify future directions for EWS derivation and validation studies. METHODOLOGY A systematic search was conducted in PubMed, Cochrane Library, and CINAHL. Only peer reviewed articles and clinical guidelines regarding developing and validating EWSs for adult patients in acute care settings were included. 615 articles were extracted and reviewed by five of the authors. Selected studies were evaluated based on the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist. The studies were analyzed according to their study design, predictor selection, outcome measurement, methodology of modeling, and validation strategy. RESULTS A total of 29 articles were included in the final analysis. Twenty-six articles reported on the development and validation of a new EWS, while three reported on validation and model modification. Only eight studies met more than 75% of the items in the TRIPOD checklist. Three major techniques were utilized among the studies to inform their predictive algorithms: 1) clinical-consensus models (n = 6), 2) regression models (n = 15), and 3) tree models (n = 5). The number of predictors included in the EWSs varied from 3 to 72 with a median of seven. Twenty-eight models included vital signs, while 11 included lab data. Pulse oximetry, mental status, and other variables extracted from electronic health records (EHRs) were among other frequently used predictors. In-hospital mortality, unplanned transfer to the intensive care unit (ICU), and cardiac arrest were commonly used clinical outcomes. Twenty-eight studies conducted a form of model validation either within the study or against other widely-used EWSs. Only three studies validated their model using an external database separate from the derived database. CONCLUSION This literature review demonstrates that the characteristics of the cohort, predictors, and outcome selection, as well as the metrics for model validation, vary greatly across EWS studies. There is no consensus on the optimal strategy for developing such algorithms since data-driven models with acceptable predictive accuracy are often site-specific. A standardized checklist for clinical prediction model reporting exists, but few studies have included reporting aligned with it in their publications. Data-driven models are subjected to biases in the use of EHR data, thus it is particularly important to provide detailed study protocols and acknowledge, leverage, or reduce potential biases of the data used for EWS development to improve transparency and generalizability.
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Affiliation(s)
- Li-Heng Fu
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.
| | - Jessica Schwartz
- School of Nursing, Columbia University, New York, NY, United States
| | - Amanda Moy
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Chris Knaplund
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Min-Jeoung Kang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kumiko O Schnock
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jose P Garcia
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States
| | - Haomiao Jia
- School of Nursing, Columbia University, New York, NY, United States; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Patricia C Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kenrick Cato
- School of Nursing, Columbia University, New York, NY, United States
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; Department of Pediatrics, Section of Informatics and Data Science, University of Colorado, Aurora, CO, United States
| | - Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; School of Nursing, Columbia University, New York, NY, United States
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Skov MJ, Dynesen J, Jessen MK, Liesanth JY, Mackenhauer J, Kirkegaard H. Including oxygen supplement in the early warning score: a prediction study comparing TOKS, modified TOKS and NEWS in a cohort of emergency patients. Scand J Trauma Resusc Emerg Med 2020; 28:26. [PMID: 32272954 PMCID: PMC7147010 DOI: 10.1186/s13049-020-00720-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background Early warning scores (EWS) are widely used in emergency departments and on general wards to detect critical illness and deterioration. TOKS (“Tidlig Opsporing af Kritisk Sygdom”) is an early warning score used in Central Denmark Region to monitor hospitalized patients. The objective of this study is to investigate whether inclusion of supplement in the TOKS algorithm (modified TOKS; mTOKS), would improve the ability to predict 7-day mortality. Secondarily, we compare the discriminatory ability between TOKS, mTOKS and the National Early Warning Score (NEWS). Methods This is a prediction study including a cohort of adult patients who attended an emergency department in Central Denmark Region during a 3-month period in 2015. The discriminatory ability of TOKS, mTOKS and NEWS was evaluated by calculating the area under the receiver operating characteristics- curve (AUROC) with 7-day mortality as outcome. mTOKS was defined by adding 2 points for oxygen supplement to the normal TOKS score. Results 18.853 patients were included. AUROC for TOKS: 0,78 (95%-CI: 0,76-0,81). AUROC for mTOKS: 0,81 (95 %-CI: 0,78-0,83). AUROC for NEWS: 0,83 (95%-CI: 0,80-0,85). The predictive ability of all three early warning scores are statistically significantly different from each other (p-value < 0,01). Conclusion The discriminatory ability of TOKS improved statistically by including oxygen supplement. All models showed moderate to good discriminatory ability.
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Affiliation(s)
- Maj Juhl Skov
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Palle Juul-Jensens Boulevard 99, J103, 8200, Aarhus N, Denmark.
| | - Jacob Dynesen
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Palle Juul-Jensens Boulevard 99, J103, 8200, Aarhus N, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Palle Juul-Jensens Boulevard 99, J103, 8200, Aarhus N, Denmark.,Department of Emergency medicine, Aarhus University hospital, Aarhus, Denmark
| | - Janet Yde Liesanth
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Palle Juul-Jensens Boulevard 99, J103, 8200, Aarhus N, Denmark
| | - Julie Mackenhauer
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Palle Juul-Jensens Boulevard 99, J103, 8200, Aarhus N, Denmark.,Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Palle Juul-Jensens Boulevard 99, J103, 8200, Aarhus N, Denmark
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97
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Korach ZT, Yang J, Rossetti SC, Cato KD, Kang MJ, Knaplund C, Schnock KO, Garcia JP, Jia H, Schwartz JM, Zhou L. Mining clinical phrases from nursing notes to discover risk factors of patient deterioration. Int J Med Inform 2020; 135:104053. [PMID: 31884312 PMCID: PMC7103062 DOI: 10.1016/j.ijmedinf.2019.104053] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/12/2019] [Accepted: 12/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Early identification and treatment of patient deterioration is crucial to improving clinical outcomes. To act, hospital rapid response (RR) teams often rely on nurses' clinical judgement typically documented narratively in the electronic health record (EHR). We developed a data-driven, unsupervised method to discover potential risk factors of RR events from nursing notes. METHODS We applied multiple natural language processing methods, including language modelling, word embeddings, and two phrase mining methods (TextRank and NC-Value), to identify quality phrases that represent clinical entities from unannotated nursing notes. TextRank was used to determine the important word-sequences in each note. NC-Value was then used to globally rank the locally-important sequences across the whole corpus. We evaluated our method both on its accuracy compared to human judgement and on the ability of the mined phrases to predict a clinical outcome, RR event hazard. RESULTS When applied to 61,740 hospital encounters with 1,067 RR events and 778,955 notes, our method achieved an average precision of 0.590 to 0.764 (when excluding numeric tokens). Time-dependent covariates Cox model using the phrases achieved a concordance index of 0.739. Clustering the phrases revealed clinical concepts significantly associated with RR event hazard. DISCUSSION Our findings demonstrate that our minimal-annotation, unsurprised method can rapidly mine quality phrases from a large amount of nursing notes, and these identified phrases are useful for downstream tasks, such as clinical outcome predication and risk factor identification.
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Affiliation(s)
- Zfania Tom Korach
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Jie Yang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New-York, NY, United States; School of Nursing, Columbia University, New-York, NY, United States
| | - Kenrick D Cato
- School of Nursing, Columbia University, New-York, NY, United States
| | - Min-Jeoung Kang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | | | - Kumiko O Schnock
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jose P Garcia
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States
| | - Haomiao Jia
- School of Nursing, Columbia University, New-York, NY, United States
| | | | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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98
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Tirkkonen J, Skrifvars MB, Parr M, Tamminen T, Aneman A. In-hospital cardiac arrest in hospitals with mature rapid response systems - a multicentre, retrospective cohort study. Resuscitation 2020; 149:109-116. [PMID: 32114070 DOI: 10.1016/j.resuscitation.2020.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/12/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
AIM To investigate in-hospital cardiac arrests (IHCAs) according to the Ustein template in hospitals with mature systems utilizing rapid response teams (RRTs), with a special reference to preceding RRT factors and factors associated with a favourable neurological outcome (cerebral performance category (CPC) 1-2) at hospital discharge. METHODS Multicentre, retrospective cohort study between 2017-2018 including two Finnish and one Australian university affiliated tertiary hospitals. RESULTS A total 309 IHCAs occurred with an incidence of 0.78 arrests per 1000 hospital admissions. The median age of the patients was 72 years, 63% were male and 73% had previously lived a fully independent life with a median Charlson comorbidity index of two. Before the IHCA, 16% of the patients had been reviewed by RRTs and 26% of the patients fulfilled RRT activation criteria in the preceding 8 h of the IHCA. Return of spontaneous circulation was achieved in 53% of the patients and 28% were discharged from hospital with CPC 1-2. In a multivariable model, younger age, no pre-arrest RRT criteria, arrest in normal work hours, witnessed arrest and shockable initial rhythm were independently associated with CPC 1-2 at hospital discharge. CONCLUSIONS In hospitals with mature rapid response systems most IHCA patients live a fully independent life with low burden of comorbid diseases before their hospital admission, the IHCA incidence is low and outcome better than traditionally believed. Deterioration before IHCA is present in a significant number of patients and improved monitoring and earlier interventions may further improve outcomes.
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Affiliation(s)
- Joonas Tirkkonen
- Department of Intensive Care Medicine and Department of Emergency, Anaesthesia and Pain Medicine, Tampere University Hospital, Tampere, Finland. PO Box 2000, FI-33521 Tampere, Finland; Intensive Care Unit, Liverpool Hospital, Sydney, Australia. Cnr Elizabeth and Goulburn Sts, Liverpool, NSW 2170, Australia.
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. PO Box 22, FI-00014 Helsinki, Finland.
| | - Michael Parr
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia. Cnr Elizabeth and Goulburn Sts, Liverpool, NSW 2170, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, Sydney, Australia. Cnr Elizabeth and Goulburn Sts, Liverpool, NSW 2170, Australia.
| | - Tero Tamminen
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital. PO Box 22, FI-00014 Helsinki, Finland.
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, Sydney, Australia. Cnr Elizabeth and Goulburn Sts, Liverpool, NSW 2170, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, Sydney, Australia. Cnr Elizabeth and Goulburn Sts, Liverpool, NSW 2170, Australia; Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Rd, Macquarie University, NSW 2109, Australia.
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Posthuma LM, Visscher MJ, Hollmann MW, Preckel B. Monitoring of High- and Intermediate-Risk Surgical Patients. Anesth Analg 2020; 129:1185-1190. [PMID: 31361670 DOI: 10.1213/ane.0000000000004345] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Linda Maria Posthuma
- From the Department of Anesthesiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
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What Do We Do After the Pilot Is Done? Implementation of a Hospital Early Warning System at Scale. Jt Comm J Qual Patient Saf 2020; 46:207-216. [PMID: 32085952 DOI: 10.1016/j.jcjq.2020.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adults who deteriorate outside the ICU have high mortality. Most rapid response systems (RRSs) have employed manual detection processes that rapid response teams (RRTs) use to identify patients at risk. This project piloted the use of an automated early warning system (EWS), based on a very large database, that provides RRTs with 12 hours lead time to mount a response. Results from a 2-hospital pilot were encouraging, so leadership decided to deploy the Advance Alert Monitor (AAM) program in 19 more hospitals. CHALLENGE How can one deploy an RRS using an automated EWS at scale? SOLUTION EWS displays were removed from frontline clinicians' hospital electronic dashboards, and a Virtual Quality Team (VQT) RN was interposed between the EWS and the RRT. VQT RNs monitor the EWS remotely-when alerts are issued, they conduct a preliminary chart review and contact hospital RRT RNs. VQT and RRT RNs review the cases jointly. The RRT RNs then consult with hospitalists regarding clinical rescue and/or palliative care workflows. Subsequently, VQT RNs monitor patient charts, ensuring adherence to RRS practice standards. To enable this process, the project team developed a governance structure, clinical workflows, palliative care workflows, and documentation standards. RESULTS The AAM Program now functions in 21 Kaiser Permanente Northern California hospitals. VQT RNs monitor EWS alerts 24 hours a day, 7 days a week. The AAM Program handles ∼16,000 alerts per year. Its implementation has resulted in standardization of RRT staffing, clinical rescue workflows, and in-hospital palliative care.
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